Introduction: The Legislative Reality Takes Shape
On November 19, 2025, Alberta Premier Danielle Smith confirmed what had been circulating in confidential draft legislation: the provincial government plans to allow physicians to operate simultaneously within both the public and private health-care systems through what is being called a “Dual Practice Surgery Model.” This announcement—following a November 18 Globe and Mail report on proposed amendments to the Alberta Health Care Insurance Act—marks a potentially watershed moment for Canada’s publicly funded Medicare system.
Under the proposed framework, surgeons (and possibly other clinicians) would be classified as “flexibly-participating physicians.” These practitioners could decide, on a case-by-case basis, whether to deliver a given surgery under the public system or in a private-pay environment—without necessarily notifying government in advance of which services they will perform publicly versus privately.
Premier Smith emphasized that participation would come with strings: surgeons wanting to take part in the dual-practice model would need to commit to a minimum ratio of publicly funded surgeries per year in order to qualify.The targeted areas are highly salient: knee, hip, eye, and shoulder surgeries—precisely the elective procedures for which wait-lists are among the longest in Alberta. Smith justified the reform by pointing to the systemic strains: patients are waiting too long, operating room capacity is underutilized, and some frustrated specialists are leaving the province—or even the country—for more lucrative opportunities elsewhere.
Smith framed the reform as a win-win: by permitting private-pay (or insurer-funded) surgeries in the “off-hours,” such as weekends, public wait-lists would shorten because more surgical volume would become available overall, and surgeons would be incentivized to stay in Alberta’s health system. She also stressed that all medically necessary care covered by Alberta Health Insurance will still be “everything your Alberta Health Insurance covers remains covered.” Importantly, Smith insists that life-threatening conditions, such as cancer surgeries or emergencies, would remain entirely within the publicly funded system, with no private-pay “line-jumping” for those cases.
Behind much of the policy advocacy for this reform are influential think tanks—such as the Fraser Institute and the Montreal Economic Institute—arguing that introducing market-based competition and financial incentives will spur efficiency and innovation. These groups portray the plan as the most significant health-care reform in decades. But while their narrative is compelling to some, a more critical analysis rooted in empirical evidence, macroeconomic logic, and comparative health policy suggests that the reform also carries profound risks.
Risks, Trade-offs, and Hidden Assumptions
1. Unproven Efficiency Gains and Allocation Risks
Smith’s government is not merely proposing dual pay structures, but a broader re-funding of surgical services via a shift to activity-based funding. According to Smith, hospitals will compete for funding based on how many and what types of surgeries they deliver. But critics warn that such a model could incentivize “cream-skimming”: private or private-adjacent providers might prioritize low-complexity, high-margin elective surgeries (like knees or hips), leaving public hospitals to handle more resource-intensive, complex cases without adequate funding. The Health Sciences Association of Alberta has expressed concern that under such a regime, major surgeries could decline in public hospitals as staff and capacity are diverted to better-funded, profit-oriented clinics.
2. Equity and Two-Tier System Concerns
The Canadian Medical Association (CMA) has strongly criticized the dual-practice plan, warning that it may worsen access disparities and degrade outcomes. Their argument is informed by global evidence: where parallel private systems operate, outcomes and access for publicly funded patients often suffer. Indeed, the CMA suggests this could lead to some Albertans paying twice—once via taxes to support the public system, and again out-of-pocket (or through insurance) to access the “faster” private track.
Opposition voices have echoed these concerns: the NDP argues the reform amounts to two-tier, “American-style” medicine, undermining the universality principle of Medicare. On the other side, the United Conservative government retorts that this is not “American-style” but more akin to European mixed models, pointing to research from the Montreal Economic Institute about the benefits of mixed public-private systems.
3. Workforce Planning & Retention Uncertainty
Smith frequently invokes physician retention as a rationale: the dual-practice model, she argues, will keep surgeons in Alberta rather than losing them to other jurisdictions. But critics contest whether this guarantee holds. There is uncertainty around safeguards: while the government mentions that “safeguards” like mandatory public service hours might be enforced, such provisions are not yet concretely detailed. Without well-designed and enforceable guardrails, there is a risk that the public system could hollow out, losing not only volume but also talent.
4. Structural Overhaul Risks
The dual-practice reform is taking place against the backdrop of wider restructuring in Alberta’s health system. Notably, the government is dismantling Alberta Health Services (AHS) and replacing it with specialized provincial agencies—including Acute Care Alberta, which now oversees chartered surgical facilities. Alberta Health Services This fragmentation raises questions about coordination, accountability, and the long-term governance of a hybrid system.
