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Paramedics bring a patient to the emergency department at Toronto Western Hospital on July 14.Fred Lum/the Globe and Mail

“Privatization” is the most fraught word in Canadian health care.

For most Canadians, it’s a taboo term. It is heard as a curse and a condemnation, portending medicare’s doom. To utter it is to call down the evil eye upon a national treasure. Other Canadians hear the word as the exact opposite – as a sort of religious incantation. Oh, if only we could “privatize” health care, that would (somehow) fix everything.

The trouble with “privatization,” whether invoked as blasphemy or blessing, is that the substance of what’s being done – and its opportunities and downsides – tends to get lost.

The private sector already plays a role under medicare, and always has. Your family doctor, though she bills the public insurer, is a private businessperson. The clinic where you got a blood test may be privately owned; the pharmacist who filled your prescription is not a government employee; the pharmacy is not a government agency.

And yet the system remains medicare – public, universal, with no fee to see a doctor. It follows the Canada Health Act. It gets the Tommy Douglas and Emmett Hall seal of approval.

So when and where is “privatization” a problem? And why? And can it ever be an opportunity?

On Thursday, Ontario announced a series of reforms: to free up space in overcrowded hospitals; to train, accredit and hire more staff; to allow paramedics to provide more forms of care; to get long-term care patients out of acute care in hospitals; and to reduce surgery waiting lists.

Almost all of what Ontario is proposing will be good for health care. Almost none of it involves mention of privatization, nor should it.

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But Premier Doug Ford’s government is talking about it in one area. On Thursday, it said it was “considering options for further increasing surgical capacity by increasing the number of [publicly funded] surgical procedures performed at independent health facilities,” and by “investing more to increase surgeries” in “existing private clinics.”

Is this a problem? It could be. It depends on what gets farmed out to the private sector, under what conditions.

Unless a province is very careful how it goes about “privatizing” any aspect of health care, it runs the risk of raising costs, cannibalizing public-sector staff and reducing services. That doesn’t have to be the outcome. But absent careful government planning, negotiation and oversight – and an understanding that “privatization” is not some sort of magic – bad outcomes are possible, and even likely.

Ontario is talking about pushing some surgical procedures out of public hospitals and into private clinics. That runs the risk of exacerbating staffing issues. If the private clinic pays more, it would tend to pull an already constrained supply of nurses and doctors out of the public sector.

An example has recently been seen in Ontario, where some hospitals are filling staff shortages by contacting nurses from private temp agencies – and paying them many times more than public-sector nurses. It’s a game of musical chairs that does nothing except raise costs.

The other danger is that a private facility, in the course of providing a publicly insured service, tries to offer or even compel patients to purchase uninsured services. That wouldn’t raise costs for the public insurer or taxpayers, but it would boost Canada’s health care spending – with the extra spending coming from patients’ pockets.

Consider Ontario’s private Shouldice Hernia Hospital. Mr. Ford invoked it the other day; it’s a hernia-repair factory, which should make it very efficient. It’s been around for decades, and its private status was grandfathered when medicare was created. The public sector sends patients there; their surgeries are entirely paid for by public medicare. Being operated on there is, in most respects, like going to a public hospital.

But in some key aspects, it’s not at all alike. Patients generally must stay for four days, versus an overnight or day surgery at a public hospital. And Shouldice generally charges you (or private insurance, if you have it) for a room that would likely be free in a public hospital.

There may be opportunities for medicare to tap into the private sector’s dynamism, innovation and profit motive. But it takes bureaucrats and politicians who appreciate that their job is designing a relationship that harnesses private interests to the fulfilment of public goals, rather than tying the public purse to private interests.

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