This article originally appeared in National Newswatch.
By Shawn Whatley, May 6, 2026
Federal Health Minister Marjorie Michel recently informed provinces they have one year to make nurse practitioners stop charging patients out-of-pocket for necessary care. A handful of nurse practitioners began charging patients, before COVID, “for the kinds of services doctors might provide.” Michel warned of cuts to healthcare transfer payments if provinces did not comply and cover the services of these nurse practitioners who provide primary care.
Media raised the alarm about enterprising nurses all the way back in 2018. Several clinics were charging patients for primary care services otherwise covered by provincial insurance plans. They had found a loophole and argued nurses weren’t doctors, so the Canada Health Act didn’t apply to them.
But even a handful of nurses charging patients out-of-pocket amounted to a festering boil on the face of single-payer healthcare. It was an affront to what royal commissioner Roy Romanow has referred to as, “This great redistributive program we call medicare.” Even though the Constitution Act places healthcare under provincial jurisdiction, the feds could not ignore it.
This whole scenario offers a case study in the layers of dysfunction within Canadian medicare. Let’s look at three inter-connected dysfunctions: priorities, economics, and governance.
Lobbies vs. Patients: upside-down priorities in medicare
Most people assume medicare focuses on patient care. In reality, patients’ needs are typically considered only after a crowd of other stakeholders have their say. Decision-makers prioritize stakeholders’ opinions before patients’ concerns. Patients’ inability to access care has little relevance.
A few of the priority stakeholders include the Canadian Medical Association, Canadian Nurses Association, Friends of Medicare, Canadian Doctors for Medicare, 13 provincial and territorial medical associations, provincial regulatory colleges (Ontario alone has 26 colleges regulating different health professions), unions such as UNIFOR, CUPE, and ONA, various societies of medicine, and a host of other voices including academia, medical colleges, media, and many others.
In addition, several stakeholder groups have hundreds of millions at their disposal. For example, UNIFOR has more than $100 million in annual revenue and is unafraid to use it in a political fight.
Attempts to solve this with patient-advisory committees or by including patient representatives as members of decision-making groups (so-called patient-informed committees) too often turns patients into tokens and not true partners in shaping healthcare policy.
Most patients love their nurse practitioners. Patients report finding care to be timely, patient-centered, with a focus on education and prevention. The Canadian Federation of Nurses’ Union reports that patients perceive their care to be as good as that received from a physician. No doubt, longer patient visits from salaried nurse practitioners who aren’t distracted by having to manage a clinical business add to patients’ positive impressions.
Assuming two equally affable clinicians, patients would want to maximize their clinical time with the most highly trained clinician they can access. But, given the choice of seeing an overworked, distracted family physician, who is trying to squeeze extra minutes out of her day, or an affable, less over-worked, and undistracted nurse practitioner, a patient would be equally (or more) happy to see the nurse. (It would take a highly informed patient to be able to point out the differences in care between the two; indeed, it would require the patient to be a physician himself.)
For the federal government to limit care by nurse practitioners, or to force that care into the dysfunctional single-payer system, places lobby group interests above patient satisfaction.
Healthcare economics: medicare doesn’t allow us to understand true costs
The nurse-practitioner case also raises the peculiar nature of so-called healthcare economics.
Nurses have long insisted that they offer basically the same services for lower costs than physicians. Role-substitution is the idea that nurse practitioners can replace GPs; registered practical nurses can replace registered nurses, and so on. Substitution apparently saves money and offers the same outcomes making it an irresistible idea in the zero-sum game of provincial spending.
The Ontario government applied this thinking in the creation of the Sudbury nurse-practitioner led clinic, in 2007. Upon review, in documents obtained by the author, it turned out that the clinic spent 3.7 times as much, per patient, compared with traditional fee-for-service family practice at that time.