Health-care unions and workers have voiced alarm: according to the Alberta Union of Provincial Employees (AUPE), Bill 55 (the Health Statutes Amendment Act, 2025) could enable a privatization agenda that “undermines public health care” and gives the government sweeping authority to shift institutions into private provision. AUPE Some warn of layoffs, reduced standards, and instability for health workers if profit-driven models take priority over patient outcomes.
5. Transparency, Accountability & Cost Controls
Smith has pledged that cost-per-surgery data will be publicly available, and that more complex procedures will be compensated at higher rates. But transparency alone does not guarantee equitable access or fiscal prudence. Without robust regulatory oversight, there is a risk that private-pay corridors may grow unchecked, leading to escalating costs or shifting public money toward profit-driven entities. Observers note that such payment models, if not properly bounded, could exacerbate inequities rather than alleviate them.
Why This Matters: A Broader Stakes Perspective
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For Patients: The reform promises faster access for some, but not without creating potential stratification in care. Albertans who can pay (or have supplemental insurance) may receive faster treatment, while others remain constrained by public wait-lists.
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For Public Medicare: The model tests the resilience of Canada’s single-payer promise. If dual practice becomes entrenched without strong safeguards, it could erode public trust and undermine the very foundations of universal coverage.
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For Health-Economics: The plan is being sold as a cost-saving, efficiency-boosting measure, but history suggests that introducing market-like incentives into health care often brings unintended consequences—especially when poorly regulated.
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For Governance: The timing of the reform, alongside the restructuring of Alberta’s health institutions, raises critical governance questions: who will regulate, oversee, and enforce equity in this new mixed system? How will public accountability be maintained when profit motives are introduced?
The announcement of Alberta’s Dual Practice Surgery Model represents more than a policy tweak—it is a paradigm shift. By explicitly allowing doctors to straddle public and private spheres, the provincial government is challenging long-standing principles of universal, publicly insured care. While the proposed reform is framed in terms of flexibility, wait-time reduction, and physician retention, the evidence—both global and local—raises serious red flags about equity, cost, and the future integrity of Alberta’s (and Canada's) Medicare.
In the next sections, a deeper dive into the comparative evidence, economic incentives, and the risk of systemic stratification will show why this so-called “reform” may be far more perilous than proponents acknowledge.
The Siren Song of Market Efficiency: Cost and Crowding-Out
The fiscal case for Alberta’s dual-practice reform is rooted in a familiar macroeconomic narrative: the current single-payer model is allegedly unsustainable, draining provincial coffers and crowding out other public priorities. Healthcare’s share of government expenditure has grown dramatically, constraining spending on education, infrastructure, and social services. Proponents argue that by allowing surgeons to moonlight in the private sector—after meeting a floor of publicly funded work—overall surgical capacity will rise, wait times will shrink, and physician retention will improve. In theory, this injects market discipline, aligns incentives, and unlocks latent capacity.
Yet this diagnosis, while superficially compelling, obscures profound risks. The free-market remedy is, in many respects, ill-suited to the realities of health care and physician behavior—and the evidence suggests it may backfire, undercutting both equity and public capacity.
The Zero-Sum Reality of Physician Time
At the heart of the reform is the assumption that physician time is essentially elastic—that doctors can seamlessly expand their hours, or shift work, to accommodate both public and private practice without degrading the public system. Empirical and experiential realities strongly challenge that assumption.
Conflict of Incentives and Allocation Risks
Dr. Brian Wirzba, president of the Alberta Medical Association, has warned that dual practice without rigorous guardrails risks destabilizing the public system. He argues that conflict-of-interest rules, safeguards against subsidization of private services by public resources, and robust workforce-planning mechanisms are needed to prevent crowding-out.
International studies back him up. A systematic review of dual practice globally found that when physicians are allowed to split time between public and private work, they may engage in predatory behavior—prioritizing higher-paying private services, steering patients toward their private practices, or shifting their best effort to the private sphere. Moreover, the same review raises concerns that dual practice can undermine public services, leading to backlogs, underused equipment, delayed treatment, and a deterioration of quality in the public sector.
Because private care often pays more, physicians have a strong financial incentive to allocate their time where it yields the greatest return. This undermines the idea that the public system remains insulated simply because of minimum public-service quotas.
