In Quebec, there is a deeply ingrained idea that certain goods and services are too important to be subject to market mechanisms. Healthcare is generally at the top of the list.
The intention is easy to understand. No one wants a sick person to be deprived of essential treatment simply because they cannot afford it. A serious illness can strike anyone without warning and lead to considerable expenses. Therefore, there are compelling reasons to pool this risk and guarantee access to care.
But from there, we often make a much more considerable intellectual leap: since health is too important to depend on the ability to pay, it should also be removed as much as possible from market mechanisms.
This is where things get complicated.
A price can be removed from an invoice. A hospital can be nationalized. Budgets and salaries can be administratively determined. Suppliers can be regulated, and the number of doctors can be planned.
But we cannot abolish scarcity, supply, demand, or opportunity costs.
Health is not exempt from the laws of economics simply because we would like it to be.
You can't negotiate with gravity.
The economy has its own laws.
They are obviously not physical laws in the strict sense. Human behavior is far more complex than a stone falling from a building. But the economic constraints they describe are very real.
We can ignore them. We cannot abolish their consequences.
You can perfectly well decide that the law of gravity doesn't apply to you and perform a swan dive from the roof of an office tower. Gravity won't be offended. It won't lecture you. It will simply do its job.
And you will probably be awarded a Darwin Award.
The economy possesses this same unpleasant indifference.
We can decree that a price is too high, but this decree does not create more of the scarce good.
We can decide that a service will be free, but that does not create doctors, nurses, imaging equipment, or operating rooms.
Wages, budgets, and production quantities can be administratively fixed. However, opportunity costs, worker reactions, and production constraints will still exist.
Economic history offers enough examples of shortages, famines, and disasters caused or aggravated by bad incentives to remind us that these mechanisms are not mere academic curiosities.
In a healthcare system, the consequences can also become very concrete.
Insufficient capacity does not become sufficient simply because the service is free. A patient waiting for intervention continues to age, and their illness continues to progress. A waiting list is not a statistical abstraction: it is composed of people, some of whom will see their condition deteriorate before receiving care.
Ignoring economic constraints does not protect us from their consequences. Above all, it prevents us from anticipating them.
Free access does not eliminate the cost
Let's take something as mundane as a magnetic resonance imaging scan.
It requires expensive equipment, a building to house it, electricity, technicians, radiologists, administrative staff, and time. All these resources could also be used elsewhere.
An MRI therefore has an economic cost, whether or not the patient receives a bill.
When we say that a treatment is "free," we simply mean that its cost is not paid directly by the patient at the time they receive it. It is transferred elsewhere: to taxpayers, an insurance plan, or another source of funding.
The distinction is fundamental.
Free service at the point of service never means no cost.
And since resources remain limited, it is still necessary to decide who can use them, when and for what purpose.
This is what economists call rationing.
The word sounds harsh when talking about health, but all systems ration care in one way or another. When demand exceeds available capacity, a mechanism is necessarily needed to adjust the two.
The question is therefore not about choosing between rationing and the absence of rationing.
The question is how scarce resources will be rationed.
The price doesn't disappear. It changes form.
Suppose that 1,000 people wish to receive an intervention, but the system can only perform 700.
Declaring the intervention free of charge does not create the 300 missing interventions.
We can use monetary pricing. We can prioritize based on medical urgency. We can create a waiting list. We can restrict clinical indications. We can impose quotas.
But as long as capacity remains lower than demand, a choice will have to be made.
This obviously doesn't mean that monetary price is always the best way to allocate care. A person suffering a heart attack isn't exactly in a position to shop around at three emergency rooms and compare their weekly promotions.
Health involves information asymmetries, emergencies, catastrophic risks, and equity considerations that justify significant public intervention.
But recognizing these particularities does not make the economic reality disappear.
If we remove the monetary price for the patient, we must pay particular attention to the other mechanisms that will match supply and demand.
Otherwise, the price might simply reappear in another form: time.
Incentives exist even when we claim to ignore them
Each financing method creates incentives.
A doctor paid per procedure has an incentive to perform more procedures. This can increase the supply, but also encourage overuse of certain services.
A capitation-based provider receives a fee for treating a patient for a specified period. This gives them a greater incentive to control costs, but the mechanism can also create an incentive to limit certain types of care.
A hospital primarily funded by a global budget operates according to a different logic. Once its budget is established, treating an additional patient increases its expenses without necessarily increasing its revenue proportionally.
Therefore, there is no system without incentives.
There are only systems that Incentives produce different behaviors.
This is particularly important when discussing the financing of institutions.
If the arrival of an additional patient is not accompanied by corresponding funding, this patient primarily represents an additional cost.
Conversely, when a significant portion of funding follows activity, treating more patients also brings more resources.
The incentive is completely different.
In the first case, customer traffic constitutes a budgetary pressure.
