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User Fees for Health Care: Why a Bad Idea Keeps Coming Back (Or, What's Health Got to Do With It?)

Published online by Cambridge University Press:  29 November 2010

Robert G. Evans
University of British Columbia
Morris L. Barer
University of British Columbia
Greg L. Stoddart
McMaster University


Calls for user fees in Canadian health care go back as far as the debate leading up to the establishment of Canada's national hospital insurance program in the late 1950s. Although the rationales have shifted around somewhat, some of the more consistent claims have been that user fees are necessary as a source of additional revenue for a badly underfunded system, that they are necessary to control runaway health care costs, and that they will deter unnecessary use (read abuse) of the system. But the real reasons that user fees have been such hardy survivors of the health policy wars, bear little relation to the claims commonly made for them. Their introduction in the financing of hospital or medical care in Canada would be to the benefit of a number of groups, and not just those one usually thinks of. We show that those who are healthy, and wealthy, would join health care providers (and possibly insurers) as net beneficiaries of a reintroduction of user fees for hospital and medical care in Canada. The flip side of this is that those who are indigent and ill will bear the brunt of the redistribution (for that is really what user fees are all about), and seniors feature prominently in those latter groups. Claims of other positive effects of user fees, such as reducing total health care costs, or improving appropriateness or accessibility, simply do not stand up in the face of the available evidence. In the final analysis, therefore, whether one is for or against user fees reduces to whether one is for or against the resulting income redistribution.


Les appels à l'utilisation de tickets modérateurs dans le système de soins de santé canadien remontent au débat qui a donné naissance au programme national d'assurance-hospitalisation vers la fin des années 1950. Même si les raisonnements soutenant une telle mesure se sont quelque peu modifiés depuis, on la justifie généralement en maintenant que les tickets modérateurs serviront de source additionnelle de revenu à un système mal en point quant à son financement, qu'ils sont nécessaires pour maîtriser les coûts de soins de santé galopants, et qu'ils décourageront une utilisation inutile (voire même abusive) du système. Toutefois, les vraies raisons qui ont permis aux tickets modérateurs de survivre à toutes les controverses touchant la politique en matière de santé partagent peu de liens avec ces justifications générales. Leur mise en application dans le financement des soins hospitaliers et médicaux au Canada avantagerait nombre de groupes, et non seulement ceux qui nous viennent habituellement à l'esprit. Cet article démontre que les personnes en santé et bien nanties bénéficieraient directement, et dans une même mesure que les prestateurs de soins de santé (et peut-être même les assureurs), d'une réintroduction de tickets modérateurs dans les soins hospitaliers et médicaux au Canada. Par contre, les personnes indigentes et malades devront porter le poids de la redistribution (car voilà les conséquences réelles des tickets modérateurs), et les personnes âgées font majoritairement partie de ce groupe. Les affirmations à l'effet que les tickets modérateurs auraient d'autres effets positifs, comme la réduction du coût des soins de santé ou l'amélioration de la pertinence ou de l'accessibilité des services, n'ont aucun fondement à la lumière des faits. En dernière analyse, par conséquent, une opinion en faveur ou non des tickets modérateurs revient à la question suivante: soutient-on ou non la redistribution du revenu qu'entraînerait leur mise en application?

Copyright © Canadian Association on Gerontology 1995

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