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Last week, Quebec began cracking down on doctors who charge "accessory fees" for goods and services like ultrasounds, colonoscopies, childhood vaccines and drops used in eye exams.

Meanwhile, Saskatchewan adopted a 2-for-1 plan for MRIs – allowing patients to pay out-of-pocket for magnetic resonance imaging scans and jump the queue, as long as the private clinic offering the procedure does a second scan, at no extra cost, for a patient on the public wait list. And let's not forget the continuing legal case in British Columbia, where Brian Day is trying to strike down the ban on the sale of private insurance for "medically necessary" care.

In other words, the ages-old debate about user fees is back with a vengeance. So, too, is the perennial angst about "two-tier" health care. The politics and history of the user-fee debate is dense and complex. The rhetoric about "extra-billing" is often suffocating. But, when you cut through all of that, the remaining question is pretty straightforward: What is covered by public funding and what is not?

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Unfortunately, the answer is not at all clear, especially around the periphery.

Under the terms of the Canada Health Act, no user fees are permitted for "medically necessary" health services, which are defined, vaguely, as hospital care and physician services. That does not mean user fees or extra billing are illegal; it means that, if they are charged, Ottawa can claw back from provincial health transfers an equivalent amount. But that clause of the law has not been enforced for more than a decade, because the previous Conservative government did not believe Ottawa had a role to play in determining how health care is delivered.

Last year, Quebec passed a law, Bill 20, that explicitly permitted user fees for a broad range of services, ranging from eye drops used for vision testing ($20-$300) through to insertion of intrauterine devices ($125-$200). Saskatchewan also announced with some fanfare, and no small amount of defiance, its 2-for-1 MRI scheme.

But there's a new sheriff in town and Liberal Health Minister Jane Philpott sent stern warnings to both provinces that monies collected from patients would be clawed back. Quebec Health Minister Gaétan Barrette huffed and puffed and then he blinked. Because the province stood to lose an estimated $83-million, he reversed course and quashed "accessory fees." But he also argued that Quebec is not subject to the Canada Health Act and vowed to sue the feds. All of this was done under a backdrop of failure to negotiate a new deal on health transfers to the provinces, making it more politically charged.

Saskatchewan, meanwhile, reached an agreement on health funding with Ottawa (as a number of other provinces and territories have done) and, at the same time, struck a side deal that allows it to continue its 2-for-1 experiment for another year to determine if it improves public access.

When medicare began 60 years ago, Ottawa promised funding to the provinces on the condition there would be no user fees, and vowed to compensate doctors fairly. When times get tough, however, governments try to rein in health spending and one of their main targets is physician fees. Physicians, in turn, start charging extra fees to compensate for losses. The Canada Health Act was a direct result of the extra-billing crisis in the early 1980s, and it is no coincidence that, as governments put the squeeze on docs, history is repeating itself.

Canada is one of the few Western countries that does not have user fees, extra billing or co-pays for hospital and physician services. However, it has some of the highest out-of-pocket charges in the world for other services, such as prescription drugs, home care and long-term care, so it's hardly a firm point of principle. There is no good evidence that extra billing discourages unnecessary procedures or raises extra money (the revenues are often offset by administrative costs), and there is evidence that it can discourage the poor from getting care. User fees are usually symbolic – to show patients are doing their part.

The real issue that needs to be tackled is not user fees – it's finding a way to determine what is "medically necessary" and covered by medicare and what is not. There is often no clear black-and-white answer to that question. User fees can help deal with some of those grey areas, to give patients choices they would otherwise not have. Universal health coverage does not mean that everything should be covered for everyone at all times. But how do we draw those lines in the sand, all the while ensuring equitable access for all? That's the public debate we really need to have.