Ililochi B. Ogbozor argues that a premium tier of healthcare can only be justified if public administration remains strong enough to stop payment from quietly becoming the price of access.
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Professor Daryl Pullman’s proposal for a two-tiered, publicly administered healthcare system reopens a vital debate about the ethics and sustainability of universal care in Canada. His idea, formalizing an out-of-pocket premium tier within the public system, attempts to reconcile an uncomfortable reality (private queues already exist in practice) with the egalitarian values underpinning Canada’s health equity culture, which holds that access to care must follow clinical need rather than the ability to pay. Pullman argues that capturing premium revenue could shorten wait times and subsidize the wider system. But the arrangement’s viability depends on one condition: whether these equity pillars can survive contact with the profit-maximization dynamics visible in more market-driven systems.
The central risk is that a fast-track mechanism for those able to pay institutionalizes a new inequality, one in which speed becomes a purchasable commodity. The American healthcare system is instructive here, though the comparison must be drawn carefully: the US is not two-tiered in Pullman’s sense but multi-tiered and largely market-driven, with safety-net programs existing alongside private coverage rather than beneath a unified public floor. Despite these programs, disparities persist because the structure allows wealth to secure superior coverage while public options face chronic underfunding. This is not a direct preview of a Canadian premium tier, but it illustrates a pattern worth heeding: once payment becomes a lever for access, stratification tends to follow.
The UK’s NHS offers a closer and more uncomfortable parallel, precisely because it shares Canada’s founding commitment to free care at the point of use. Years of rising demand for health services, workforce shortages, and constrained funding have left the NHS with a substantial backlog and wait times that, in some specialties, now stretch well beyond a year. This pressure of long wait times has fueled a marked rise in private healthcare use among those who can afford to pay their way past the queue. What makes the NHS case so pertinent is that it shows how a chronically underfunded public system, however strong its founding principles, can drift toward an informal two-tier reality without anyone formally designing one. Patients with means increasingly opt out of the queue rather than campaign to shorten it, easing pressure in the short term while quietly reducing the political urgency to fix it. Canada should treat this as a caution: a premium tier introduced without robust safeguards could accelerate the same dynamic.
Photo Credit: Wikimedia Commons. Image Description: A map of Canada.
Nigeria’s healthcare system offers a starker warning. It is fragmented and heavily reliant on private out-of-pocket spending, and wealth visibly dictates both the quality and speed of care, while public facilities remain underfunded. This is the trajectory Canada must guard against: a public system that quietly becomes residual, reserved only for those without the means to buy their way past it.
The most defensible feature of Pullman’s proposal is that both tiers remain under public administration, a condition that carries most of the argument’s weight. Centralized governance is what prevents private operators from cherry-picking low-risk, high-margin procedures while leaving costly complications for the public system to absorb. It also gives the state tools to control staff allocation and limit the drift of skilled clinicians toward higher-paying private-adjacent roles, a dynamic the NHS has struggled with as consultants split time between public lists and private practice. Where regulatory oversight is weak, as in much of Nigeria’s private sector, care becomes an ordinary “merchandise” rather than a right. Strong public administration is what keeps a premium tier from drifting toward this outcome.
A two-tiered system is only ethically defensible if premium revenue is earmarked for the structural problems that created the debate, not absorbed into general healthcare funds. Two priorities matter most: 1) workforce expansion, since physician shortages (as in the NHS backlog) drive wait times, so Canada should fund medical education and capacity rather than purchase speed for paying patients; and 2) telemedicine and access infrastructure extending care to remote, rural, and Indigenous communities otherwise excluded from the premium tier’s benefits. Revenue should also support preventive care and health literacy, reducing long-term demand rather than merely managing today’s backlog.
If Canada moves toward a two-tiered system, the case for doing so responsibly rests on one question: can public oversight withstand commercial pressure once a premium tier legitimizes payment as a lever for faster access? Pullman’s answer is that strict public administration makes this possible in principle. Whether it holds in practice is the test Canadian health policy would face, measured against outcomes already visible in the US, the UK, and Nigeria whenever that safeguard has weakened.
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Ililochi B. Ogbozor is an alumnus of Memorial University’s Master of Health Ethics program and maintains an academic affiliation with the Memorial Centre for Bioethics..
