Posted By Lana McCrea
Bill 20 – or An Act to enact the Act to promote access to family medicine and specialized medicine services and to amend various legislative provisions relating to assisted procreation – is a healthcare reform bill proposed by Mr. Gaétan Barrette, the Quebec Minister of Health and Social Services.
The bill is divided into two parts. Part I – an Act to promote access to family medicine and specialized medicine services – imposes certain obligations on physicians who participate in the Quebec Health Insurance Plan. Part II affects the practice and availability of assisted procreation activities.
Part I: Family Physician Obligations
One of the big controversies regarding Part I was the imposition of annual patient quotas on family physicians: either take on a caseload of 1,000 patients per year, or face penalties.
On March 30, 2015, approximately 1,000 Quebec medical students from McGill University, Université de Montréal, Université Laval, and Université de Sherbrooke gathered in Quebec City to speak out against Bill 20. The protests followed a mémoire signed by the deans of all four Faculties of Medicine expressing their concerns regarding the new bill.
Quebec physician groups such as the Fédération des médecins spécialistes du Québec and the Fédération des médecins omnipraticiens du Québec also criticized Bill 20, saying that it would aggravate the problem it was designed to address.
Why the imposition of quotas?
While Quebec has more family physicians per capita than most provinces, access to healthcare doesn’t measure up. One study analyzed this discrepancy. The study largely blamed the fact that Quebec physicians have a shorter work week, at 34.9 hours, compared to 43 hours in Ontario. It also noted that Quebec has fewer enrolled patients per physician at an average rate of 1,081 compared to 1,539 in Ontario.
Is Bill 20 the answer?
Critics expressed fear that the bill would encourage ‘assembly-line’ practices in medicine, favouring quantity over quality of care.
The mémoire prepared for the Commission de la santé et des services sociaux by the deans of four faculties of medicine also expressed concern that the bill would have a negative impact on the education and training of physicians. They claimed that the bill did not recognize the additional teaching and research responsibilities that some physicians will have to undertake, such as those practicing in hospitals and other health care institutions with educational missions (e.g. Family Medicine Units).
Further, there were concerns that the bill would affect the number of family physicians in the province. Increasing obligations on family physicians could eventually reduce the amount of family physicians in Quebec as it becomes a less attractive career choice. It could even push doctors out of the province. The average doctor in Canada earned $307,482 in 2010-2011, compared to $253,539 in Quebec and $340,020 in Ontario.
Part II: Assisted Procreation
Part II of the bill, which amended assisted procreation practices, imposed new penal provisions and increased the amount of fines already prescribed in the Act.
Some of the provisions were highly controversial as they seem unnecessary, patronizing, and not justified by medical evidence. There was concern that these elements constituted an attack on women’s rights.
While Quebec was the first province to fully fund in vitro fertilization (IVF) treatments, Bill 20 amended the Health Insurance Act to no longer cover any assisted procreation activities, except for artificial insemination. It also made it an offense to provide IVF treatments to women outside the age range of 18 to 42 (article 10.1).
An additional requirement was that physicians make sure that a woman seeking in vitro fertilization engaged in a suitable period of sexual relations or a number of artificial inseminations “determined by government regulation” (10.3).
Under article 10.2, it also stated that if the ‘parental project’ involves a third party’s genetic material, then fertility treatments could no longer be provided unless the parties seeking treatment have gotten a ‘positive psychosocial assessment’, at their own expense. The bill even imposed these restrictions on parties who are willing to pay out-of-pocket, and prohibited physicians from referring them out of province.
Thus, the concern was that these elements amounted to discrimination on the basis of age, social condition, and sexual orientation, prohibited under section 10 of the Quebec Charter of Human Rights and Freedoms. In particular, the provisions targeted women who choose to wait to procreate and parents who use third party genetic material – often same-sex couples.
On May 25, 2015, the Minister of Health and Social Services announced a new agreement with family physicians that would delay the effects of the bill for two years. Family doctors would be spared the quotas and penalties for non-compliance in exchange for a guarantee that by 2017, 85% of Quebec’s population would have a family doctor.
Just one day later, the Minister also backtracked on some of the provisions affecting assisted procreation. The new amendments would give the responsibility of determining guidelines for assisted fertilization to the Collège des médecins du Québec. They would take away the requirement that couples engage in a period of sexual activity before they are eligible for fertility aid and reduce the ‘positive psychosocial assessment’ requirement to cases when the doctor has reason to believe there is a risk to the security or development of the child.
Although the changes still incorporate certain controversial elements, albeit in a less draconian manifestation, the new changes can definitely be counted as a victory for reproductive rights – Pyrrhic as it may be.