Should Ontario Residents Be Allowed to Opt Out of Primary Care?

From: Will Falk and Rosalie Wyonch
To: Canadian health policy watchers
Date: February 27, 2025
Re: Should Ontario residents be allowed to opt out of primary care?

In healthcare discussions, a fundamental yet often overlooked question is: Should people have the option to go without a primary care provider?

Canada prides itself on individual freedoms, yet other leading healthcare systems treat primary care attachment as essential.

In the highest-performing healthcare systems, not having a primary care provider is not a choice. Instead, these systems employ “quasi-truancy mechanisms” to ensure universal attachment, treating access to a general practitioner as a civic expectation rather than a personal decision.

Lessons from Europe

Several Organisation for Economic Co-operation and Development (OECD) countries have taken steps to guarantee that every citizen is attached to a primary care provider, either by mandate or default assignment. Approaches vary, but the principle remains the same: You don’t get to opt out of primary care because that would mean the system won’t function properly.

• UK: The National Health Service mandates general practitioner registration, with schools ensuring children are enrolled. While adults aren’t forced to register, accessing NHS services requires a general practitioner (GP), making attachment a practical necessity.
• The Netherlands: Registration with a GP is mandatory under its insurance system. If a person fails to register, the government assigns them a provider, ensuring nearly 100 percent coverage.
• Norway: The Regular General Practitioner Scheme automatically assigns every resident a GP. Patients can change providers twice a year but cannot opt out entirely.
• Finland: Residents are automatically linked to a local health centre based on their address. While switching is allowed annually, every citizen remains attached to a provider.
• Denmark: Like Norway, GP registration is a condition of healthcare access, ensuring every citizen has a designated family doctor.

The rationale in all these nations is simple: Continuity of care improves health outcomes, reduces costs, and alleviates ER pressures.

The Canadian system is built on individual choice. The government funds universal hospital and physician services but does not require participation. Even vaccination efforts have faced significant pushback.

Interestingly, personal freedom has limits in other public services. Children must attend school, even if their parents disagree. Children and adolescents in Ontario and New Brunswick must have proof of vaccination to attend school (or have a documented medical or ideological exemption). Truancy laws exist because an educated populace is essential to society.

Would assigning every Ontarian a primary care provider – just like they are assigned a school district – be an overreach or simply a necessary step toward a functional system?

What if we used ServiceOntario?

As a thought experiment, consider using the ServiceOntario registration system as a starting point. Under this model:

1. Every Ontario resident would be assigned to a primary care practice based on their home address.
2. Residents could switch providers but could not be unattached.
3. New residents would select a provider when updating their health card or driver’s licence.
4. Non-residents (refugees, visitors, and pre-OHIP citizens) would be assigned under current or expanded programs.

At first glance, this could improve access and planning. But the reality is far more complex.

• Some desperately need care but remain disengaged. Simply listing them in a system does not address social determinants of health. Equity-deserving populations need more than just a roster assignment.
• Many communities lack providers. Universal attachment could create a Quebec-style PREM crisis, forcing doctors to work in areas they don’t want to live, leading to dissatisfaction and system exits. Additionally, most provinces don’t have legal mechanisms to force physicians to practice in a particular location.
• In communities with too few providers, attachment does not necessarily guarantee access. Some physicians will be assigned more patients than they can reasonably handle, while others could have much smaller assigned rosters – effectively creating an income disparity within the profession based on region.
• Physicians also have a duty of care to their patients, meaning a legal responsibility to provide care to the patient as the situation requires and as circumstances reasonably permit.

Admiring Europe’s seamless systems is easy, but implementing a similar model in Ontario is fraught with challenges. The province lacks the physician supply, infrastructure, and political will to enforce mandatory attachment. Forcing physicians to take on patients in underserviced areas could backfire, worsening recruitment and retention.

Furthermore, should Ontarians have the right to refuse attachment? If assigned but unable to get an appointment for weeks, is that really “universal primary care”?

For Ontario, this debate is not just about logistics – it is about whether we value primary care as a public good. If we do, universal attachment should be an early policy step. If we don’t, we must accept a fragmented system where millions remain unattached, relying on ERs and walk-in clinics for basic care.

Will Falk is an executive in residence at Rotman School of Management and a senior fellow at the C.D. Howe Institute, where Rosalie Wyonch is associate director of research.

To send a comment or leave feedback, email us at blog@cdhowe.org.

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

A version of this Memo first appeared in Doctor Daily.