Empirical Evidence from Alberta’s Own System
Recent provincial experience suggests that these risks are not abstract. A November 2025 investigation by The Tyee, drawing on internal Alberta Health Services (AHS) data and expert research (including work by the Parkland Institute), found that while private surgical facilities (chartered surgical facilities, or CSFs) have accommodated more low-acuity, elective procedures, wait times for complex, high-priority surgeries in the public system have actually increased.
This phenomenon aligns with the “cream-skimming” critique: private or private-like providers focus on volume, high-margin procedures (e.g., hips, knees, cataracts), leaving public hospitals to handle the more complex, less profitable cases—often at a higher cost per case, but without the same financial incentives. As The Tyee report warns, this may produce inequities in access, as well as resource strain on public acute-care centers.
The Illusion of Risk Mitigation
Supporters of the reform, such as think tanks like the Montreal Economic Institute, argue that requiring a minimum threshold of publicly funded work will prevent physician “abandonment” of the system. But even with such a model, the dual-practice system removes the protective barrier that currently discourages doctors from going fully private—a barrier that some medical academic leaders, like former University of Calgary medical school dean Jon Meddings, describe as central to preserving public-sector supply. In his view, since very few physicians currently opt out of Medicare (because it would threaten their income), the public system has had a de facto shield. By contrast, the hybrid model empowers physicians to “test the private waters” without risking full exclusion from public payments.
Macroeconomic and Policy Trade-offs
Viewed through the lens of macroeconomics and public policy, the dual-practice reform may represent a short-term fix with long-term costs:
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Budgetary Reallocation vs. Structural Strengthening
While the reform seeks to optimize fiscal efficiency by aligning payment to productivity (via activity-based funding), critics warn that this may reallocate rather than add capacity. The new funding model announced by Smith ties grants to surgical volume and type, creating direct competition between public hospitals and private-leaning surgical centers. But as unions and health workers have cautioned, this could lead public hospitals to lose key staff or even rent out OR time to external entities—potentially weakening the public core.
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Equity Risks
Dual practice inherently raises equity concerns. Canadian Doctors for Medicare, among other voices, argue that if doctors can be paid more by patients in the private sector than by the government for the same procedures, they will almost certainly spend more time privately, to the detriment of those who rely solely on the public system. As this happens, a two-tier structure may emerge: privately paying or insured patients get quicker access, while public-system patients face stagnating or even worsening wait times.
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Sustainability vs. Fragmentation
The proposed reform does not occur in isolation. It coincides with a major restructuring: the dismantling of Alberta Health Services and its replacement with specialized agencies (e.g., Acute Care Alberta) that oversee surgical volume under the new activity-based model. This institutional fragmentation may erode accountability and continuity, making it harder to ensure equitable distribution of resources. Dr. Wirzba, among others, has warned that instead of fixing “old silos,” the reform risks building new ones.
In sum, the fiscal logic of dual practice—more efficiency, more supply, shorter waits—is alluring, especially in a constrained budgetary environment. But it rests on a dangerously optimistic assumption: that physician labor and time can simply be dialed up like any other market good. The evidence, both from Alberta’s own unfolding reforms and decades of international study, suggests otherwise. Without strong conflict-of-interest regulation, transparent allocation, and protections for the public core, dual practice risks undermining the system it purports to strengthen.
Far from being the panacea for wait-time woes, this reform could precipitate a crowding-out of public care, exacerbate inequities, and shift scarce resources from complex, publicly funded cases to easier, more profitable ones. If Alberta is serious about sustainability, the answer lies not in privatizing care, but in strengthening public infrastructure, workforce planning, and systemic coordination—not diluting it.
The Empirical Record: Lessons from Dual Practice Internationally
The international evidence on physician dual practice offers a far more cautionary tale than the optimistic projections put forward by Alberta’s reformers. While the concept of doctors working in both private and public settings can seem like a pragmatic compromise, real-world data suggest serious trade-offs—and systemic risks.
Historical and International Evidence on Dual Practice
Canadian and North American Experience
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In Manitoba, research from the 1990s revealed that public-stream patients of surgeons who also maintained private practices waited significantly longer than patients of surgeons who worked exclusively in the public system. These waits were not trivial: the Canadian Medical Association Journal recounts that the differential could be as much as 13 additional weeks.
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In Alberta itself, dual-practice in cataract surgery has historical precedent: surgeons operating in both public hospitals and private clinics (charging facility fees in the private setting) have been scrutinized. A report from the Consumers’ Association of Canada noted long public wait times and higher fees in private clinics.
