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Brian Day performed two knee surgeries and one shoulder operation at his private Vancouver clinic yesterday; there's no shortage of people willing to pay for timely access to medical care.

And on no other day did it seem more fitting: The Supreme Court of Canada's ruling that government bans on private health insurance have increased the risk to the life and health of Canadians is a sentiment the orthopedic surgeon shares.

The ruling struck down Quebec laws that guarantee a virtual monopoly on medically necessary treatment in the public health system. But Dr. Day, medical director of Cambie Surgery Centre, sees it as essentially legalizing private health care across Canada.

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"I think that this is much bigger than private clinics and private hospitals," he said in a telephone interview from Vancouver yesterday. "We may end up with a mix of public and private delivery like they have in some European countries."

It's not as if private health care hasn't already made a splash in Canada.

Dr. Day operates in a province that has 14 private clinics. An estimated 50,000 British Columbians chose to expedite their surgery by paying a facility fee last year. And he works in a country that has 39 private diagnostic MRI machines, CT scanners and PET scanners, the first of which opened in Montreal in 1992.

According to the Canadian Institute for Health Information, 30 per cent, or $39.2-billion, out of $130.3-billion of this country's health care was paid for out of pocket last year, mostly by patients or their insurers.

And they do so to get treatment quicker, something, Dr. Nicolas Duval of the Duval Orthopedic Clinic facility in Laval, Que., knows well.

His 3½-year-old practice is essentially a hospital on two sites. In Montreal, he operates in a private cosmetic-surgery facility and, in Laval, patients recover in a convalescent centre. The price for a hip replacement, hospital stay and rehabilitation is $12,000 to $18,000.

Half of the patients are from Quebec; the rest are from Ontario, British Columbia, Alberta and Saskatchewan.

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"I'm close to the limit of what I can [physically]do in a year," said Dr. Duval, an orthopedic surgeon who performs 400 operations a year. "I may have to look for a colleague to join me."

Dr. Duval can perform private operations in Quebec because he opted out of the public health-care system. So while his counterparts often get only one day a week to operate on patients in public hospitals, he does surgery three to four days a week.

But the orthopedic surgeon is busy because some of the longest waits Canadians face involve hip and knee replacements, with many languishing on long queues, in some cases a year or more.

And that is where this whole story began, ending in the Supreme Court of Canada.

George Zeliotis was a Montreal patient who waited nearly a year for hip replacement surgery in the mid-1990s. His lawyer argued that the waiting lists in the publicly funded system are so long they violate the Charter of Rights guarantee to life, liberty and security of the person. Some seven years later, the Supreme Court agreed.

"I see people like Mr. Zeliotis every day," said Dr. Albert Schumacher, Canadian Medical Association president.

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"Some [patients]can afford to get small things done, like a CT scan or MRI but can't afford a total joint replacement in the U.S. for $20,000 or $30,000."

Although some call this decision the end of medicare, Dr. Schumacher disagrees.

"I don't think this is going to cause medicare to fall apart," he said. "My fellow doctors, we're going to continue to do the best under the principles of the Canada Health Act. No one who needs care is going to be turned away as a result of this."

But Normand Laberge, chief executive officer of the Canadian Association of Radiologists, likened the ruling to an "atomic bomb on the health-care system."

He said some private clinics might open, which will propel governments to launch legal action. And he predicted that frustrated patients, waiting in lengthy queues for medical care, would commence their own lawsuits.

"What it is doing is sending a very strong signal to governments to get their act together or else the health-care system is gone," Mr. Laberge said.

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Indeed, some worry that it may be going already.

While Maude Barlow, national chairwoman of the Council of Canadians, agrees that the long waits are unacceptable, she is concerned that the Supreme Court of Canada decision opens the door to large, U.S. health insurers to set up shop in Canada.

"The only way we maintain our exemption from health care under the North American free-trade agreement is if it's done in the not-for-profit sector by government or a government agency," Ms. Barlow said. "Once you have privatized, you cannot say to an American chain that you'll only allow Canadians."

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