Smith has kept doctors and dollars in Alberta – but it doesn’t change access to care 

Premier Danielle Smith’s announcement permitting physicians to work in both the public and private systems has been widely interpreted as a major step toward a two-tier health-care model. The public debate has focused on the idea that Alberta is opening the door to private care in a way that fundamentally changes how health care is delivered.

In reality, however, Smith’s reform hasn’t created private access; it has formalized an activity that has been occurring for years, redirected it into Alberta’s hospitals and removed a structural barrier that could potentially contribute to the movement of surgeons out of the public system. It’s a calculated and pragmatic shift – but a defensive one, not a transformational one.

Albertans already pay for private care through multiple channels. Private surgical centres – such as Clearpoint Health Network – perform hip, knee and spine procedures for patients who pay out of pocket. Private diagnostic clinics provide MRI and CT scans for those willing to pay to bypass long waits. There is also evidence that many Canadians travel outside their home province or outside Canada for treatment when they can’t access surgery in a reasonable time. A Fraser Institute analysis estimated that more than 63,459 Canadians received non-emergency medical treatment abroad in 2016. The figures are national – and we don’t know how many of those patients originated specifically from Alberta – it is reasonable to assume that Albertans form part of that cohort. The two-tier structure is not new; the reform merely restructures where it can be received, keeping those dollars in the public system rather than elsewhere.

The same logic applies to hospitals. By extending surgical hours to accommodate private-pay cases, Smith keeps private medical spending inside Alberta’s hospitals and economy. Allowing private procedures during off-hours and weekends enables hospitals to generate revenue that would otherwise flow to private clinics in Alberta, other provinces or other countries entirely. According to the province, this change will expand total surgical volume by using more hours of the week for care delivery – but only for those who pay privately.

The most consequential – and most misunderstood – aspect of the reform is the structural change that allows surgeons to work in both sectors. For many, this signals privatization. In practice, Smith is taking steps to prevent a loss of surgical capacity in the public system, not to create a new two-tier reality. The reform addresses two critical pressures: high physician burnout rates and the financial and structural strain that make full-time public practice difficult to sustain.

Physicians in Alberta – as in the rest of Canada – have long faced workload and financial pressures under the public system. The 2025 Canadian Medical Association (CMA) National Physician Health Survey reports that 46 per cent of physicians nationwide experience high levels of burnout, and 37 per cent plan to reduce their clinical hours in the next two years. At the same time, physicians report a growing unpaid administrative workload: 64 per cent say they regularly spend time on electronic medical records and billing outside regular hours, averaging an additional 10.4 unpaid hours per week.

Before the reform, surgeons coping with these pressures had three realistic options – reduce their public operating time, retire early or leave the public system entirely to work privately, where fewer hours can generate comparable income.

Smith’s reform introduces a fourth option. Under dual practice, a surgeon who reduces public hours due to burnout can remain available in the public system – even if for fewer hours – and supplement earnings through private work. The trade-off, however, is a reduction in public surgeries.

And there are several other unresolved questions.

First, the eligibility of procedures is unclear. Smith indicates that the dual practice model will apply to elective surgeries, but that term includes a vast category of medically necessary procedures that are not optional or urgent such as joint replacements, spinal decompression, advanced hernia repair or cancer-related reconstruction. No list has been released. If the scope is broad, public demand, hospital revenue and surgeon interest could be high; if it is narrow, uptake may be modest. Whether this list is determined clinically, politically or economically will determine the scale of the reform.

Second, the work requirement remains ambiguous. The legislation states that surgeons will have to complete a defined volume of publicly funded procedures before accepting private-pay cases, but it does not say whether this refers to a minimum number of surgeries, hours or some other quota. Before the reform, surgeons dealing with burnout could already reduce their public operating room (OR) time without losing licensure – the consequence was financial, not regulatory. Without clarity on what the defined volume will mean, it’s impossible to know whether surgeons will retain that flexibility or whether they will effectively be required to maintain a full public caseload before performing private work.

The opposite problem is also possible: if the volume is set too low, surgeons may end up reducing their public OR time even further while increasing their private work, weakening the public system.

In other countries where dual practice is entrenched, such as the United Kingdom, Ireland, Italy and Austria, doctors generally do private work only once their contracted public sessions are fulfilled; some systems cap the proportion of hospital beds or activity devoted to private patients to prevent crowding out public care. These examples suggest that dual practice can be made workable, but only when limits on hours, workload and private volume are clearly defined and enforced.

The reform also becomes less exciting when we examine what it doesn’t change. Wait lists for surgery in Canada are not driven by a shortage of ORs, but by a shortage of staff to run them. National labour data show that 48.5 per cent of all health-occupation vacancies remain unfilled for 90 days or longer – including many essential to OR function. At the same time, shortages of anesthesiologists have resulted in postponed elective surgeries and, in some jurisdictions, temporary suspension of surgical and obstetrical services. None of these constraints are addressed by dual practice. The reform doesn’t increase the clinical workforce, expand public operating hours or accelerate diagnostics. In short, it does not change the structural causes of wait times. For Albertans who cannot or will not pay privately, the experience of accessing the public system is unlikely to improve.

Fairness also remains unresolved. Albertans pay taxes for a universal system that guarantees medically necessary care but the new policy does not change the fact that those who cannot pay must continue to wait. And for those who can pay, it does not alter the reality that they are paying twice: once through taxes to fund a service they are not receiving, and again out of pocket for the care they need.

In time, Alberta’s model may offer useful insight into whether a province can strengthen its public system by formally incorporating private activity rather than resisting it. The long-term impact will depend not simply on the presence of private surgery, but on how dual practice is regulated, how surgeon workload is structured and whether revenue generated through private procedures is directly reinvested into improving public access.

For now, the reform remains structurally significant but clinically neutral: it changes how the system operates, not the experience of patients who rely on it.