These Canadian cases underscore an enduring pattern: dual practice may create perverse incentives that disadvantage publicly insured patients.
Broader Global Evidence
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A systematic literature review by Karolina Socha and Mickael Bech (University of Southern Denmark) found that while dual practitioners may benefit financially, there is a structural risk of them shifting effort toward private practice, favoring more lucrative patients, and under-serving their public-sector obligations. The review also warns of “cream-skimming” (selecting the most profitable patients) and of public resource misuse, including self-referrals from public patients to private practices.
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According to a World Health Organization (WHO) governance report, dual practice is very widespread globally, but its negative impacts—especially for universal health-care coverage—are poorly quantified because evidence remains largely descriptive.
Structural and Behavioral Dynamics: Why Dual Practice Undermines Public Provision
Much of the problem lies in economic incentives, not necessarily the morality of individual doctors. Dual practice embeds what economists call principal–agent problems: physicians (agents) may be strongly motivated by profit, which can diverge from public-system goals (the principals).
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The incentive structures inherent in dual practice can lead physicians to prefer private patients, especially when public waiting lists are long. The longer public wait times become, the stronger the incentive to channel patients into their private practices. This is not simply a matter of greed but of rational economic decision-making under an unbalanced system.
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The WHO report also highlights how weak governance or regulatory frameworks fail to correct these misaligned incentives.
The Cost Arithmetic of Private Delivery
Critics of dual practice often argue that private-provision efficiency gains outweigh the costs. But the empirical record suggests otherwise.
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In Canada, case studies show that privatized procedures can be materially more expensive. For instance, a study in Quebec found that certain procedures at private clinics cost up to 150% more than the same procedures in public hospitals. Another source reported that private colonoscopies cost $739 vs. $290 in public settings.
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More recently in Alberta, a Parkland Institute analysis found that for-profit surgical facilities (chartered surgical facilities, or CSFs) are billing the government more than twice the cost of equivalent public-hospital procedures for hip, knee, and shoulder surgeries. The same report shows that public spending on these for-profit centers has ballooned, while surgical capacity in public hospitals has actually declined.
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Additional cost-inflation concerns arise from contract negotiations: according to internal documents, some CSFs have raised their rates sharply, with increases that far outpace general healthcare inflation.
These fiscal dynamics directly challenge the reformers’ argument that a mixed public-private model will save money or relieve pressure on the public system. In practice, profit motives and administrative burdens may actually increase net cost to taxpayers.
Why This Matters for Alberta’s Reform
Putting Alberta’s dual-practice proposal in light of this evidence raises several red flags:
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Behavioral Risks Are Not Theoretical
The empirical record—from Manitoba’s cataract backlog to global dual-practice studies—shows that unless tightly regulated, dual-practice systems create strong incentives for physicians to prioritize private over public patients.
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Governance Deficits
The WHO and other reviews stress that governance mechanisms (regulation, oversight, conflict-of-interest rules) are often weak or underdeveloped. Without robust oversight, the negative externalities of dual practice can erode public-system integrity.
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Cost Overrun Potential
The assumption that private delivery will reduce public costs is challenged by real-world data: in multiple jurisdictions, private delivery has proven more expensive, and the administrative costs of managing two parallel systems can consume or even outweigh the projected savings.
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Equity Implications
Because private services are often accessible to wealthier patients (or insured ones), a dual-practice model can reinforce or worsen health inequities. Public patients may end up disadvantaged—not just by longer waits, but also by being systematically routed into lower-capacity or under-resourced public segments.
Alberta’s proposed dual-practice reform may be sold as a pragmatic, win-win solution—but the empirical record warns that such models are fraught with structural risk. Historical Canadian cases, global reviews, and recent cost-overrun evidence all suggest that dual practice, if not carefully constrained, tends to siphon capacity, degrade equity, and drive up public expenditures.
If Alberta proceeds along this path, policymakers must pay close attention to governance, regulation, and rigorous cost-benefit assessment—not just ideological appeals to market efficiency. Without strong checks, the “solution” risks becoming a backdoor privatization that undermines the public system’s long-term sustainability..
The Scandinavian Fallacy vs. The American Spectre
The invocation of Scandinavian mixed-delivery models—often deployed by advocates of Alberta’s reforms—is a powerful rhetorical device but a profoundly misleading one. Premier Smith referenced countries such as Sweden, Germany, and Australia as successful examples of dual-model systems, and Nadeem Esmail of the Fraser Institute argued that the proposed reforms would align Alberta more closely with global norms. This logic trades on the prestige of high-performing European health systems while obscuring the very conditions that make those systems function.
