Over 20 years ago, a Supreme Court of Canada decision put Quebec’s health-care system on a different trajectory than the rest of Canada’s.
In a 2005 decision known as Chaoulli, the court struck down Quebec’s ban on private insurance for some medically necessary services, ruling that lengthy wait times could violate patients’ rights.
In the years since then, Quebec has seen more private surgical clinics open and more publicly funded procedures performed in private facilities.
Experts are divided on whether the resulting expansion of private delivery has been a net positive for the province.
“[H]ospitals have been slowly transferring some volumes of surgeries in private clinics, surgeries that would be paid for by the public system … in order to alleviate the wait list,” said Yanick Labrie, a Quebec-based economist and senior fellow at the Fraser Institute think tank.
“I think it could be emulated in the rest of Canada.”
But critics argue the model diverts scarce public resources.
“The surgeries that are funded by public funds and delivered in private clinics — it’s public doctors that are doing those surgeries,” said Anne Plourde, a researcher at L’Institut de recherche et d’informations socioéconomiques (IRIS).
“We are just taking doctors from public settings and putting them in private clinics.”
Chaoulli v. Quebec
The Chaoulli case centred on a Quebec law that prohibited patients from holding private health insurance for medically necessary services, such as hip replacement surgery.
In a 4–3 decision, the court held that banning private insurance amid long wait times violated patients’ rights under Quebec’s Charter of Human Rights and Freedoms.
Three justices also found a violation of the Canadian Charter of Rights and Freedoms. But since that finding was not binding, the ruling applied only in Quebec.
In response, Jean Charest’s government passed Bill 33, a law that allows Quebecers to purchase private insurance for just three procedures: hip replacements, knee replacements and cataract surgeries.
“In most provinces, you’re not allowed to have that kind of [insurance] product available,” said Labrie.
Ultimately, though, the law’s narrow scope limited insurers’ interest in providing coverage.
“It’s like you’re allowed to buy a car, but there are no cars,” said Labrie.
“People would be willing, probably, to buy such insurance, but no insurance companies are interested in providing that type of insurance.”
What actually changed?
However, Chaoulli did nonetheless have an impact on Quebec’s health-care system.
The decision created legal and political pressure to address wait times. And it helped legitimize a larger role for private-sector involvement, Labrie says.
“Private clinics were allowed a greater role in the publicly funded system,” he said.
The bill also expanded the government’s ability to purchase publicly funded surgeries from those clinics.
Today, medically necessary services remain funded by the province. But an expanding share of publicly funded diagnostic services, procedures and surgeries are delivered in private clinics.
Quebec is not unique in this respect, but it has gone further than most.
In 2025, nearly 20 per cent of surgeries in Quebec were performed in publicly funded private clinics — a level only matched by Alberta.
In B.C., by contrast, just under five per cent of surgeries were delivered in private clinics in the 2021-22 fiscal year. Meanwhile, Manitoba, New Brunswick, P.E.I. and Newfoundland and Labrador have minimal to no private surgical capacity. (Ontario does not publish a comparable system-wide percentage.)
The number of specialized medical centres in Quebec has also grown, from 45 facilities in 2014 to 73 in 2023. Most of these centres’ procedures are still publicly funded, according to a 2025 report.
Taken together, Labrie argues these figures point to a greater reliance on private surgical delivery than seen in most provinces.
“To some extent, other provinces have introduced some sort of reforms … but nothing compared to Quebec in terms of consistency,” he said.
Labrie says long wait times and physician shortages have also contributed to greater public openness toward private-sector involvement in Quebec.
“We’re not different from other provinces. We do have to operate under the Canada Health Act … [but] there’s not the backlash and the … opposition that we generally see in the rest of Canada about the private sector in health care,” he said.
“It’s something that we just feel comfortable having … in Quebec.”
Is it working?
But among experts, Quebec’s evolution remains contentious.
Plourde, of IRIS, says the expansion of private delivery is drawing workers and surgical capacity away from the public system. She points to workforce data revealing a long-term shift in labour from the public network into private delivery.
Quebec’s reforms under Bill 33 also enabled physicians to fully opt out of the public plan and bill patients directly, including for primary care. A 2023 investigation by the Globe and Mail found the number of Quebec doctors that are fully private has more than doubled over the past decade.
Plourde says these changes leave the public system — which still handles emergencies, cancer operations and complex cases — with the sickest patients, and fewer resources to treat them.
She also notes that the province may be spending more as a result of its reliance on private facilities. A 2023 IRIS analysis found some procedures cost as much as 150 per cent more in private settings.
Dr. Shaun Selcer, an internist at the Montreal Heart Institute and assistant professor at Université de Montréal, says he sees many patients who have “consulted in the private sector.”
“My personal impression is that many are willing to pay for private care, although it does not always address the underlying medical issues,” Selcer said in an email.
“I also think the private system often distinguishes itself more through accessibility and customer service than through medically necessary care.”
The impact on wait times also remains unclear.
According to a 2024 Fraser Institute report, Quebec had the shortest median wait for an initial specialist consultation at nine weeks. P.E.I. had the longest wait, at nearly 40 weeks.
However, the wait time from the initial referral to treatment in Quebec was nearly 29 weeks — right around the nationwide average of 30 weeks.
Cambie in B.C.
The Chaoulli ruling never established whether long wait times violated the Charter rights of residents of other provinces.
In B.C., a years-long constitutional challenge on this issue — known as Cambie Surgeries — resulted in both B.C.’s trial and appellate courts upholding the province’s ban on private insurance and other restrictions.
In 2023, the Supreme Court of Canada declined to hear a further appeal, effectively ending the case.
“The Supreme Court of Canada’s decision to refuse leave in the Cambie matter is a shocking dereliction of the Court’s duty to provide legal clarity across the country,” Joanna Baron, executive director of the Canadian Constitution Foundation, which helped bring the challenge, told media at the time.
“It is inexplicable and stunning that it elected not to hear this challenge.”
Experts say the court’s refusal to revisit the issue reflects a court that is more cautious today than it was in the early 2000s.
“I think it’s difficult to have those legislative changes going through courts,” said Labrie, noting courts are increasingly reluctant to use constitutional rulings to reshape health policy.
“It’s always a political game … and they always [err] on the side of being more prudent. They’re afraid that they would open Pandora’s box.”
But in Quebec, that box is open and debate over an expanded private sector continues unabated.
In May, at a national gathering of conservatives, Quebec Conservative Leader Éric Duhaime said he supports a two-tier system combining public and private care, arguing that federal pressure against reform is “completely undemocratic.”
“The public monopoly is a failure, and we have to admit it,” he said. “We have to make sure that we find a new model.”
