Do parallel private systems actually worsen outcomes? The data isn’t so clear

Public debate on healthcare reform in Canada is understandably charged. Access problems are real, clinicians are frustrated and patients are waiting too long for care. In this environment, professional bodies such as the Canadian Medical Association (CMA) play an influential role in shaping public understanding and policy direction. That influence carries a responsibility to represent evidence accurately and proportionately.In recent public communications, the president of the CMA, Dr. Margot Burnell, has asserted that “the evidence from around the world is clear: where a parallel private health system operates, both health outcomes and access to care are worse.” This is a strong and categorical claim. Having requested and reviewed the evidence the CMA cites in support of this position, I believe it is important—particularly for physicians and policymakers—to clarify what that evidence does, and does not, show.This is not an argument for an American-style system, nor a defence of unregulated privatization. It is an argument for evidentiary precision.The evidenceThe materials provided by the CMA span a wide range of contexts and concepts, including:Comparisons of private versus public insurance in the United StatesStudies of for-profit delivery of publicly funded services, largely from the U.S.Systematic reviews of private sector care in low- and middle-income countries (LMICs)OECD cross-national comparisons of health system performanceThe CMA’s own 2024 synthesis, Public and Private Health Care in Canada: What Does the Evidence Say?These sources examine distinct phenomena. Private insurance, private delivery, private financing and parallel systems are not interchangeable. Conflating them under a single conclusion risks overstating what the research can support.Access to careSeveral studies cited by the CMA show that greater reliance on private insurance and out-of-pocket payment is associated with increased cost-related barriers to care. This finding is well established and should inform policy design.However, OECD data also demonstrate that multiple countries with mixed public–private systems—such as Germany, the Netherlands and France—achieve faster access to specialists and diagnostics than Canada. The evidence therefore supports a conditional risk of inequity, not a universal worsening of access wherever private care exists.Notably, the CMA’s own 2024 report repeatedly characterizes the access evidence as “mixed,” “context-dependent,” and in some cases “dated.”Health outcomesThe assertion that parallel private systems worsen health outcomes is less well supported.The systematic review of LMICs identifies quality and outcome concerns in fragmented, weakly regulated private markets. But the authors explicitly caution against extrapolating these findings to high-income countries with strong regulatory frameworks.OECD comparisons do not demonstrate consistent deterioration in mortality, morbidity or patient-reported outcomes in systems that include parallel private components. Nor does the CMA’s own synthesis conclude that outcomes are inherently worse in mixed systems. Instead, it emphasizes evidence gaps and the need for further Canadian-specific research.CMA’s own reportThe CMA’s 2024 report adopts a notably more careful tone than its public statements. Its conclusions focus on:Increased system costs associated with certain forms of private financingRisks to equity under poorly designed policiesThe importance of regulation, safeguards and system designThese are important considerations. But they are not equivalent to a finding that parallel private systems inevitably worsen both access and outcomes.Canada’s healthcare challenges are real and urgent. Addressing them will require open, evidence-informed discussion of all policy options—including which design features protect equity and quality, and which do not.When evidence is presented as settled and categorical where it is in fact conditional and contested, the quality of public debate suffers. Physicians, policymakers, and patients deserve clarity about what the research actually demonstrates, where uncertainties remain, and how conclusions are being drawn.Invoking evidence carries weight. Using it precisely is not a matter of ideology, but of professional responsibility.Dr. Jeffrey Brock is a Montreal physician and president of MedExtra, a provider of corporate health solutions.

Do parallel private systems actually worsen outcomes? The data isn’t so clear

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