Melanie Schmidt started out willing to wait her turn. The Calgary woman was used to being on the go. At fifty, she retired from corporate life in the oil sands and eventually trained as a sommelier. After that, she went back to school to finish the university program she’d started when her two daughters were small, and she graduated with a bachelor’s degree (psychology major, sociology minor). She power-lifted. She rode long distances on her bike, sometimes 200 kilometres over a weekend.
Schmidt did all of this with bad arthritis in both knees and a shoulder. At fifty-one, she was referred to an orthopaedic surgeon at Foothills Medical Centre who told her she was too young for joint replacements. She tried injections of cortisone and hyaluronic acid to ease the pain. She walked eight, nine, ten kilometres per day to keep up the strength in her legs. (“Motion is lotion,” doctors say.) Eventually, she had to sell her beloved Audi TT Roadster—the two-seater standard-shift convertible she drove even in winter with the top down and the heat on bust—because stomping on the clutch had become too much.
“I did everything,” she says, “but slowly the things I really enjoyed began to drop off.”
When she was fifty-eight, it was time for Schmidt to see a surgeon again. Her family doctor referred her to a central-intake orthopaedic clinic, and eighteen months later, she saw a new surgeon. He told her she was a candidate for new knees, and she received a letter saying she would be booked for surgery. She had no idea how long the wait would be.
As the months passed and her pain and limitations worsened, she began looking at private options. To get her knees done in Arizona would cost her around $70,000 (US), including travel and accommodation. She could get the surgery in Mexico for less than half that but was worried about a language barrier. She explored all kinds of tips from friends.
“It’s amazing how many people crawl out of the woodwork to tell you they’ve done it privately,” she says.
In early 2023, seven months after her appointment, she learned a miscommunication at the surgeon’s office in Calgary had meant she’d never made it to the wait list in the first place. She was reassured again that she would be booked for surgery. Again, she held out hope that her phone might ring with a date. Months passed and she heard nothing.
Eventually, she stumbled on John Antoniou, a surgeon who works at a private surgical centre in Westmount, a tony area of Montreal. He could do both knees for just over $32,000. Additional costs, including travel, a hotel stay, and medication, would be around $8,000. She found this option appealing: it was more affordable than getting the surgery done in the US.
After a virtual appointment in January 2024, she was offered a surgery date for later that month. Though she’d been waiting years, not even she could get everything in place quite that quickly—she lives on her own, and one of her daughters, a nurse, needed to rearrange her work schedule to help with the recovery. She deferred the surgery by a few weeks, and soon mother and daughter left for Montreal and found the place where Schmidt’s operation would take place: Westmount Square, a slate-grey office and residential complex overtop a mall with a handful of painstakingly curated boutiques: a florist, kitchenware, a spa. The stone floor glistened under calm lighting, and a coffered ceiling graced the food court.
On Tuesday, February 20, she walked through the glass doors of Centre de Chirurgie, changed into a gown, and was put to sleep. Four hours later, she woke up and was wheeled into the mall elevators and down to the floor below for a post-op X-ray. She spent two nights with the clinic and then moved to a hotel. By Sunday, she was home. After years of feeling hopeless and depressed, she was finally on the road to recovery.
“The surgery was spectacular,” Schmidt says. “On the flight back, the WestJet gal told me business class in almost every flight is full of people going for surgery. I would do it again in a second.”
Talk about excusing oneself from the public health queue can make Canadians cagey. A 2019 poll found that more than 70 percent of us see universal health care as an important source of pride. Under the Canada Health Act, Ottawa transfers money to the provinces and territories, and each region manages its own health care insurance plan. Clinics are prohibited from charging patients for insured services like medically necessary lab tests, diagnostic imaging, and treatment by a family doctor or specialist. But provinces are otherwise free to determine what they will or won’t cover.
That means some patients end up paying for part of their care. If I break my ankle in my home province, where I have health care insurance, I won’t have to pay for my visit to the emergency department, my X-rays, or my surgery, but I will have to pay for physiotherapy and pain medication. If I see my family doctor about a mole, I won’t pay for the visit and assessment; if the mole is not cancerous but I want it removed anyway, then I may have to pay for that. Canadians, on average, pay more than $1,000 annually for out-of-pocket health care costs, according to the Canadian Medical Association (CMA).
“They’re saying, ‘I’ve only got fifteen years left. Why am I waiting three years for a knee replacement?'”
In addition to getting that mole off, other surgeries I may want are not covered: breast augmentation and reduction, liposuction and body contouring—procedures that aren’t considered essential for good health. Someone with the desire and means to do so could go to a private clinic in their own city to have these done.