Scandinavian Models Operate Under Vastly Different Structural Conditions
Countries like Sweden and Norway do indeed maintain mixed public–private delivery arrangements. However, these systems are embedded within—and dependent upon—structural conditions that bear little resemblance to Alberta’s fiscal, regulatory, and political context. Scandinavian systems combine strict regulatory controls, robust public financing, centralized health workforce planning, and unusually high levels of social spending. Private-sector participation remains supplemental, tightly circumscribed, and designed explicitly to avoid the siphoning of personnel, resources, or political support away from the public system.
The balance of probabilities suggests that selectively borrowing the form of Scandinavian dual practice—while refusing the substance that sustains it—amounts to an attempt to produce high-equity outcomes under incompatible institutional conditions. Fiscal conservatives in Canada frequently argue that public services are already overburdened, yet the very Scandinavian systems they invoke rely on higher taxation, more generous social insurance, and deeply coordinated governance mechanisms to achieve the outcomes used to justify reform. It stands to reason to expect that importing only the “private option” component effectively amputates the institutional foundations that prevent dual practice from widening inequities or distorting incentives.
The Evidence on Parallel Systems: Access and Equity Concerns
Canadian medical organizations have consistently warned that dual practice risks transforming health care into a two-tier system, with preferential access for those able to pay. The Canadian Medical Association and Canadian Doctors for Medicare emphasize that queue-jumping is not merely a theoretical concern but an unavoidable feature of systems where private pay creates differential access pathways. The British Columbia Supreme Court’s 2020 ruling against Cambie Surgeries Corporation made this point with exceptional clarity. The court concluded that introducing parallel private care would:
• increase public-sector demand,
• reduce public capacity,
• raise system-wide costs,
• incentivize physicians to prioritize private over public practice,
• increase risks of ethical conflicts,
• undermine political support for public funding, and
• exacerbate inequities in access to medically necessary care.
This comprehensive judicial assessment underscores that dual practice does not simply coexist with public access—it fundamentally reshapes the allocation of time, talent, and resources in ways that disadvantage public patients.
International evidence reinforces these findings. Countries such as Australia and the United Kingdom, which maintain sizeable private-pay sectors operating parallel to public systems, have not seen reductions in public wait times. In many cases, public wait times have remained static or worsened, despite significant private-sector expansion. The balance of probabilities indicates that private practice redistributes rather than creates system capacity. Those with financial means benefit from faster access, while public-system patients face longer queues as physicians shift time and attention toward higher-revenue private work.
Alberta's Current Wait Time Crisis: Context and Causes
Understanding the magnitude and drivers of Alberta’s wait time crisis is essential for evaluating the merits and limitations of proposed reforms. Alberta currently faces some of the longest specialist wait times in Canada. Orthopedic surgery patients wait an average of 46.1 weeks from referral to treatment—nearly double the national average—and recent estimates place the median wait to consult an orthopedic surgeon at approximately 64 weeks. Premier Smith has noted that more than 80,000 Albertans are waiting for elective surgeries such as hip and knee replacements. These figures are not abstract metrics but indicators of profound physical suffering, reduced mobility, and diminished quality of life for tens of thousands of residents.
However, it stands to reason to expect that the roots of these delays extend far beyond payment models. Analyses consistently show that surgical wait times are driven by structural bottlenecks—particularly shortages of operating room capacity and nursing staff—while physician compensation models rank low among explanatory factors. The COVID-19 pandemic further strained an already overstretched system, but Alberta’s targeted measures—including the expansion of accredited private surgical centres, the addition of operating rooms in public hospitals, and the implementation of centralized intake pathways—demonstrate that incremental, system-focused reforms can produce measurable improvements without fundamentally restructuring physician payment arrangements. The balance of probabilities suggests that Alberta’s comparatively strong pandemic-era surgical performance, maintaining higher completion rates than Ontario, reflects the effectiveness of these targeted interventions rather than any need for sweeping dual-practice reforms.
The Naïveté of Supply-Side Simplification
Proponents of dual practice often assert that allowing physicians to work privately after meeting minimum public commitments will “eliminate the gap between supply and demand for doctors.” This represents a significant oversimplification of the structural realities that drive workforce shortages. Alberta’s health-care capacity challenges stem from intertwined labour, training, and institutional dynamics that dual practice does nothing to resolve.
