Skip to main content
The Globe and Mail
Support Quality Journalism.
The Globe and Mail
First Access to Latest
Investment News
Collection of curated
e-books and guides
Inform your decisions via
Globe Investor Tools
per week
for first 24 weeks

Enjoy unlimited digital access
Enjoy Unlimited Digital Access
Get full access to
Just $1.99 per week for the first 24 weeks
Just $1.99 per week for the first 24 weeks
var select={root:".js-sub-pencil",control:".js-sub-pencil-control",open:"o-sub-pencil--open",closed:"o-sub-pencil--closed"},dom={},allowExpand=!0;function pencilInit(o){var e=arguments.length>1&&void 0!==arguments[1]&&arguments[1];select.root=o,dom.root=document.querySelector(select.root),dom.root&&(dom.control=document.querySelector(select.control),dom.control.addEventListener("click",onToggleClicked),setPanelState(e),window.addEventListener("scroll",onWindowScroll),dom.root.removeAttribute("hidden"))}function isPanelOpen(){return dom.root.classList.contains(}function setPanelState(o){dom.root.classList[o?"add":"remove"](,dom.root.classList[o?"remove":"add"](select.closed),dom.control.setAttribute("aria-expanded",o)}function onToggleClicked(){var l=!isPanelOpen();setPanelState(l)}function onWindowScroll(){window.requestAnimationFrame(function() {var l=isPanelOpen(),n=0===(document.body.scrollTop||document.documentElement.scrollTop);n||l||!allowExpand?n&&l&&(allowExpand=!0,setPanelState(!1)):(allowExpand=!1,setPanelState(!0))});}pencilInit(".js-sub-pencil",!1); // via darwin-bg var slideIndex = 0; carousel(); function carousel() { var i; var x = document.getElementsByClassName("subs_valueprop"); for (i = 0; i < x.length; i++) { x[i].style.display = "none"; } slideIndex++; if (slideIndex> x.length) { slideIndex = 1; } x[slideIndex - 1].style.display = "block"; setTimeout(carousel, 2500); } //


The news is full of stories about overcrowded hospital emergency rooms and people waiting a long time for medical treatments. Why don't we charge a reasonable user fee for medical services? That should reduce the number of people going to doctors needlessly while also raising money for our cash-strapped health-care system. It seems like a win-win.


Story continues below advertisement

You're not the first person to put forward that proposal and you won't likely be the last. However, a large body of scientific evidence suggests that user fees are a bad idea when it comes to health care.

It's true that charging a fee – even a small one – results in fewer people seeking medical care. But it reduces both unnecessary and necessary care – especially among lower-income individuals.

That's a problem because putting off necessary care can lead to worse health down the road. Think of the people who forgo a cancer-screening test because they don't want to pay a fee – or can't afford it.

It's also unrealistic to expect the general public to know what is, or is not, a serious health problem needing prompt attention, says Dr. Michael Schull, an emergency department physician at Sunnybrook Health Sciences Centre in Toronto.

He points out that a pain in the chest might be caused by common indigestion or a potentially deadly heart attack. Sometimes, it takes a visit to a hospital emergency department to make that determination.

And even patients who come with minor complaints, such as a cough or cold or sprained ankle, "doesn't actually affect the wait times for other patients who are sicker," says Schull, who is also a scientist at the Institute for Clinical Evaluative Sciences.

That's because patients are assessed on arrival through a triage process in which those requiring immediate care are seen right away. Many emergency departments also have an additional system to channel patients into separate treatment paths based on the severity of their conditions. "They are in different streams and have virtually no influence on each other's wait time," he says.

Story continues below advertisement

In fact, a study co-authored by Schull found that people showing up with minor problems had only a negligible impact on others' care.

The study looked at more than four million patient visits at 110 emergency departments across Ontario. The results revealed that for each low-complexity patient who arrives, the remaining patients experience an increased length of stay of just 32 seconds on average, and an increase in time to be treated by a physician of 13 seconds.

