This week, the provincial government in Ontario announced that it was expanding the number of private clinics providing medical services.

Right now, Ontario has about 900 such clinics, and they mostly offer medical imaging and cataract surgeries. Sylvia Jones, the province’s health minister, said this week that the government was expanding its program to include hip and knee replacements.

The province is being careful not to violate the Canada Health Act by requiring people to pay for medically necessary procedures. That would jeopardize the 20 billion Canadian dollars the province will receive this year from the federal government for health care. While the clinics will be privately operated, their procedures will be covered under the provincial health care plan as if they had been performed in public hospitals.

Ms. Jones said that the expansion would allow more such procedures to be performed and that doing so would cut wait times for patients. Her critics say it will further undermine the public system, that it may actually increase wait times and that it is a step toward full privatization of health care.

The government’s announcement came at about the same time as the release of a study from the C.D. Howe Institute that does not take a side in the debate but tallies up the level of private health care already in place in Canadian provinces.

Like everything in Canadian health care, the level of privatization varies by province. But the very short version of the paper is that the level is already much higher than most people might expect and that some of it is entrenched.

Katherine Fierlbeck, the author of the report and a professor of political science at Dalhousie University in Halifax, told me that when you add up all the major services provided privately, including drugs, dentistry, physiotherapy and optometry, “it’s a heck of a lot of health care — about 30 percent — that we have no problem, for the most part, with it being in the private sector.”

On top of that, private entities, both for-profit and nonprofit, have long provided medical testing, supplied nurses for home care or to cover hospital staff shortages, built new hospitals in partnerships with governments, and operated costly equipment like M.R.I. machines in similar arrangements. In Quebec, 642 doctors now work outside the public system, which has 22,981 physicians.

Professor Fierlbeck, who studies Canada’s health care systems, said that she had noticed something of a shift in the political dynamics surrounding public health care. In the past, she said, talk of privatizing health care or making patients, or private insurers, pay for procedures covered by the provinces was politically toxic.

“In my lifetime, and especially in the past number of decades, Canadians have had a real visceral fear of private health care, largely because of proximity to the U.S. and all the horror stories coming out of that,” she said. “That’s why you get this knee-jerk reaction to private health care. Things are sold politically more easily when they’re black and white. When you say there’s a lot of gray out there, it’s harder to grab the public imagination.”

But Professor Fierlbeck said that factors like a severe lack of family physicians in many provinces, long wait times for some surgeries and in emergency rooms, and hospital closings because of staff shortages had created “a certain form of moral distress” among many Canadians.

Those people “still support public health care in principle,” she said, but if a private clinic could see their ailing child before the public system could, many of them would not hesitate to choose that option.

Professor Fierlbeck said that she was testing some assumptions about private health care in other research. But she offered a note of caution to provinces like Ontario that are moving more treatments and procedures out of hospitals and into privately owned clinics.

To date, most such clinics have been owned by groups of physicians, and they are relatively small businesses. But Professor Fierlbeck predicts that as the clinic business grows, large health care companies based in the United States will take a keen interest in the Canadian market.

“Now we’ve got these small independent clinics that are set up by local people,” she said. “They don’t have that much political clout, and they’re not interested in behaving aggressively. But if you open the door and allow these huge corporations to come in from the States, then they are going to act aggressively, the way that pharmaceutical companies act aggressively, and you’ll sort of have to fend off interests who really want to expand the parameters of private business with constant lobbying or lawsuits.”


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