Workforce Planning and Training Pipeline Constraints
One of the most binding constraints on physician supply is the limited number of medical school placements and residency positions—both tightly rationed across Canada. Alberta also faces protracted delays in integrating internationally trained physicians, due to credentialing barriers and regulatory fragmentation. The balance of probabilities suggests that these pipeline constraints—rather than physician payment models—set the upper limit on provincial health-care capacity. Introducing dual practice does not expand medical school enrolment, increase residency training slots, or streamline assessment for international graduates; it simply redistributes how existing physicians allocate finite time.
Retention and Burnout in the Post-Pandemic Environment
Retention challenges compound these structural shortages. Burnout, worsened during the COVID-19 pandemic, has driven many physicians and nurses toward early retirement, reduced clinical hours, or alternative career paths. It may be argued with considerable confidence that dual practice risks worsening this trend. By creating a more lucrative and flexible private alternative, it incentivizes practitioners to reduce their public commitments in favour of environments offering greater control over scheduling, workload, and remuneration. Far from stabilizing the workforce, the policy may accelerate the shift of experienced clinicians out of the public system, deepening capacity shortfalls rather than alleviating them.
Geographic Imbalances and Rural Health-Care Deserts
Critical shortages in rural and remote regions remain one of Alberta’s most persistent and politically sensitive health-care challenges. The balance of probabilities strongly suggests that dual-practice policies will overwhelmingly incentivize physicians to concentrate in high-demand, high-income urban centres where private surgical markets are most financially viable. Surgical wait times already vary sharply across regions, mirroring longstanding disparities in health-care access, staffing capacity, and facility availability. Market-based reforms, by their very nature, systematically favour areas capable of sustaining profitable private-pay practices—precisely the opposite distribution required to support under-resourced rural communities.
It stands to reason to expect that Alberta cannot close the structural “gap” between supply and demand by enabling physicians to gravitate toward lucrative private-market opportunities while failing to address chronic underfunding, recruitment challenges, and inefficiencies in public workforce management. This represents a form of trickle-down health policy that assumes expanded access for wealthier, private-pay patients will somehow produce downstream benefits for the public system—a proposition lacking empirical support in comparable jurisdictions.
The Canada Health Act: Compliance Questions and Federal Response
The proposed reforms raise serious questions regarding Alberta’s compliance with the Canada Health Act (CHA), which prohibits extra-billing or charging for medically necessary services already insured under provincial plans. Several medical leaders have warned that the dual-practice proposal could put Alberta in direct conflict with federal legislation. Dr. Paul Parks, past president of the Alberta Medical Association, warned the reforms could constitute a “death blow” to the Act—an assessment that reflects the unprecedented nature of the proposed flexibility for physicians to toggle between public and private billing streams.
Guillaume Bertrand, director of communications for federal Health Minister Marjorie Michel, stated that Ottawa “will always protect” Canada’s universal health-care system, confirming that Health Canada officials are actively engaging with Alberta counterparts to analyze the reforms and their potential implications. This signals early-stage federal scrutiny and suggests the federal government is preparing for a more assertive posture should Alberta proceed.
Ottawa possesses well-established enforcement mechanisms for provincial non-compliance. The CHA requires mandatory dollar-for-dollar deductions from federal health transfers in cases of extra-billing or user fees. Historically, these penalties have been substantial: between 1984 and 1987, $244,732,000 in deductions was refunded to provinces—including Alberta—after non-compliant charges were eliminated. More recently, in March 2023, more than $76.4 million in Canada Health Transfer deductions were levied against British Columbia, Alberta, Saskatchewan, Manitoba, Quebec, New Brunswick, and Nova Scotia for medically necessary diagnostic services that had been improperly billed to patients.
Legal experts caution that Alberta’s dual-practice model—unprecedented in Canada for allowing physicians to actively operate in both systems simultaneously—would almost certainly trigger legal challenges and potential clawbacks. The balance of probabilities suggests the reforms will face significant federal scrutiny, and Alberta risks material fiscal penalties should components of the proposal be deemed inconsistent with the CHA.
