Universal healthcare is based on need and not ability to pay. Most Canadians consider MediCare, a publicly funded system, to be a point of national pride (Martin et al., 2018). Although the main goals are to eliminate health inequities and increase accessibility to valuable services, there are several ways in which Canadian MediCare can be improved. I will review the history, limitations and criticisms of Canada’s health care approach and provide recommendations for modernization of the Canada Health Act (CHA).
An overview of the Canadian health system is shown in Figure 1 (Martin et al., 2018). The Federal government as well as Provincial and territorial governments have specific roles. The split between powers is determined by the British North American Act from 1867, which was later renamed as the Constitution Act in 1982 (Canadian Human Rights Commission, n.d.). Generally speaking, provinces are responsible for funding and administrating the system and the Federal Government provides financial incentives and holds provinces accountable to the CHA’s principles (Flood & Thomas, 2016). The CHA’s 5 core principles are comprehensiveness, accessibility, universality, public administration, and portability (Flood & Thomas, 2016). Portability refers to allowing Canadian residents to keep coverage when travelling or moving within the country (Martin et al., 2018). The Canada Health Act states universal coverage is limited to “medically necessary” hospital and physician services, to the exclusion of vital goods and services (Flood & Thomas, 2016). Notably, excluded from public funding are dental care, vision care, complementary medicine, and outpatient physiotherapy as seen in layer three in Figure 1 (Martin et al., 2018). Every province has slightly different political philosophies, budgeting systems, and overall governance; however, they all work within the same framework according to the rules of the CHA (Canadian Human Rights Commission, n.d.). CHA prohibits user chargers and extra-billing (Flood & Thomas, 2016). In order to access federal funding for care, provinces and territories must adhere to the CHA (Martin et al., 2018).
Figure 1. Governance and coverage of the Canadian health system (Martin et al., 2018).
Saskatchewan was a trailblazer, being the first to implement universal public health insurance in all of North America (Martin et al., 2018). The leader of this change was the Premier of Saskatchewan; He was a Scottish Canadian named Thomas Clement “Tommy” Douglas, who nearly lost a limb to osteomyelitis in his childhood since his family was unable to afford care (Martin et al., 2018). Douglas’ approach was later adopted by the rest of the country (Martin et al., 2018). Figure 2 highlights key events in the adoption of the Canada Health Act (Martin et al., 2018). In Saskatchewan, physicians went on strike for 23 days because they wanted professional autonomy and economic bargaining power (Martin et al., 2018; Flood & Thomas, 2016). To end the strike, it was agreed that physicians would remain independent professions and would bill the government on a fee-for-service basis (Martin et al., 2018). They operate as self-regulated, independent contractors (Flood & Thomas, 2016). This separation has created some issues with accountability (Martin et al., 2018). An estimated 30-40% of total health care utilization in Canada is unnecessary, with Flood and Thomas (2016) attributing it to “physician-induced demand.” A suggestion to help reduce this is to give physicians “prescribing budgets" so they internalize the costs for the drugs they prescribe (Flood & Thomas, 2016). Martin et al. (2018) describe further fragmentation in hospitals and health authorities, explaining that decisions about services are generated by independent boards with separate budgets (Martin et al,. 2018).
Figure 2. Timeline of historical process for the Canada Health Act (Martin et al., 2018).
Canada’s health care needs are evolving. With the growing number of chronic disease, a gap in the scope of coverage becomes increasingly obvious. More and more Canadians are required to pay privately for services outside the public basket (Flood & Thomas, 2016). Figure 3 shows the total health expenditures for Canadians, with 70.9% being funded publicly via general taxation.
Figure 3. Breakdown of funding for health care in Canada
Paying through private insurance or out-of-pocket has resulted in "passive privatization", a term used by Flood and Thomas (2016) to describe the dynamic growth of overall health spending. Those that do not have supplemental private insurance to access certain services outside the public basket are more likely to be women, youth, and low-income individuals (Martin et al., 2018). Working poor people are also vulnerable because public coverage typically focuses on seniors or those that are unemployed and receiving social assistance (Martin et al., 2018). Out of all the developed countries with universal health coverage, Canada is the only one that does not include prescription medications (Martin et al., 2018). More than half of prescription drug funding is financed through private means (Martin et al., 2018).
