By: Leo Kristal-Polci
Edited by: Madeleine Hamilton
To anyone who has done the rounds of the Queen’s University Biosciences Complex or Chernoff Hall, the sound of Ontario’s next generation of doctors ruminating on the injustice of medical school applications is all too familiar. Amid frustrations surrounding exams, GPAs, MCAT scores, and supplementary essays, talk usually ends up turning towards the more deep-seated systemic issues at the heart of the pre-med nightmare. Among these topics, one seems to command a more central presence than any other—the lagging growth in medical school class sizes.
Since 2015, Canada’s population has grown around 12%, yet med school admissions across the country have failed to keep pace, only increasing 6% in the same period. While this is an understandably worrisome reality for the prospective doctors currently coming through the system, this trend has proven anxiety-inducing far beyond the bounds of undergraduate campuses. In Ontario in particular, various medical advocacy groups have been outspoken in their criticism of the anemic state of family medicine in the province, at least partially fuelled by the slow trickle of graduates coming out of med school. The Ontario Medical Association (OMA) estimates that by 2026, 4.4 million Ontarians will be without a family doctor, up from 2.5 million in 2023. With about 40% of practicing family doctors expected to retire in the next few years, the OMA says 3,500 replacements are needed as soon as possible.
For their part, the provincial government has been reluctant to acknowledge the urgency that these advocacy groups attach to the lack of general practitioners in Ontario. As recently as May of 2024, the Health Ministry said it did not view recruitment and retention of doctors as a major concern in the middle of compensation arbitration with the OMA. The Ford government did, however, pick up on calls for the creation of new med school opportunities and committed $33 million dollars over three years to the financing of 100 new undergraduate and 154 new residency spots in existing schools. More recently, they also announced the creation of an entirely new medical school in Brampton, operating under the purview of Toronto Metropolitan University. Yet, even as groups like the OMA welcome the new education opportunities with open arms, they reiterate that these measures are only effective in the medium-term and do not address a far more pressing issue: physicians have been driven out of family medicine.
Of the roughly 17,000 family doctors across Ontario, most numbers indicate that as many as 6,000 of them are not practicing family medicine, opting instead to work at walk-in clinics or as associates to other medical professionals. Much has been said about why exactly this is, but the two main culprits that emerge in nearly any explanation are the stagnant rates at which family doctors are compensated and the increasing headache of running a private practice.
Statistics Canada estimates that between 2014 and 2023, inflation rose 25%, while OMA numbers suggest that GPs’ billings to the Ontario Health Insurance Plan (OHIP) only increased 6.1% in the same timeframe. At face value, this represents a substantial financial hit to some of the most essential medical professionals in the province, but it has also sent family doctors the message that in spite of the public-facing talk framing them as frontline heroes, the province does not in fact value their work.
The provincial government also tightly controls the compensatory frameworks that doctors have access to, causing frustration across the board (Crawley, 2024). While about 60% of family doctors operate on the generally desired “capitation” model in which they are paid a set annual fee per patient on their roster, another 40% use the “fee-for-service” model in which they are paid per individual service rendered to a patient. Despite a vast majority of doctors preferring capitation, the province has neglected to allow a greater share to switch to the model (Crawley, 2024). In any case, neither system accounts for the roughly 19 hours of paperwork that GPs report completing each week, presenting another disincentive to physicians eyeing family medicine.
These factors, and the Ford government’s reluctance to address them, have combined to produce a healthcare landscape starved of family doctors. Against this backdrop, municipalities have been forced to compete amongst themselves for the doctors that do remain in the system, inadvertently filling in financial and logistical gaps left by the province.
At home in Kingston, the city has poured $3.6 million into recruitment efforts over the past three years. Through complementary golf tee times, sailing outings, trolley tours, and, perhaps most importantly, the $100,000 in cash incentives available to each new doctor, the program has drawn 33 GPs to the Kingston area. Hoping to build on its success, the city has now set its sights on $400,000 in funding aimed at planning the succession of retiring doctors’ medical clinics (Hutchins, 2025).
