It doesn't matter what the intentions are. The provincial government's actions are resulting in a shift to two-tier health care in B.C.

People who can pay get fast, effective treatment. The rest of British Columbians wait, suffer and get sicker.

Last month, the Vancouver Island Health Authority said provincial funding was inadequate to maintain health care services. It cut surgeries and support for seniors and people with mental illness.

For example, last year the health authority did 124 bariatric surgeries. The operations help obese people who have been unable to lose weight in less extreme ways. Their stomachs are made smaller or bowels shortened to reduce the absorption of calories.

It's not easy to get on the list for the surgery, which is expensive and, of course, carries risks. Patients who receive referrals have tried other ways of losing weight and face serious health complications from obesity.

Tough luck, some would say. Try harder or suffer.

That ignores the reality of their illnesses. And it ignores the great costs that the system would face in coming years if they remain obese. Pragmatically, effective treatment is a good investment.

Last year, the health authority performed 124 of the procedures in Victoria. This year, it will cut the number to 80. Next year, it will reduce the number of surgeries to 52.

Demand hasn't fallen. The wait for treatment is measured in years.

But the health authority's provincial funding for this year falls $45 million short of what is needed to provide health-care services. The gap will be greater next year.

So patients won't be treated. Unless they have money.

The False Creek Surgical Centre, a private clinic in Vancouver, has been advertising an information session in Victoria this weekend on its weight loss surgery. People can register for a presentation with light snacks and a chance to have questions answered. A similar session is planned for Kelowna later in the month.

It's a good business move. There are desperate people who have waited several years for surgery, and now face an even longer wait. The surgical centre can offer them speedy, effective treatment.

Or it will if they have about $17,000 to cover the costs of lap band surgery and follow-up. The procedure involves placing an inflatable ring around the upper stomach, limiting the amount of food the person can eat and increasing the length of time to digest the food.

Bravo, say some people. If I can pay extra to jump the queue for other services or for higher quality treatment, why not for health care?

But so far Canadians have decided that health care is different. We have, after a fierce public discussion, decided that when care is rationed, it shouldn't be auctioned off to the highest bidder.

If two people have an illness, then the decision on who gets treatment is to be based on medical need.

We've even written the principle into law. The Canada Health Act and B.C.'s Medicare Protection Act say people cannot pay extra for speedier treatment for any medically necessary procedure.

But the law is routinely ignored. Private clinics have pushed the boundaries in offering more and more surgery to those who can pay for faster treatment.

You can't argue credibly that the weight-loss surgery isn't medically necessary. The diagnosis of medical need has already been accepted by the health-care system, at least for people on the wait list.

The False Creek Surgical Centre emphasizes the point. Obesity is not the result of a lack of willpower. "It's a disease that requires treatment," the centre says on its website. And the centre also points out that the surgery can reduce patients' risk of diabetes, heart disease, stroke, cancer and other serious conditions.

I don't fault people who decide to pay for the surgery. I probably would.

But the combination of surgical cutbacks and inaction on the expanding role of private clinics is taking us a long way from the principles of medicare -- and the laws that set them out.

Footnote: The issue might end up being resolved in the courts. Four private clinics are challenging the government's ability to enforce the Medicare Protection Act. And a group of patients is suing to require the government to enforce the act.