In the second scenario, an increase in activity can lead to the necessary resources to increase capacity.
That is why simply adding a few private clinics to the periphery of a huge public network does not necessarily constitute structural reform.
While the fundamental mechanisms that determine resource allocation remain the same, the core of the system remains essentially the same.
We will have grafted some private services onto a public mammoth without changing the way the mammoth functions.
When we plan the offer ourselves
There is a second paradox.
We have been complaining for years about the lack of doctors, while continuing to treat the number of doctors to be trained as a quantity to be determined administratively.
For the 2025-2026, 2026-2027 and 2027-2028 academic years, Quebec has set 1,209 is the total number of new medical school admissions authorized each year., including 1,165 in the regular Quebec contingent. It is written in black and white in the government memorandum..
The same logic applies to residences. For 2026-2027, Quebec authorizes 1,008 positions, including 554 in family medicine and 454 in other specialties. Quebec publishes the detailed breakdown.
Planning part of medical training is obviously not absurd.
Training a doctor requires professors, laboratories, clinical placements, patients, teaching hospitals, and several years of residency. One does not become a surgeon after three YouTube tutorials and a free Saturday afternoon.
Therefore, there are real capacity limits.
There are also excellent reasons to maintain extremely rigorous competence standards.
But we must distinguish between two things:
a limit imposed by the actual capacity to properly train doctors and a limit resulting from an administrative decision on the number of doctors the system wishes to produce.
The government does not hide this planning dimension. When it announced the residency positions for 2026-2027, it explained that their determination served in particular to meet the needs of the population and to distribute the specialties, but also to "limit the risk of medical unemployment and control the costs associated with training". This is one of the objectives cited by Quebec.
These objectives may be reasonable.
But above all, they reveal something important:
The supply of medical services does not freely respond to demand. It is subject to explicit planning.
Are we really in a surplus situation?
So that's the question that arises.
Quebec had approximately 260 doctors per 100,000 inhabitantsthat's about 2.6 per 1,000. This is higher than the Canadian average of 241 per 100,000 and even among the highest provincial ratios, according to the Canadian Institute for Health Information.
View from CanadaQuebec therefore appears to be relatively well provided.
But Canada itself accounted for approximately 2.7 doctors per 1,000 inhabitants, against 3.9 on average in the OECD according to comparative data published in Health at a Glance 2025.
The statistical definitions used for Quebec and in international comparisons are not perfectly identical. It would therefore be unwise to claim that Quebec is precisely 33% below the international average.
But the order of magnitude deserves our attention.
Canada certainly does not suffer from a clear excess of doctors.
And the data on access to primary care confirms this.
In 2024, only 82.6% of Canadian adults reported having access to a regular healthcare providerleaving approximately 5.7 million adults without a regular provider. CIHI now tracks this indicator.
Even more striking, CIHI estimates that an increase of approximately 49% of the number of family doctors to meet current demand. His assessment of the healthcare workforce explicitly highlights this.
In this context, it becomes difficult to treat the shortage as a simple problem of perception.
Scarcity is not just a matter of numbers
However, it would be just as simplistic to conclude that the only problem is to graduate more doctors.
The raw number does not tell us how many hours they dedicate to clinical care.
He doesn't tell us how much time is taken up by the administration.
He does not tell us whether a surgeon could perform more operations if he had more time in the operating room.
He doesn't tell us if the doctors are located in the right areas.
He doesn't tell us if we are training in the right specialties.
And it certainly doesn't tell us whether the work organization is effectively using their skills.
That's exactly what raises Mario Dumont, when he asks where doctors in a larger private sector would come from.
If a surgeon currently has time that he cannot use because he lacks operating slots, transferring some procedures to a facility with this capacity can increase the total amount of care without immediately requiring a new surgeon.
In other circumstances, a private clinic might simply attract a doctor who would otherwise have worked in the public sector.
Both phenomena are possible.
The right empirical question, therefore, is to determine What amount of additional capacity is actually created and what amount is simply displaced?.
That is why a serious reform must simultaneously examine the number of professionals, their productivity, the available facilities, their incentives and how resources are allocated to them.
A sign of a shortage
However, there remains one economic principle that is difficult to circumvent.
When a shortage persists for years, it constitutes a signal.
In an ordinary market, persistent scarcity normally drives up prices or remunerations, attracts new producers, encourages investment, and ultimately increases supply.
Medicine obviously has a particular constraint: adjustment is extremely slow.
The market cannot produce a family doctor by next Tuesday.
But that is precisely why the signal must be taken seriously well in advance.
A persistent shortage should lead to a continuous review of faculty capacity, the number of residencies, additional training opportunities, and the obstacles faced by foreign-trained physicians who meet professional requirements.
The Quebec government has significantly increased medical school admissions in recent years. It itself acknowledges that the needs are increasing with population growth and aging.
This is an important correction.