Some critics of universal health care have used a right-focused argument, stating that a patient has the right to purchase care privately in order to minimize suffering due to wait times. However, this can leave certain groups vulnerable. In general, people who argue for pivoting away from universal health care and embracing further privatization either seek to gain financially or have an ideology against redistribution (Flood & Thomas, 2016). I am in favour of universal health care and based on my review of the literature, here are the recommendations I have to modernize the Canada Health Act:
1) Change the scope of coverage:
A transparent, evidence-based process should be used to decide which services are included in the public basket (Flood & Thomas, 2016). Recommendations from the Canadian Agency for Drugs and Technologies in Health should continue to be respected (Martin et al., 2018). The impact of health care services should be evaluated carefully. A broader range of services should be included in the scope of coverage, beyond those supplied by physicians and in hospitals. In particular, the coverage should include prescription drugs, mental health, home care and dental care (Flood & Thomas, 2016). It is important to note that it is impossible to add services to the list without also delisting some of the relatively less important or unnecessary services. Otherwise, there would be ever-increasing expenditures and it wouldn’t be financially feasible in the long term. Flood and Thomas (2016) highlight the successful implementation of universal drug insurance in New Zealand, called Pharmac, despite considerable amounts of resistance through protest and political interference. Including pharmaceutical drugs in the public basket will help with prevention as well since many lower income Canadians avoid or delay seeking care for fear of incurring costly prescriptions (Flood & Thomas, 2016).
2) Aim to reduce wait times:
Priority areas including cancer care, cardiac care, and diagnostic imaging should continue to have targeted funding and programs that experiment with wait-time guarantees (Martin et al., 2018). Across all areas, including elective care, using inter-professional teams and a centralized referral system can reduce wait times (Martin et al., 2018). For example, with team-based care and reorganization of the referral model, the Alberta Bone and Joint Health Institute in Calgary were able to reduce wait times dramatically (Martin et al., 2018). Wait times for consultation for hip and knee replacements went from 145 days to only 21 days (Martin et al., 2018).
3) Minimize health disparities in vulnerable populations:
Ameliorating the relationship between the Government and Indigenous people is necessary. First Nations, Inuit, and Métis are the constitutionally recognized groups that make up 4.3% of the Canadian population (Martin et al., 2018). They experience significantly worse health outcomes and lower life expectancy (Martin et al, 2018). Indigenous people have higher rates of chronic disease, infant mortality, trauma, interpersonal and domestic violence, and suicide (Martin et al., 2018). The suggestions for fostering a constructive relationship are to critically evaluate the current health care system, create cultural safety and humility to rebuild trust, and include more Indigenous peoples as leaders and health care providers (Martin et al., 2018). Using Telemedicine to prevent losing patients to follow-up and to provide rapid access is crucial for those living in rural and remote communities (Martin et al., 2018).
4) Improve overall governance and accountability:
Canada’s governance has been criticized as being “passive, opaque, and only tenuously evidence-driven.” (Flood & Thomas, 2016). Increasing professional accountability is required, especially for Canadian physicians if they are to remain self-employed (Martin et al., 2018). Flood and Thomas (2016) suggest that the Minister should appoint a taskforce that evaluates the services and categories of care to be listed or delisted from coverage. A comparison between publicly funded services across the provinces should be easily accessible for Canadians on a central website (Flood & Thomas, 2016). Flood and Thomas (2016) explain how philosophers Daniels and Sabin view the problem stating:
“Citizens in pluralistic societies will never reach moral agreement on principles for resolving rationing problems…our aspirations for justice in health care should aim at achieving fair processes for rationing.”
In a sense, budging the line simply because one has a financial advantage over someone else goes against the Canadian core values of equity and solidarity. Universal health care with modernization of the CHA to reflect the changing needs of our citizens will help keep Canadians proud, safe, and healthy.
Canadian Human Rights Commission (n.d). A Three-Minute Guide to the BNA Act, 1897. Human
Rights in Canada: A Historical Perspective. Retrieved from https ://www.chrc-
ccdp.gc.ca/historical-perspective/en/browseSubjects/bnaguide.asp Flood, C.M. & Thomas, B. (2016). Modernizing the Canada Health Act. Dalhousie Law Journal,
39(2), 398-411. Retrieved from https://papers.ssrn.com/sol3/papers.cfm?
abstract_id=2907029 Martin, D., Miller, A.P., Quesnel-Vallee, A., Caron, N.R., Vissandjee, B., Marchildon G.P. (2018).
Canada’s universal health-care system: achieving its potential. Canada’s Global Leadership
on Health, 391(10131), 1718-1735. Retrieved from https://doi.org/10.1016/S0140-
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