Institutional Perspectives: Professional and Advocacy Responses
The response from the medical community reflects deep divisions and significant concern regarding the reform’s design and potential consequences. The Alberta Medical Association (AMA) insists that any health-care reform must be evidence-based, transparent, and developed through meaningful engagement with physicians, patients, and frontline providers. The AMA has articulated specific conditions for any dual-practice framework, including:
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clear conflict-of-interest policies to prevent physicians from steering patients toward private options;
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safeguards to prevent public resources from subsidizing private services;
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mechanisms to ensure adequate public-system workforce allocation, particularly for highly complex and emergent care;
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rigorous prioritization of medically necessary services in resource planning;
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and maintenance of access based primarily on need, not ability to pay.
Advocacy groups have expressed even sharper concerns. Friends of Medicare argues that the reform would make Alberta the only jurisdiction in Canada to allow doctors to work freely in both systems—an arrangement they characterize as “an unprecedented attack on Albertans’ public health care” that would “unequivocally bulldoze a path for American-style health care in Alberta.” Chris Gallaway, the organization’s executive director, questioned how the proposal could remain compliant with federal law and asserted that the UCP government has persistently sought mechanisms to redirect public dollars toward private profits, allegedly contributing to higher costs, longer waits, and chronic understaffing.
It may be argued with substantial confidence that these critiques reflect not ideological alarmism but well-documented empirical patterns in countries operating dual-practice systems. The concerns raised by medical professionals and advocacy groups map closely onto known outcomes—crowding out of public-sector care, widening equity gaps, and destabilization of public capacity—observed internationally when financial incentives are allowed to pull physicians toward private practice at the expense of public commitments.
Alternative Reform Pathways: Evidence-Based System Improvements
The severity of Alberta’s current health-care crisis requires urgent, pragmatic intervention. However, the balance of probabilities strongly suggests that robust, evidence-based alternatives to dual practice offer far more credible pathways for improving system performance without undermining the equity principles at the core of Medicare. These alternatives are grounded in international best practices, empirical evaluation, and structural reforms that actually expand system capacity rather than simply reshuffling existing providers.
Activity-Based Funding and Improved Resource Allocation
Alberta has announced plans to implement activity-based funding (ABF) beginning in 2026. Under this model, health-care providers are compensated for each patient treated, with payments calibrated to the patient’s diagnosis, acuity, and complexity. Nearly every advanced universal health-care system—from Scandinavia to Western Europe to Australia—relies on variants of ABF. The empirical record indicates that such models consistently increase the volume of services delivered using existing infrastructure, reduce wait times, improve quality, enhance access to cutting-edge medical technologies, and decrease wasteful spending.
It stands to reason to expect that activity-based funding directly addresses one of the central inefficiencies in Canada’s current model: the perverse incentive structure of global (lump-sum) hospital budgets, which can lead institutions to view additional patients as cost burdens rather than service imperatives. ABF changes this calculus by tying funding to outputs rather than fixed annual envelopes. Unlike dual practice, it does so entirely within the public system and without creating financial incentives for physicians to divert time away from publicly insured patients. The result is a structurally aligned, equity-preserving mechanism that enhances efficiency while upholding the universality provisions of the Canada Health Act.
Expanded Roles and Team-Based Care
International evidence overwhelmingly shows that expanding the scope of practice for non-physician professionals can yield substantial improvements in wait times and care quality. Nurses and nurse practitioners performing pre-admission assessments, biopsies, hysteroscopies, endoscopic procedures, chronic disease management, and other delegated tasks have enabled specialists to focus on complex surgical and diagnostic cases. Jurisdictions such as the United Kingdom, the Netherlands, and New Zealand have demonstrated that these task-shifting strategies materially expand effective system capacity.
The balance of probabilities suggests that optimizing health-care team utilization constitutes a true supply-side reform—one that increases the total volume of care delivered rather than merely redistributing a finite pool of physician labour between public and private settings. Unlike dual practice, which structurally incentivizes physicians to prioritize higher-paying private work, team-based care reforms expand the range of providers capable of delivering timely, high-quality care within the public system.
Digital Health Infrastructure and Process Improvements
Investments in digital health infrastructure—such as interoperable electronic health records, national patient-tracking platforms, shared diagnostic imaging systems, and province-wide referral management tools—have demonstrated significant improvements in efficiency across numerous international health systems. When combined with process improvement methodologies (Lean, Six Sigma, clinical pathway redesign, centralized booking, and queue management algorithms), digital transformation can reduce bottlenecks, streamline patient flow, and shorten wait lists without undermining the foundational principle of universal access.