Then there are the loopholes, ones that make what Schmidt did not only entirely legal but increasingly popular—and lucrative for private companies. These are surgeries that would typically be covered under the provincial health care insurance plan—like a knee replacement. Canadians and residents with provincial health insurance can do one of two things. The first option is to do what Schmidt did and travel to another province and pay out of pocket. The Canada Health Act does not forbid public surgeons in one province from working on patients who hold health insurance in another. (However, some argue that any privatization is a violation of the act.)
One of the biggest players in the private surgery market nationally is Clearpoint Health Network, which operates its Surgical Solutions Network—SSN—across eight private surgical suites in Canada: one in New Westminster, one in Vancouver, two in Calgary, and one each in Winnipeg, Etobicoke, Laval, and Brossard. SSN’s website advertises the chance to get “immediate, self-funded care” without the risk of “getting procedures done in foreign countries.”
The second option, at least in some parts of Canada, is to find a surgeon in your home province who has opted out of the public insurance plan altogether; an Alberta surgeon who has left the public system can legally treat an Alberta patient in a private facility in the province. In Quebec, opting out is not only allowed but appears to be increasingly attractive: 775 of Quebec’s 22,479 physicians worked exclusively in the private sector in 2024, a 70 percent increase since 2020, prompting provincial health minister Christian Dubé to introduce a bill forcing Quebec-trained physicians to remain in the public system for five years. Quebec is also the only province where a patient facing long wait times in the public system can choose surgery in a private facility and then be reimbursed by private insurance.
In principle, it all seems like a great deal. Maybe not one envisioned by the authors of the Canada Health Act in 1984, but if some people on a public wait list can step off it and access parallel private services, that should allow those still in the public queue to get closer to a surgery date, right?
Not necessarily. Critics will tell you that Canada has a finite number of health care workers, and any day a nurse or surgeon is working in the private system, they are not working in the public one. Private facilities also receive funding from the public system: provinces are increasingly contracting them to take some of their more straightforward surgical load—and paying handsomely for the service.
I want to introduce you to Eric Rogers. That’s a completely made-up name we’ve given a senior orthopaedic surgeon in a major Canadian city who performs private-pay joint replacements and who agreed to talk to me on the condition of anonymity.
Rogers started “dabbling” in private surgery only recently. Not too much, maybe a day every couple of months. That work is in addition to the five or so operating days per month he’s allotted in the public system.
There are a couple of great things about the gig. The first is that regardless of the setting or who’s footing the bill, when he replaces a joint, it generally eases a person’s suffering. His elderly patient from another province could barely walk and was told she’d need to wait three years for a knee replacement.
“You know their life is going to be better if you fix it,” Rogers says. “They’re saying, ‘I’ve only got fifteen years left. Why am I waiting three years for a knee replacement? Fuck it. I’ll cash in some bonds and pay for it.’ I would do the same thing.”
The second perk is that work in the private system is usually easier—and far more lucrative—than in the public system. In the private system, he sees healthy people booked for straight-ahead surgeries. He can knock off three joint replacements by midday, get paid four times what he’s paid in the public system, and still be home to walk the dog.
In the public system, his schedule is more unpredictable and the surgeries can be urgent, he says. “We’re not physicians because of money. But it is a part of it.”
That’s it for the pros. Then there’s the list of cons.
The first has to do with the doctor–patient relationship. Rogers says that patients in the private system often come with a certain level of entitlement. He tries to speak exactly the same way to a patient who is paying for the surgery as to a patient in the public system.
“[But] it’s a different vibe. They feel like they’re paying for it and want some guarantees. It doesn’t matter if you’re paying for it. The infection risk is still the same. There are still certain complications that go along with it. It doesn’t matter how good the surgery is; it’s going to happen.”
And in his experience, the private system is not set up well to deal with complications. For example, it’s possible to break a femur during a knee replacement. It’s rare, but if it happens, the patient needs an entirely different operation. The private facility where Rogers works doesn’t have the equipment for that procedure, so a broken femur means transferring the patient to the hospital, and the public system pays for that fix. Rogers thinks a lot of surgeons are cautious about entering the private system because they’re not comfortable with that level of intra-operative risk.
“Private medicine is coming. There’s no plan to stop it creeping in, and nobody seems to know the rules.”
Then there are the post-operative complications, and Rogers has been on both ends of those. He’s been the surgeon who does a two-week follow-up with a patient (by phone, when they’re back in their home province) only to learn they have an infection and he has to tell them to go to their local emergency department, where he knows they’ll likely face judgment.
“The culture is: treat them like they did something wrong,” Rogers says. “It’s not the patient’s fault. They’re just trying to advocate for themselves.”