Of course, there are very real concerns about certain wait times in Canada's health-care system. But those issues are complex and relate to serious cases that are not affected by some people going to emergency departments with minor ailments.

Schull says user fees for medical services would simply penalize vulnerable low-income individuals, who often have greater need of health-care services.

Dr. Danielle Martin, a family physician and vice-president at Women's College Hospital in Toronto, agrees with that assessment.

In her recently published book – Better Now: Six Big Ideas to Improve Health Care For All Canadians – she calls user fees "Health Care Zombies" because support for them doesn't seem to die despite ample evidence they don't achieve their desired results.

Story continues below advertisement

"When user fees prevent patients from seeking necessary care, people end up suffering complications that are much more expensive to treat," she says.

To make matters worse, they don't actually raise much money, once the administrative costs are taken into account.

"You need someone to collect the fee, someone to chase after the person who still owes the fee and someone to determine who should be exempt from the fee," Martin explains. "By the time you've put in place the army of bean counters, you're running a bureaucracy to pay for itself."

She points to a study that was done in 2010, when the Quebec provincial government was considering a $25 charge per medical visit. It would have been paid as a lump sum when people filed their end-of-year taxes, an approach designed to minimize administrative overhead. (The very poor were exempt.)

The study found that the potential revenue was small – representing less than 1 per cent of the $27-billion public health-care budget in Quebec.

"That shows if you actually want to raise money to pay for the health-care system, you'll need to charge pretty hefty user fees," Martin says.

Story continues below advertisement

Over all, a user fee "is a blame-the-patient approach that's based on the assumption people are abusing the health-care system," Schull says.

"I have been doing emergency medicine for 30 years and it's my experience that only a tiny minority of patients inappropriately seek care and that proportion has been getting smaller over time."

In most cases, "patients simply don't know what's wrong" with them or they can't get a timely appointment with a family physician. "I have no problem with these patients coming to my emerg," Schull says.

Paul Taylor is a Patient Navigation Advisor at Sunnybrook Health Sciences Centre. He is a former health editor of The Globe and Mail. You can find him on Twitter @epaultaylor and online at Sunnybrook's Your Health Matters.

Elsa Nega needs a bone marrow transplant to beat the leukemia that has struck the mother of two. But the registry of donors carries relatively few fellow Africans for her to find a compatible donor.
Report an error Editorial code of conduct
Due to technical reasons, we have temporarily removed commenting from our articles. We hope to have this fixed soon. Thank you for your patience. If you are looking to give feedback on our new site, please send it along to If you want to write a letter to the editor, please forward to

Welcome to The Globe and Mail’s comment community. This is a space where subscribers can engage with each other and Globe staff. Non-subscribers can read and sort comments but will not be able to engage with them in any way. Click here to subscribe.

If you would like to write a letter to the editor, please forward it to Readers can also interact with The Globe on Facebook and Twitter .

Welcome to The Globe and Mail’s comment community. This is a space where subscribers can engage with each other and Globe staff. Non-subscribers can read and sort comments but will not be able to engage with them in any way. Click here to subscribe.

If you would like to write a letter to the editor, please forward it to Readers can also interact with The Globe on Facebook and Twitter .

Welcome to The Globe and Mail’s comment community. This is a space where subscribers can engage with each other and Globe staff.

We aim to create a safe and valuable space for discussion and debate. That means:

  • Treat others as you wish to be treated
  • Criticize ideas, not people
  • Stay on topic
  • Avoid the use of toxic and offensive language
  • Flag bad behaviour

If you do not see your comment posted immediately, it is being reviewed by the moderation team and may appear shortly, generally within an hour.

We aim to have all comments reviewed in a timely manner.

Comments that violate our community guidelines will not be posted.

Read our community guidelines here

Discussion loading ...

To view this site properly, enable cookies in your browser. Read our privacy policy to learn more.
How to enable cookies