Premier Doug Ford is in a pinch. The ballooning growth of Ontario’s expected health-care spending is thwarting his plan to balance the budget within five years. A recent report indicated that, in the absence of economically damaging tax hike or big cuts elsewhere, the government would likely need to spend $8.6 billion less on health care than currently projected to balance the budget by 2022-23.

Premier Ford’s most recent salvo is the delisting (or restricting) of 11 “inappropriate” medical procedures and billing practices, estimated to save the province $83 million. These include services ranging from relative no-brainers (elective ear-wax removal) to potentially questionable restrictions on “unnecessary” CT and MRI scans for hip and knee surgeries, urine pregnancy tests in physician’s offices (unless there’s imminent harm) and “ineffective” knee arthroscopies (except under specific conditions).

To be clear, this isn’t a unilateral decision from the government—it’s based on recommendations from a working group composed of representatives at the Ministry of Health and Ontario Medical Association.

It is, however, a remarkably bold interpretation of the Canada Health Act (CHA), the financial tool that dictates the terms and conditions provinces must follow to receive federal health-care dollars. While provinces have jurisdiction over the delivery of health care, Ottawa can call the shots behind-the-scenes via the threat of financial penalty.

Ontario’s delisting of medical procedures indicates the province is asserting its ability to define what is (and isn’t) “medically necessary.” Importantly, once a procedure is no longer considered medically necessary, CHA restrictions on private insurance and delivery of care may no longer be relevant. In other words, delisting may allow patients (sick of long wait times) to pay for these treatments, save the province health-care dollars, and show other governments how they too can open the door to private-sector involvement.

The situation in Ontario also highlights the strange nature of Canada’s health-care system.

For example, 150,000 patients in Ontario received urine pregnancy tests and 20,500 patients received knee arthroscopies—two of the procedures that now face restrictions. While the recommendations made by the working group suggest many of these procedures were likely “unnecessary,” it’s clear that some doctors and patients believe these tests provide medical benefit.

So the real question is, exactly how many of these procedures were medically necessary and why does our health-care system ostensibly perform more than this optimal number?

One reason is because while doctors are incentivized to deliver care (as they should be), patients face no monetary cost for receiving treatment and are therefore more likely to demand potentially unnecessary care. While Premier Ford’s solution to this problem is to delist or severely restrict access to these treatments (once correctly identified), there’s another simpler and more dynamic solution. Require copays and user fees for patients.

Most other universal health-care systems (Switzerland, the Netherlands, Sweden, etc.) expect patients to share the cost of their treatment—either through deductibles or co- insurance. Of course, these countries have annual limits on such payments and exemptions for vulnerable populations. But they understand that such payments help patients be more conscious of the treatments they receive.

Unfortunately, the CHA has clear financial penalties for user-fees and co-payments for medically necessary care. However, as Premier Ford recently demonstrated, determining what exactly falls into the “necessary” category is up to the provinces to decide.