Outside the province of Ontario, the town of Colwood, British Colombia has adopted an entirely novel approach to recruitment. Though not facing the same healthcare crisis as Ontario’s municipalities, the town’s rural location makes it difficult to attract doctors, even as its population continues to grow. In response, Colwood’s mayor set out to make family doctors municipal employees, affording them a steady set salary, government benefits including a pension, and the advantages of the town’s administrative apparatus. By taking care of the logistical headache of running a clinic and by offering doctors financial predictability, Colwood has already made a dent in its family doctor problem. Other municipalities have already taken note, including Orillia, Ontario which has expressed its interest in repurposing the Colwood model to make up for Ontario’s crisis in family medicine (Cuttler, 2025).
While Kingston, Colwood, and other municipalities have been rightfully praised for their innovative approaches to an urgent problem, the broader takeaway of this situation should be the dilemma of legal and constitutional responsibility it has created. Given that Ontarian municipal governments subsidized healthcare, a nominally provincial responsibility, to the tune of $320 million in 2023, the question of how exactly that’s possible is unavoidable.
The answer largely lies in the constitutional framework, or lack thereof, that governs the operation of Canada’s municipalities. The Constitution Act (1867), Canada’s founding legal document and the text that lays out the general model of the country’s federal system, makes only very brief note of municipal governments. It states that provincial legislatures have exclusive jurisdiction over “municipal institutions in the Province” so long as they do not contravene federal law, but does not elaborate on what that looks like in any further depth.
Now, this is not to say that municipalities have been entirely legally bound to a single line of the Constitution Act for the past 158 years, but it does hint at the root of the problem: provinces have arbitrary control over what amounts to a municipal obligation. In Ontario, the Municipal Act (2001) has provided further clarification on what the province expects of municipalities, and the Health Protection and Promotion Act (1990) details these responsibilities in a specifically health-related context. Between the two documents, the government makes it clear that municipalities are expected to fulfill several public health duties, but certainly does not imply these duties to include the provision, or even subsidy, of primary care.
Where this breaks down is in the malleability of these statutes. While a document like the Constitution Act is extremely hard to modify, the Municipal Act and HPPA can be changed by the province unilaterally, allowing provincial governments to bend the municipality-province relationship to their liking. In other words, while the province’s supremacy over municipalities is firmly entrenched in law, municipalities’ responsibilities are highly variable. The family medicine crisis serves as a textbook case: by failing to be more proactive about finding new GPs, the province informally shifts that burden to municipalities, leading cities like Kingston and Colwood to spend their limited tax revenue paying doctors in “cash incentives” and “government benefits”.
Another health-specific example of this dynamic occurred in 2022 surrounding the division of funding to public health units. While funding to these bodies had long been informally anchored at 75% provincial and 25% municipal, this balance began to tip further towards municipalities during the pandemic. In response to calls to institutionalize the original ratio in legislation, the provincial government passed Bill 142 amending the HPPA to declare that municipalities would pay a maximum of 25% of these costs. The asterisk? This clause would only take effect if the government had dedicated money to this purpose in its most recent budget. What this effectively meant was that so long as the province did not set money aside for the purpose of fulfilling the amendment, it did not have to abide by it.
In an environment marked by unpredictability in both funding and broader administrative commitments, it becomes very easy for the provincial government to offload work to municipalities according to its interests, and very hard for municipalities to plan their government business accordingly. While municipalities have done an admirable job of dealing with the crisis in family medicine, it is impossible not to wonder at what point this arrangement ceases to be sustainable. Though this article has focused on this dilemma in the context of healthcare, the Association of Municipalities of Ontario estimates that when accounting for all municipal services, cities and towns across Ontario subsidized the province about $4 billion as of 2022. As roughly the same figure sits untouched in the coffers of Ontario’s “contingency fund,” it is difficult to comprehend what greater game the province might be playing. Whatever that game might be, the province’s handoff of the family doctor crisis has raised a definitive dilemma of fairness.
As daunting a task as it may seem, might it be time for a new constitutional arrangement that gives municipalities full sovereignty over a defined set of affairs?