He’s also been referred patients who’ve had complications following private surgeries. There was one who still wasn’t walking well six months after a hip replacement. His family doctor referred him to Rogers, who diagnosed the problem and told the patient it had been a surgical error. The patient went back to his out-of-province surgeon and demanded his money back—which went about as well as you might imagine.
And there’s more. People don’t necessarily get the surgery they need—which is often no surgery at all. “The number of consults I get from people who have no arthritis but want a knee replacement is shocking,” he says. “I wouldn’t do it. But somebody will.”
Rogers has no illusions about the effect the private system is having on the public. He’s working less in the public system because of his private work. His set operating-room time in the public system hasn’t changed, but in the past, when extra OR time became available, he would have picked up a few more cases on his public wait list. Now, he’s often using free time to do private surgeries. This pattern is particularly problematic when it comes to anesthesiologists. When too many of them opt to work private shifts, there aren’t enough to staff public surgeries—which leads to public procedures being delayed. Rogers is clear on what that means: private health care cannibalizes the public system.
You might wonder, as I did, why Rogers, who benefits from the private system, didn’t hold back when speaking to a journalist about all of this.
“Private medicine is coming,” he says. “There’s no plan to stop it creeping in, and nobody seems to know the rules.”
Brian Day rejects the notion that the private system poaches resources from the public one. Day is an orthopaedic surgeon in BC. In 1996, he opened the Vancouver-based Cambie Surgery Centre, which is believed to be home to Canada’s first private operating rooms.
In 2009, a year after he completed his tenure as president of the CMA, Day and his clinic took the BC government to court to argue that patients should be allowed to use private insurance to pay for surgery in private facilities like his—at least when public wait times are too long. The court ruled against him, and his subsequent appeals in 2022 and 2023 were dismissed. To him, private medicine is a vital part of the health care ecosystem in Canada, because it provides patients with choice. He believes the private system keeps health care workers in Canada—workers who might otherwise be tempted to leave.
“This may shock you,” Day says, “but we have about a hundred doctors [who work at] our clinic; twenty-three of them have said they would not be in Canada if it were not for the extra operating-room time that our facility offers them.”
Almost thirty years after starting Cambie, Day no longer operates in the public system at all. On any given day, he will see private patients from Alberta, while his colleagues in Alberta work on private patients from BC, doing procedures patients can’t pay to have done in their own province.
We have little information on how much money facilities are making, or the number of complications incurred, provincially or nationally.
And demand is rising. Day estimates he sees 30 percent more Albertans at his clinic now compared to a few years ago. But good luck trying to corroborate those numbers. The CMA doesn’t track private surgery in Canada. The College of Physicians and Surgeons of Alberta couldn’t tell me how many surgeons in the province participate in private-pay surgery. A spokesperson for the Canadian Institute for Health Information couldn’t even think of where to send me.
The best lead on numbers I could find was Rebecca Graff-McRae, a research manager at Parkland Institute, a non-partisan (though left-of-centre) research institute housed at the University of Alberta in Edmonton. Her group has done work on the adjacent issue of contracted surgeries: these are procedures done in private facilities but paid for by the public system. Their research provides a window into Canada’s increasing reliance on private facilities.
Over the past decade, provinces have increasingly looked to private clinics to deal with Canada’s very real problem with wait times. (According to the Commonwealth Fund, Canada’s health care system has consistently ranked at the bottom for timeliness and access to care compared to other high-income countries.) Contracting out surgeries has become a major health system strategy in Alberta, where both Graff-McRae and Schmidt live.
In 2019, the newly elected United Conservative Party government announced its Alberta Surgical Initiative, or ASI. Some of the more straightforward, lower-risk operations—cataracts and joint replacements in otherwise healthy people, for example—would be done in private facilities, at no cost to the patient.
Hypothetically, that would free up hospitals to look after the higher-acuity cases with greater likelihood for complications. A sum of $400 million would be spent to outsource surgeries to private, for-profit facilities, with the goal of having 30 percent of Alberta surgeries done outside hospitals.
The Parkland Institute report found that from 2019 to 2022, the number of surgeries offloaded to private clinics increased by almost 50 percent, and payments to private clinics from the public purse climbed by 61 percent. If you looked at these numbers alone, you might assume that the ASI is going according to plan, but in some cases, wait times still aren’t improving. Parkland Institute’s analysis showed that wait times overall for cataract surgery under the ASI improved but wait times for hip and knee replacements actually worsened: prior to the ASI, 64 and 62 percent of hip- and knee-replacement patients respectively received surgery within nationally recommended wait times; in 2022, those numbers had fallen to just 38 and 27 percent.
Graff-McRae’s group has had to cobble all these numbers together from a variety of sources.
