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Globally, the mix of private- and public-sector involvement in health care delivery is a focus of political concern. This concern in Canada takes place within the parameters of the federal Canada Health Act. Private for-profit activities in the health care sector in Canadian provinces have moderately shrunk the definition of ‘necessary medical and hospital services’ that must be provided by the public administration system under the federal Canada Health Act. In this article, we argue that the development of new technologies, pharmaceutical innovations, competing (non-health) demands on the federal dollar, and an aging population together create an environment where pressures for economic and political sustainability have led to some erosion of necessary health services in the provinces. Such pressures have, in turn, led to the growth of private commercial-sector health services. Within Canada’s federal system, provincial negotiation of the role of commercial health care organizations has developed in different ways in Ontario and Quebec. Such subnational developments are a significant focus for comparative health policy analysis. [ABSTRACT FROM PUBLISHER]