The question remains, however, whether a highly planned system can adjust supply quickly enough when needs change.
Because limiting capacity for too long today could produce a shortage that will last for another decade.
Public versus private: probably the wrong question
However, the debate in Quebec continually revolves around this opposition.
More audience?
More privacy?
As if the legal ownership of an establishment were sufficient to determine its effectiveness.
She doesn't.
A public institution may be subject to strong incentives regarding quality, productivity and patient satisfaction.
Conversely, a private company benefiting from a guaranteed government contract can be largely protected from competition.
What matters is also the way the provider is financed, the rules to which it is subject, the patient's ability to choose, and the consequences that result from its performance.
The real question, therefore, is not simply:
Who owns the hospital?
We must also ask:
What happens when he treats more patients?
What does he gain by improving his efficiency?
What happens to him if the patients prefer to go elsewhere?
If the answer to these questions is "not much", we have discovered a problem more fundamental than the ownership of the establishment.
What would a well-designed system look like?
Before choosing between different models, let's start by identifying the problems that a system should solve.
We must allow access to essential care without exposing a family to financial ruin.
We must protect sick and vulnerable people without making all stakeholders completely insensitive to the costs.
Suppliers should be encouraged to increase their capacity without incentivizing them to multiply unnecessary treatments.
We must reward efficiency without encouraging the selection of the least expensive patients.
We must allow for innovation and a certain degree of competition while maintaining rigorous standards of safety and quality.
Funding must be sufficient to meet the activity so that an efficient supplier can increase its capacity.
The supply of professionals needs to be able to gradually adjust to the real needs of the population.
And when patient choice is possible, this choice must have a real impact on the resources received by the provider.
In other words:
The patient should not simply represent an additional expense to be absorbed. Their presence should help determine where resources are allocated.
This distinction may seem technical.
However, it completely changes the incentives of the system.
To make the market mechanisms work
Ensuring universal access does not necessarily mean that the state must produce all care itself.
Sharing financial risk does not necessarily mean that price should disappear from all decisions.
Regulating quality does not necessarily mean preventing all competition.
And allowing certain market mechanisms does not necessarily mean leaving a sick person without care because they are poor.
These functions can be separated.
The state can guarantee access and finance or subsidize part of the care.
Insurance can pool the heaviest risks.
Public, private, or non-profit providers can deliver care.
Patients can, when circumstances allow, choose between them.
Payment mechanisms can transmit information about activity, costs, and scarcity.
And regulations can establish the standards within which these mechanisms operate.
We then move beyond the simplistic opposition between "The State" and "the market".
The real question becomes:
What combination of institutions allows for the use of economic mechanisms while protecting universal access to healthcare?
The curious case of Singapore
This is where Singapore becomes particularly interesting.
Not because he would have discovered a perfect system. Such an institutional animal has never been observed in its natural habitat.
But because Singapore deliberately combines state intervention and economic mechanisms.
Its funding framework is called S+3Ms : government subsidies, MediSave, MediShield Life and MediFund.
MediSave is a mandatory medical savings plan. MediShield Life offers citizens and permanent residents universal, lifetime basic insurance against major medical expenses. MediFund provides an additional safety net for people who still cannot pay after other forms of support.
THE Singapore Ministry of Health explicitly states that no one should be denied appropriate care because of their inability to pay.
This is certainly not a laissez-faire system.
The Singaporean state intervenes heavily. It subsidizes, regulates, mandates medical savings, organizes universal insurance and maintains a safety net.
But it does not attempt to eliminate all financial participation, individual responsibility, or price signals.
In other words, it does not treat universal access and market mechanisms as two necessarily incompatible concepts.
This is what makes it a particularly interesting case to study.
Not necessarily a model to copy.
But certainly the demonstration that there are many more possibilities between the integrated public monopoly and every man for himself.
We will return to Singapore in a future article.
The market is already here
Ultimately, that's the most important point.
We can decide that the patient will not pay directly for their operation.
We can decide that the state will finance the hospitals.
We can control prices, budgets, medical admissions, and the number of suppliers.
But we still will not have eliminated supply, demand, scarcity, or opportunity costs.
If we reject price rationing, we must choose another mechanism.
If we underpay for an activity, the supply may not meet the demand.
If we limit the training of professionals for too long, a shortage may appear several years later.
If we blindly reward volume, we may encourage overproduction.
If we never reward additional activity, we may instead discourage increased capacity.
Each rule changes behaviors.
Each financing method creates incentives.
Every rationing mechanism has a cost.
And no decree suspends economic laws.
For decades, we have often framed the debate as if it were about protecting health from the market.
Perhaps we should start with a more fundamental question.
Since economic constraints will continue to exist regardless of what we decide, the real question is rather:
How can we use them to improve access to care rather than simply suffering the consequences?
We cannot abolish the market.
We need to make him work for us.
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