“It’s basically a combination of anything publicly reported,” she says. “Sometimes this is through ‘boasting’ press releases. Like, ‘Wow, we tripled the number of contracted-out surgical procedures.’ Sometimes it’s newspaper reports. Alberta Health Services sometimes includes things in their annual report. Then you’re dealing with the [Freedom of Information and Protection of Privacy Act], which is highly constrained, particularly in Alberta.” FOIP regulations in Alberta are extremely conservative about protecting any information that could be perceived as being of third-party interest.
The Parkland Institute has little information on how much money facilities are making, or the number of complications incurred, provincially or nationally.
“We’re basically thirteen little fiefdoms [in Canada] that have different types of oversight and regulation and reporting and tracking,” says Graff-McRae. “As our premier is very happy to point out, provinces have complete jurisdiction over health care, and the feds’ only job is to write the cheque and shut up.”
When it comes to private-pay surgery, there is hardly any publicly available information at all. The picture that emerges is one of for-profit business interests stepping into a loophole in a forty-year-old piece of legislation, drawing away public resources with little accountability. How many private-pay surgeries are being done? Where? On whom? By whom? For what? How often are surgeries in the public system postponed because anesthesiologists have chosen to work in the private system on a particular day and there’s no one around to run the public list?
And what complications occur in the private-pay system? The case of television producer Micheline Charest was particularly horrific. In 2004, Charest received a facelift and breast augmentation at a private surgical clinic in Montreal and died several hours later; coroner Jacques Ramsay found that her breathing tube had been removed while she was still unconscious and that a lack of oxygen caused her heart to stop beating. It was a death that had to be reported, but what about the cases that aren’t immediately life threatening, such as infections?
How often are surgeries postponed because anesthesiologists have chosen to work in the private system on a particular day?
It all worries CMA president Joss Reimer. She doesn’t begrudge people—or providers—for choosing private surgery, but she wants everyone to understand the consequences for the system.
“When you’re working in a private centre,” she says, “there’s no overnight call; it’s simpler situations. I certainly don’t blame the health care providers who are feeling burnt out for wanting [simpler work]. But when we’re shutting down operating rooms because we don’t have the nurses, the physicians, the surgeons, the anesthetists to run them, that’s a huge problem for Canadians.” Simply put, while Canadians struggle for access to basic services, such as primary care, Reimer doesn’t want the private system benefiting off the public one.
Recently, a scandal has been brewing in Alberta over similar concerns. In February, the Globe and Mail reported on allegations that government officials pressured the provincial health authority’s chief executive officer to approve deals with private surgical facilities despite her concerns that the contracts were too costly. Athana Mentzelopoulos filed a wrongful dismissal suit, claiming she had been fired because she had launched a forensic audit into the system of awarding contracts.
As concerned as Graff-McRae is about the slow bleed of public medicine in Alberta, she does not want to see patients or health care providers vilified. “You have massive levels of burnout, of depression and anxiety, particularly among doctors and nurses,” she says. “There was no breathing room to come out of the pandemic and then say, ‘Oh, good, we survived this.’ We forget that these are human beings within a system.”
Graff-McRae did her PhD research in Belfast and, a few years ago, looked into post-Troubles divisions around the time of Brexit. When she moved back to the Prairies, she was initially told there was little need for a Northern Ireland expert in Alberta.
“But the more polarized our political system gets here,” she says, “the more parallels I find. I’ve learned that basic human needs can spiral into division and polarization really, really quickly.”
Polarization is obvious in the divide between the CMA and proponents of private-pay surgery. Medical research suggests these services end up being more expensive and lower quality, Reimer says. “But without the oversight and accountability, it’s hard to even measure.” Day, on the other hand, says, “It’s shocking that our CMA president would opine on stuff she knows nothing about.”
If you’re someone like Melanie Schmidt, a person in pain with the light of joy growing dimmer and dimmer, all of this can seem a little academic. Six months after we first spoke, and nine months after her surgery, I called her up to see how she was doing. I’d hoped to go for a walk with her, but winter’s ice and snow were keeping her pretty close to home, because her left knee was still giving her some trouble. Her right knee is great, though. Some days, she feels she could run on it.
“It’s moving along the way it should,” she told me. “But it’s non-linear.”
Schmidt is aware that queue jumping with private-pay surgery probably disadvantages those who can’t afford to do it. But she was not a person stepping over the homeless on her way to the opera. She was a single mom who worked for forty years and doesn’t have a pension.
“There is no safety net for me,” she says. “I have enough, but I have to watch it. I’ve paid taxes all my life, and this is $40,000 gone. I just feel a little bit abandoned. We’ve set up a system that begs for privatization.”
For now, she’ll continue to focus on her rehab and the possibility of getting back on her bike this coming summer.
“I can’t tell you what that means to me.”
