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Two-tier health care is a form of national health care system that is used in most developed countries. It is a system in which a guaranteed public health care system exists, but where a private system operates in parallel competition. The private system has the benefit of shorter waiting times and more luxurious treatment, but costs far more than the public one for patients. Thus there are two tiers of health care, one for the public at large and another for those who can afford to pay for better care. Some advanced countries in the world have two-tier primary health care to varying degrees. In Canada, the Healthcare Act prohibits private for profit healthcare, but in Quebec, where it is officially illegal, it is in practice.

The term is often used in Canadian health discussions where the debate over two-tier health care has long been central. Moving to a two-tier system is supported by conservative think tanks such as the Fraser Institute. The potential for profits has created a strong lobby in the health industry, which is today confined to the periphery. As it stands now, Canada does not have a parallel system: free market health care for Canadians is almost wholly banned in fields covered by the national health system; some private hospitals which were operating when the national health care plan was instituted (for example, the Shouldice Hernia Centre in Thornhill, Ontario) continue to operate, although they may not bill additional charges for medical procedures (the Shouldice Hospital does, however, make mandatory additional room charges not covered by public health insurance which place it in the upper tier of a two-tier system – welfare recipients, for example, cannot be referred there). Clinics are usually private operations, but may not bill additional charges. Private health care may also be supplied in uncovered fields and to foreigners.

The proponents of two-tier system argue that it would introduce more flexibility into the system, reducing wait lists and that competition from the private sector would make the public one more efficient. However, in the case of Quebec this has shown not to be true. Furthermore opponents argue that a two-tier system would tend to draw many of the best doctors out of the public system, reducing the overall quality of care. Some, e.g. Richard Gwyn at the Toronto Star, also believe that a two tier approach with private care would be more expensive^[1] than single tier health care. The Canada Health Act is also committed not only to access to health care to all, but access to the best health care available for all. Many consider access to the best possible care an important right of all citizens. Competition from the private sector would also almost certainly drive up the wages of doctors and other medical professionals in the entire system. Those who support a wholly public system also say that there is some concern that if Canada would allow a parallel private system within the country, it would be opening itself up to trade sanctions under some of its trading agreements^[2].

The majority of Canadian people are largely opposed to the notion of two-tier health care, and no major political parties currently support the notion. In the 2000 federal election, the Liberals and the New Democratic Party accused the Canadian Alliance of secretly supporting it, leading to a famous incident when in the leaders debate Canadian Alliance leader Stockwell Day began waving a hand written "No Two-Tier Medicine" sign. Some argue that Canada already does have a two-tier health care system as the wealthy can go to the United States for treatment, and quite a few Canadians do each year. Some provinces have increasingly allowed the private sector to provide medical services for a fee. Quebec, due a court ruling against against the public system, has especially allowed the for-profit private sector to provide enhanced medical services to the public for a fee.

The phrase is also used in other countries and among health care experts. It is a phrase usually entering into any discussion of health services in the Republic of Ireland, which has a particularly high rate of private health insurance take-up, and treatment of private patients in public hospitals (thus denying beds and facilities to those on the lower tier of health service). In Europe, it often has the same meaning as in the Canadian context, but is used there to describe the status quo. However, sometimes it has a somewhat different meaning relating to the expansion of private sector involvement through voucher programs or other initiatives.

1. ^ The Toronto Star
2. ^ The Council of Canadians

• Canadian and American health care systems compared