Imagine you drive schoolchildren to class and home every day in your safe, clean bus. For years, public funding for school transportation has not kept up with needs. More students have moved to your province; more of them need rides. The buses have become overcrowded; students stand in the aisles; your heart aches every time you leave a child at the side of the road because the bus is too full.
The solution seems clear: maintain the buses, hire more drivers, ferry students safely to school and back.
Yet the government proposes something different: “Let’s allow bus drivers to run a private charter service for families who can pay.” Even the most dedicated drivers will be tempted to drive into affluent neighbourhoods for a quieter ride with fewer children.
For the rest of us, the same buses now have fewer drivers. The wait gets longer; the ride more crowded; the journey less safe.
Accessing health services under Alberta’s proposed dual health-care model isn’t much different.
Among the Government of Alberta’s provisions in Bill 11, the Health Statutes Amendment Act, 2025, is a dual practice model that would allow physicians to work simultaneously in public and private practice. Currently, this dual practice is restricted – and for good reason.
The government’s stated goals are reasonable: reduce surgical wait times, improve physician recruitment and retention and expand patient choice. But the evidence from Alberta’s own experience – and from jurisdictions worldwide – suggests that dual practice achieves the opposite.
Alberta’s health system is stressed, as are its providers and patients. The government has played a role in this through chronic underfunding, ongoing undermanagement and treatment of physicians so disrespectful that it encourages migration both away from generalist family practice and out of the province. Now the government is proposing to physicians a false choice between a stressed public system and expanded private care. Health-care providers can martyr themselves in the public system or leave their public duty of care and sustain themselves in private care.
A third option exists: adequately fund the public system we already have.
Premier Danielle Smith defends the bill by arguing that dual practice will allow surgeons to operate outside their regular hours – evenings and weekends – when operating rooms (ORs) would otherwise sit idle. This argument does not align with available evidence.
The Ernst & Young Performance Review of Alberta Health Services (2019) found that physical OR capacity was used at just 71 per cent in 2018-2019, with an additional 18,713 OR slots available during evenings and weekends. Surgical wait times in Alberta do not stem from a shortage of physical infrastructure. They stem from a shortage of funded staff.
A surgical bed is not merely a physical bed. It requires an anesthesiologist, OR nurses, unit clerks, post-operative nurses and cleaning and transport staff. The ORs exist. The teams to staff them do not – the funding isn’t there.
The buses aren’t broken – they’re parked. The drivers are ready. But rather than fuel the fleet, the government is offering to subsidize private charter services.
Adding a profit margin to a surgical procedure in a private facility and expecting it to cost taxpayers less than providing it publicly defies simple math. Evidence from across Canada confirms this.
In British Columbia, a 2011 study found that WorkSafeBC paid almost four times more ($3,222) for an expedited knee surgery in a private clinic than for a non-expedited surgery in a public hospital ($859) – with no improvement in return-to-work outcomes.
In Ontario, private clinics receive an overhead fee of $605 for single-cataract surgery and $1,015 for double-cataract surgery, compared to roughly $500 paid to non-profit hospitals for the same services.
In Alberta itself, the Parkland Institute’s 2025 report Operation Profit documents the trajectory of the Alberta Surgical Initiative. Since the ASI began, public payments to private surgical facilities have risen by 225 per cent. Private hip, knee and shoulder replacements cost more than double the same procedures in public hospitals.
Increased government spending becomes difficult to justify when neither care quality nor access improve.
Yet the budget to keep the current buses on the road has just shrunk. Tax money is paying for easier work, as well as for the car payments for private vehicles that the charter drivers use.
And what happens to the health-care workforce under dual practice? Operation Profit documents that Alberta’s chartered surgical facilities have drawn practitioners – particularly anesthesiologists and nurses – away from public hospitals through preferential scheduling and working conditions. Clinicians are a fixed resource. Private practice does not create new practitioners; it redistributes existing ones. Private surgical care requires selecting healthier patients with simpler problems. That leaves the increasingly understaffed public system with complex, high-risk patients. And that leaves physicians who want to provide universal care with more cases that are difficult, complex and accompanied by a high emotional burden.
