Quebec’s Bill 2: How Not to Fix Primary Care

To: Quebec healthcare observers
From: Tingting Zhang
Date: February 26, 2026
Re: Quebec’s Bill 2: How Not to Fix Primary Care

History tends to repeat itself, especially when governments refuse to learn from past mistakes. Quebec’s recent Bill 2 is a case of how good intentions, heavy-handed implementation, and physician coercion create the exact opposite of what reformers seek.  

Last October, Quebec passed Bill 2, attempting to overhaul how family doctors are paid and held accountable. The bill shifted physicians from fee-for-service (FFS) to a blended model combining capitation, hourly rates, and performance-based targets. While the approach appeared sound in theory, it tied 10 percent of physician pay (initially 25 percent) to meeting government-set patient volume quotas and automatically registered 1.5 million Quebecers to clinics regardless of capacity.

Physician groups faced collective responsibility. If targets were not met, everyone’s pay was cut, regardless of individual effort or patient complexity. The bill also imposed daily penalties of up to $20,000 for “concerted action” by physicians that disrupts, slows, or reduces access to health services, thereby restricting their ability to protest or collectively challenge government policies.

Widespread protests ensued and more than 400 Quebec doctors applied to practise elsewhere in Canada. Some clinics warned of closures. Some medical directors of regional family medicine departments refused to assign orphan patients to overburdened physicians and clinics.

Sound familiar? It should. Bill 20 in 2015 used nearly identical punitive tactics – quotas, penalties, collective punishment. It generated the same physician outrage and threats of exodus.

Under immense pressure, Quebec temporarily suspended Bill 2 and scrapped its most coercive elements: Performance-based pay clawbacks, patient vulnerability colour-coding, and penalties for speaking out. The forced assignment of 1.5 million patients was replaced by voluntary incentives of $76 million for 500,000 patients enrolled by this June. Health Minister Christian Dubé resigned over the changes and his successor, Sonia Bélanger, is negotiating a new remuneration model with FMOQ and introduced Bill 19, which significantly amends Bill 2 to reflect the agreement reached with the FMOQ.

Trust between doctors and governments has been damaged. In the Outaouais region, 41 family doctors confirmed departures. In Montreal’s West Island, 20 doctors are leaving their clinics to work in another province, retire early or take positions elsewhere in the health system. While some doctors reconsidered their plans over amendments to Bill 2, a few still decided to leave.

Nearly 2 million Quebecers lack a regular healthcare provider, despite the province having one of Canada’s highest physician-to-population ratios. Clearly, governance and payment structures need reform.

One key problem is FFS dominance. In 2023-24, most Quebec family physicians derived 50-100 percent of their income from FFS; only 17 percent relied primarily on alternative payment, among the lowest in Canada. FFS is incompatible with team-based care. It fails to foster collaboration because physicians have little incentive to delegate tasks to their colleagues, such as nurse practitioners or pharmacists. Quebec has more interprofessional primary care teams than any other province, yet these teams struggle with functioning as teams. The payment model prevents it.

What’s needed is a blended model combining capitation (fixed per-patient payment that varies by complexity), selective FFS, infrastructure funding, program funding, and performance payment bonuses – not penalties. Such models mitigate each approach’s weaknesses: Overserving under pure FFS, cherry-picking under pure capitation, and underperformance under pure salary. However, the effectiveness of the blended model in improving access to primary care also depends on mandatory enrollment and clearly defined accountability for both patients and providers.

Value-based care models – where care providers assume full responsibility for quality and total cost of care – have proven successful internationally, reducing hospitalizations by 18 percent and costs by 12 percent compared to traditional fee-for-service. These models emphasize patient-reported outcomes and experiences, guide resource allocation, identify areas for improvement, and foster efficiency.

But Bill 2 arguably set arbitrary and unrealistic targets that physicians couldn’t meet. Why enforce collective responsibility when family physicians practise in vastly different contexts across diverse communities? Why use penalties instead of performance bonuses?

Other provinces offer better models. British Columbia’s 2023 longitudinal primary care payment model has attracted 800 family physicians. Alberta introduced a blended capitation model the same year. Ontario recently updated its capitation model to allow Family Health Organization physicians to bill for administrative tasks, such as charting, based on the complexity of their rosters. These reforms engaged, and did not coerce, physicians.

Cooperative reform against powerful physician associations is never easy. But achieving universal attachment to primary care providers is impossible without their support.

Bill 19 is a welcome admission that tying doctors’ pay to rigid quotas and penalties was a dead end. The real test now is whether Quebec follows through on a new path of genuine collaboration with physicians. After two failed attempts, the lesson should be clear. Trust-building, evidence-informed design, and physician engagement are important for success.

Course corrections are never too late. But the clock is ticking, doctors still have one foot out the door, and patients are still waiting.

Tingting Zhang is a policy analyst at the C.D. Howe Institute.

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The views expressed here are those of the author. The C.D. Howe Institute does not take corporate positions on policy matters.