These innovations do not depend on market segmentation or private-sector diversion. Instead, they enhance the functionality of the public system itself. A growing body of evidence from jurisdictions such as Denmark, Estonia, and the United Kingdom shows that integrated digital systems can reduce duplication, accelerate diagnostics, and enable data-driven resource allocation—all without introducing inequities or imposing user fees.
These evidence-based alternatives share a crucial characteristic: they focus on genuine capacity expansion, structural efficiency gains, and equitable access, rather than creating parallel markets that risk draining resources from the public system. In contrast to dual practice—which depends on redistributing existing labour while introducing powerful incentives that may destabilize public provision—these reforms strengthen the system from within.
Conclusion: A Crisis of Democratic Values, Healthcare Equity, and System Stewardship
The debate surrounding Alberta’s proposed dual practice reforms now stands as far more than a contest over administrative design or service delivery modalities. It has evolved into a decisive test of Canada’s democratic commitments, institutional integrity, and the foundational principle that access to medically necessary care should reflect clinical need rather than purchasing power. Alberta is not merely adjusting governance mechanisms—it is redefining the moral and constitutional architecture of Canadian healthcare.
The draft amendments would authorize physicians to determine, on a case-by-case basis and without notification requirements, whether a patient is treated within the public system or in a privately paid setting. This discretionary model is not benign. It creates structural and behavioural incentives—mapped extensively in comparative health-systems research—that enable systematic capacity diversion from public to private channels. The result is a predictable pattern in which patients with financial resources consistently secure faster access, while those reliant on public insurance face longer waits, diminished continuity of care, and reduced provider availability. The policy architecture itself manufactures inequity.
The promise of a market-driven solution that can simultaneously reduce wait times, lower public expenditures, and preserve investment for other public services is, as the evidence demonstrates, analytically inconsistent. Jurisdictions that successfully integrate limited private activity—particularly in Scandinavia—do so under regulatory regimes far more stringent, transparent, and resourced than anything contemplated in Alberta. They rely on rigid separation rules, real-time monitoring of clinical hours, mandatory disclosure, robust enforcement, and—critically—sustained investment in the public workforce. Alberta’s reforms include none of these safeguards. Without them, dual practice becomes not a supplement to public capacity but a conduit for its fragmentation.
International comparisons reveal a consistent reality: countries with shorter wait times do not succeed because they introduce more private financing or delivery. They succeed because they manage personnel, productivity, and investment more effectively. Their advantage lies not in ideology but in institutional design—activity-based funding that aligns incentives without abandoning universality; team-based models that expand real capacity rather than redistribute existing bottlenecks; digital infrastructure that reduces administrative frictions; and long-horizon workforce planning that stabilizes service availability. These principles, not privatized dual practice arrangements, are the evidence-based lever for modernizing Canadian Medicare.
On the balance of probabilities, the socioeconomic costs of a two-tiered system—where the speed and quality of care become contingent on financial means—will surpass the fiscal and political challenges posed by Alberta’s current wait time pressures. Once private financial incentives become embedded in clinical decision-making, reversal becomes not only administratively difficult but politically fraught. The erosion of universality is gradual, silent, and cumulative—yet once the equilibrium shifts, it cannot easily be restored.
The implications extend well beyond provincial borders. Premier Smith’s government is advancing regulatory changes that would inaugurate the most consequential restructuring of Canadian healthcare since the establishment of Medicare. The question facing Canada is not whether reform is necessary—system strain is real and mounting. The question is whether reform will be guided by evidence, stewardship principles, and the constitutional ethos of equality, or by untested market mechanisms that privilege the affluent while fracturing the collective foundation upon which Medicare rests.
History and international health-systems research converge on a clear conclusion: dual practice models, absent exceptional regulatory architecture and significantly increased public investment, systematically degrade access, equity, and public-sector performance. Alberta’s current trajectory aligns not with the successful hybrid systems of Northern Europe but with jurisdictions where privatization has entrenched inequality and weakened public care. The balance of available evidence suggests that the reforms as proposed will not deliver innovation or efficiency, but rather initiate an incremental dismantling of universal Medicare—one that, once underway, may be effectively irreversible.
At this moment, courage is required—not the courage to experiment with market ideology, but the courage to pursue genuine, evidence-based system renewal. Canada’s commitment to healthcare as a core democratic right is being tested. The future of that commitment will be determined by whether policy-makers choose to reinforce the principles that have long safeguarded equitable access, or to abandon them in favour of a model whose risks are well known, and whose consequences will be borne most heavily by those with the least ability to pay.