Image Citation: Louis, A. (2012). Doug Ford speaks to the media [Photograph].. Flickr.com. https://www.flickr.com/photos/hyfen/6843314333
References:
Association of Faculties of Medicine of Canada. (n.d.). Medical school admissions not keeping up with population growth. AFMC. https://www.afmc.ca/medical-school-admissions-not-keeping-up-with-population-growth/
Association of Municipalities of Ontario. (n.d.). Municipal 101. AMO. https://www.amo.on.ca/about-us/municipal-101
Association of Municipalities of Ontario. (2025). Pre-Budget Submission. AMO. https://www.amo.on.ca/sites/default/files/assets/DOCUMENTS/Pre-Budget%20Submissions/2025/Pre-Budget_Submission_2025_V7_FINAL_011525.pdf
The Constitution Act, 1867, 30 & 31 Vict, c 3. (2025, November 20). CanLII. https://www.canlii.org/en/ca/laws/stat/30—31-vict-c-3/latest/30—31-vict-c-3.html
Crawley, M. (2024, March 11). Want more family doctors in Ontario? Pay them better, say physicians. CBC. https://www.cbc.ca/news/canada/toronto/ontario-family-doctors-pay-compensation-ohip-billing-fees-1.7137716
Cuttler, M. (2025, September 21). ‘I’m a problem solver’: Meet the mayor whose plan to attract family doctors is turning heads across Canada. CBC. https://www.cbc.ca/news/health/cities-hiring-family-doctor-1.7638292
Harrison, L. (2024, November 29). 3 million Ontarians at risk of losing family doctor to retirement, provincial Liberals say. CBC. https://www.cbc.ca/news/canada/toronto/ontario-family-doctor-retirements-1.7396133
Health Protection and Promotion Act, R.S.O. 1990, c. H.7″. (2025, June 5). Ontario.ca. https://www.ontario.ca/laws/statute/90h07#BK6
Hutchins, B. (2025, October 9). Update: Approved – Kingston’s doctor recruitment strategy seeks more funding with a change in focus. https://www.kingstonist.com/city-hall/kingstons-doctor-recruitment-strategy-seeks-more-funding-with-a-change-in-focus-updated/
Jones, A. (2023, March 1). Ontario public health units press province for more stable funding. The Globe and Mail. https://www.theglobeandmail.com/canada/article-ontario-public-health-units-press-province-for-more-stable-funding-2/
Jones, A. (2024, May 8). No concern about ‘diminished supply’ of doctors: health ministry. CBC. https://www.cbc.ca/news/canada/toronto/doctors-ontario-medical-association-fees-1.7197475
Karpoche, B. (n.d.). Bill 114, Pandemic Preparedness Act, 2022. Legislative Assembly of Ontario. https://www.ola.org/en/legislative-business/bills/parliament-42/session-2/bill-114
Municipal Act, 2001, S.O. 2001, c. 25″. (2025, June 5). Ontario.ca. https://www.ontario.ca/laws/statute/01m25#BK1
New Data Shows There Are Now 2.5 Million Ontarians Without a Family Doctor. (2024, July 11). Ontario College of Family Physicians. https://ontariofamilyphysicians.ca/news/new-data-shows-there-are-now-2-5-million-ontarians-without-a-family-doctor/
Office of the Premier. (2023, March 30). Province Helping More Ontario Students Become Doctors at Home in Ontario. Ontario. https://news.ontario.ca/en/release/1002882/province-helping-more-ontario-students-become-doctors-at-home-in-ontario
Ontario Medical Association. (2024, April 3). Ontario’s doctors say new medical school spots are one piece of the puzzle to fix the crisis in family medicine. OMA. https://www.oma.org/newsroom/news-releases/2024/april/ontarios-doctors-say-new-medical-school-spots-are-one-piece-of-the-puzzle-to-fix-the-crisis-in-family-medicine/
Ontario Medical Association. (2024, October 21). Stop the Crisis. OMA. https://www.oma.org/advocacy/stop-the-crisis/?shpath=/priorities/every-ontarian-needs-a-doctor
Tranjan, R. (2025, November 6). Ontario Fall Economic Statement: No help on the way. Canadian Centre for Policy Alternatives. https://www.policyalternatives.ca/news-research/ontario-fall-economic-statement-no-help-on-the-way/?fbclid=IwY2xjawOJ8aBleHRuA2FlbQIxMQBicmlkETFMT0JqTlJtbHFZWllRbzVEc3J0YwZhcHBfaWQQMjIyMDM5MTc4ODIwMDg5MgABHkCUJAhyW2RcGwDCD4PeyF5qS5CnzfCG0c0kcGeYoUqbHj-u-uF