Provincial premiers and territorial leaders will meet on Wednesday to discuss health care in the picturesque town of Niagara on the Lake, Ont. What they’re not going to talk about is whether or not Quebecers will have full access to Canada’s health care system under the portability clause of the Canada Health Act.

The portability clause, section 11 of the Canada Health Act, states that “residents who are temporarily absent from their home province or territory or from Canada must continue to be covered for insured health services during their absence. This allows individuals to travel or be absent from their home province or territory, within a prescribed duration, while retaining their health insurance coverage.”

But when 73-year-old Montreal native Gerry Ouwendyk’s friend visited Toronto and needed to see a doctor and be treated, the doctors refused his Quebec health card.

“They said, ‘Quebec won’t pay us, so you have to pay us first and get your money back from the Quebec government.’ So he paid, and when he got back to Montreal, he got back less money. I think this is ridiculous, we’re one country,” said Ouwendyk. “If I go to Newfoundland, why should I be treated like a leper?”

According to Paige Raymond Kovach, a media relations officer with Health Canada, the Quebec government is not complying with the Canada Health Act. Kovach said that under the portability clause of the Canada Health Act, provinces are required to pay medically-insured services at the host province’s rate, but Quebec is paying Canadian doctors out of the province its own provincial rate and are not facing any consequences.

Dr. Charles Shaver, an Ottawa physician, said it’s annoying that the Canada Health Act is not applied uniformly.

“We’re obeying our portion and the feds are ignoring Quebec’s violation,” he said.

Shaver has been a vocal proponent about Quebec’s participation in national health care for the past few years. Quebec is the only province not to sign the reciprocity agreement between the Canadian provinces and territories which states that other provinces would be reimbursed according to their own rates for services they provide to Quebecers outside Quebec.

“Doctors should pay the local fee,” said Shaver.

Nobody at Premier Jean Charest’s office could be reached for comment on the issue; however, after many calls to the Minister of Health’s office, Philippe Couillard’s press secretary, Cathy Rouleau, said that Quebec is doing its part on the portability issue, but said the issue is not as big as people think.

“Mr. Couillard went to two health meetings with the other provinces and the portability issue did not come up,” she said. “It’s an issue between Ontario and Quebec at places like Ottawa, not the other provinces.”

Shaver disagreed. He said that the non-reciprocal agreement between Quebec and the other provinces affects many Quebecers who travel, study or move across the country.

Shaver explained that because Quebec refuses to pay the local fee for services physicians provide Quebecers outside Quebec, many doctors are choosing not to accept the Quebec health insurance card which forces patients to pay up front or be billed for the service. This is what happened in Ouwendyk’s friend’s case.

“The people pay the difference,” said Dr. Andre Senekas, president of the Quebec Medical Association. “For people that leave the province, in principle, it doesn’t respect the Canada Health Act.”

This is what makes the Canadian system not truly universal, said Shaver.

The problem, said Senekas, is that the local fee in other provinces is 30 to 50 per cent higher than Quebec’s fees. He said that Quebec has the highest number of doctors in the country and they are paid the lowest.

“It’s quite a marked difference,” he said.

According to the Canadian Medical Association Journal, in 2001-2002, general physicians in Ontario made the highest salary, with an average of $240,096 per year while in Quebec, general physicians made $179,803 — the lowest in Canada.

“Quebec has the lowest per capita spending in the country,” said Senekas.

Ouwendyk believes no one should be paid more or less depending on where they live. “Location should not make a difference,” he said. “If you live in Toronto or Montreal, living costs are going to be higher than if you lived in Timbucktoo middle of nowhere Canada. These are the realities of the country and health care should not be decided on where you live. There needs to be total equality on health care as far as I’m concerned.”

Shaver also added that the Quebec government is in essence forcing other provinces to subsidize its health care system because it’s not paying the host province’s rates for medical services.

“I give money to a lot of charities, I donate to my church, but the Quebec government is not on my list of charities,” said Shaver.

According to the RAMQ’s records, approximately 1,150 doctors across Canada accepted Quebec’s lower fee and billed the Quebec Regie for Quebec patients they saw in their province, said Marielle Bilodeau, spokesperson for the Regie. This is in comparison to another 75,828 Quebecers who billed the Regie themselves for medical services they received in other parts of the country in 2003.

Health Canada said it is perfectly legal for physicians to charge patients up front. “Doctors can refuse a health card and paying out of the pocket is okay,” said Kovach, “as long as service is not refused.”

In the case where patients can’t pay up front, Bilodeau said doctors normally ask for credit cards or send a bill to their homes to be paid later.

Still, Shaver argued that people shouldn’t have to pay. “Some doctors would rather see the patient for free as a charity case rather than accept the Quebec health card and be paid less than what they’re worth as a matter of principle,” he said.

When it comes to other Canadians coming to Quebec and needing medical service, Senekas said it isn’t as big a problem. “Ontario is very happy to pay Quebec rates,” he said.

Rouleau said that discussions are still taking place between Quebec and Ontario to address portability in the Ottawa and Temiscamingue regions. Quebec already has an agreement with Ontario to pay doctors at the Ontario rate for services that are not offered on the Quebec side of those two regions. Quebec also pays doctors the host province’s rate for hospital emergencies but there is still no agreement on physician services.

Kovach said the penalty for violating the Act is a deduction of transfer payments under the Canada Health and Social Transfer. “We’ve raised it on a few occasions and anytime we can, we do,” she said. “Our preference is to work with the provinces and use financial penalties as a last resort.”

Rouleau said that the portability issue will not be discussed at this week’s Council of the Federation meeting, prior to Prime Minister Paul Martin’s health summit on Sept. 13. “That shows that it’s not a big issue with the other provinces,” she said.

Senekas said the QMA supports the Canada Health Act but recognizes it has to be looked at and updated. “It needs to be revised and studied again,” he said. “Citizens should be involved. People are paying lip service and ignoring it. Couillard brought a lot of sincerity and he understands the system. There have been changes in the right direction but there needs to be more. It’s time to have a debate over the issue.”

Ouwendyk agreed that there should be a portability discussion in order to make health care truly universal. “Stop the abuse,” he said. “We should all share the costs of health care. If it’s supposed to be universal, let it be universal.”