All parties involved showed little interest in publishing the data, indeed the Ontario Medical Association (OMA) embargoed the study for a decade or longer. Doctors didn’t want to look like they were attacking nurses. (The OMA even refused to release the data several years after the study, when I asked for it in my role as a board director from 2010-2019.)
Eventually the data surfaced, long after anyone cared about it. Family practice has transformed in the last 20 years, and the spending gap may have closed. The point here is that role substitution does not always translate into savings, at least within the single-payer system.
Role-substitution cannot create savings by itself. We also need to address incentives, productivity, the nature of the work being done, ownership, management, and a host of other issues. These factors stand at a distance from policy, at the level of implementation, far from government itself.
In this, medicare assumes a peculiar view of so-called “costs”: Economists remind us that medicare only has spending, not costs. The amount government spends on a given service reflects the outcome of negotiations between government and labour. True costs reflect prices that are set by patient choice and demand, things medicare prohibits.
In the absence of prices and true costs, government ends up making decisions on ‘common knowledge.’ For example, every schoolboy knows that doctors earn more than nurses. Ergo, nurses doing doctors’ work will cost the province less. In a single-payer system that makes the knowledge of actual costs impossible, we make policy decisions on potentially false assumptions and bias.
Allowing nurse practitioners to operate outside the single-payer system, with real demand signals from patients, would risk introducing a knowledge of actual ‘costs’ into a system that lives comfortably within its own pseudo-economic assumptions. In other words, if nurse practitioners were allowed to operate outside the system it might reveal the dysfunction of healthcare economics in Canada and the way policy decisions have more to do with maintaining the status quo governance arrangements than with patient care itself.
Medicare’s broken governance: The iron triangle
Medicare exists as a version of corporatism. It is an iron triangle between government, labour, and organized medicine. Change can only happen if it does not compromise the relative standing of each member in the triangle.
On the surface the 3-party, iron-triangle structure simplifies healthcare governance. It restricts the number of parties required to approve structural change. But it ends up harming each party in the long run.
Governments suffer first from the monopolistic bargaining power of the other parties in the triangle. But provinces tilt the balance in their favour by diluting the power of the other parties with things such as role substitution, facility transition, or regulatory amendments: e.g., medical duties are shifted to nurses, nursing duties to registered practical nurses, hospital services moved into independent health facilities, or legislation is changed to reassign the status of particular services (e.g., as covered, uncovered, restricted, and so on).
No matter which party in the iron triangle proposes change, it is always couched in terms of cost reduction, efficiency, or improving patient access. In the absence of prices and costs, ‘common knowledge’ about nurses costing less for providing the ‘same care’ become accepted dogma. As long as nurse practitioner clinics do not compromise doctors’ negotiating positions, doctors will remain silent, for example, by embargoing the Sudbury clinic data. The iron triangle remains intact: nurses get their publicly funded clinic, government gets positive political messaging about expanded care, and doctors are no worse off in the process. As we have discussed, these pseudo-economic arguments are about the political balance of spending, resource allocation, or power, not economics.
In all of this, the status quo is maintained and patients continue to wait.
In the end, the medical moral high ground remains the same: how to get the best possible care for patients, in the right place at the right time. But Canada is now world famous for wait times. Despite over 30 countries offering universal care, Canadians still seem to think that we are the only country that offers care to every citizen.
We cannot brag anymore about offering equal care regardless of ability to pay. We have known for 30 years that patients living in wealthy neighborhoods receive more care and wait less for it: 23% more services and 45% less waiting, in one study. Dozens of newer studies say the same thing.
The federal government’s fight with nurse practitioners will make friends and advocates of Medicare feel better by defending the status quo. But it won’t help patients. Even the handful of patients the nurse practitioners were treating will now be forced to join the 6.5 million other Canadians who, dependent exclusively on the ever-limited resources of government to pay their way, cannot access primary care.
Shawn Whatley is a physician, past president of the Ontario Medical Association, and a senior fellow at the Macdonald-Laurier Institute.