Why would we incentivize a more lucrative, easier, simpler system that fails to serve all?
Even before the implementation of Bill 11, Alberta experienced an increase in privately funded simple procedures while median wait times for nine of 11 priority surgical procedures in public hospitals increased.
You cannot create more bus drivers by letting them moonlight for charter companies. You simply have the same drivers doing fewer public routes – and the children on those routes wait longer or are never picked up at all.
Successful dual systems require robust regulation, but Bill 11 has none. For instance, would you rather have health care in Germany or the United States? Both integrate public and private care, but Germany regulates it tightly to benefit the public, and everyone receives care, while the U.S. remains the global exemplar of inequity and unaffordability. And it is to our south that Premier Smith and her cabinet are looking. What they fail to mention are the rigid regulations that effective dual systems require:
- Ireland limits private surgeries to under 20 per cent of a surgeon’s clinical workload
- Spain pays public-only doctors 10-15 per cent more to discourage dual practice
- The Netherlands mandates basic private insurance for all citizens and provides comprehensive universal coverage.
Only where strict regulation and oversight exist can dual systems succeed. Not only is there no reason to move to a dual system, but in its current form, Bill 11 does not specify what safeguards would exist, if any. And without such regulation, potentially vulnerable populations – rural communities, the average citizen who cannot afford it and those without the ability to advocate for themselves – risk being further marginalized. And the evidence confirms that the public suffers alongside them.
A fundamental flaw in Bill 11 – and where legal challenges are anticipated, but likely to be too slow to guarantee reversal – is that dual practice models as proposed violate the Canada Health Act (CHA). Specifically, the foundational tenets of universality and accessibility are ignored. Section 12 of the CHA requires “reasonable access” to insured services without financial barriers. Enabling patients to pay out-of-pocket to bypass public waitlists for medically necessary surgeries compromises this requirement. Additionally, the workforce migration from public to private practice can exacerbate public wait times, as documented in Australia and the United Kingdom, further undermining “reasonable access.”
Section 10 requires all insured residents to receive services on uniform terms. Allowing physicians to bill privately for services covered by our public plan breaks this tenet. Two patients with identical conditions would access care on different timelines based on their ability to pay. Can we tell grandparents with arthritic pain that quality of life in their final years is not worth timely care simply because of the size of their wallet? Unamended, Bill 11 creates two classes of citizens within the health-care system.
Evidence-based alternatives to dual practice exist. They build on existing infrastructure rather than fragment it, and some of these we have had success with include:
- Single-entry waitlist systems that allocate surgical slots based on clinical need
- Surgical booking systems that maximize use of existing OR capacity
- Training more health-care professionals, especially family physicians with comprehensive practices, and necessary specialists
- Adequate funding for the staff to fill the operating rooms that already exist
These approaches have been shown to reduce wait times without the workforce drain, increased costs, or equity concerns that accompany privatization.
Remember the child at the top of this article watching the bus pull away? That child is an Alberta senior waiting 18 months for a hip replacement. That child is a rural mother driving two hours for a specialist appointment, and every patient whose care is delayed because we chose to fund charter services over public routes.
The buses exist. The drivers are willing. What’s missing is the political commitment to keep them running for everyone. The government has failed to support comprehensive family physicians effectively, and now it wants to legislate guaranteed failure for patients needing specialist care.
Albertans require sufficient access to the world-class care that is available currently. The consequences of an unregulated dual practice model – reduced access, inflated costs, workforce drain and likely violations of federal law – are both severe and, if the evidence is any guide, inevitable.
Public health care, paid for by the public and created by the public, should serve the public. Bill 11, as written, serves a different purpose. Our provincial government can – and must – do better.
