Canadians not only love their publicly funded health-care system, they are defined by it.
When CBC asked Canadians in 2004 to identify the greatest Canadian, 1.2 million voted for the father of Medicare, Tommy Douglas, beating out Terry Fox and Pierre Elliott Trudeau, who finished second and third, respectively.
But decisions made more than a century ago during the drafting of the Constitution Act of 1867, and health policy decisions made since then, have resulted in a health-care system that is mediocre – at best – and a never-ending feud between the provinces and the federal government over health-care funding.
These decisions restricted public funding to physicians and institutional care; other health-care providers, community-based care and home care were initially excluded. Drug costs were also left out, resulting in perennial discussions about a national pharmacare program.
It is time to take off our rose-coloured glasses and look for practical health-care solutions.
Under our founding Constitution Act of 1867, section 92, provinces have jurisdiction over the design, management and delivery of health care, with a few exceptions, such as marine hospitals and quarantine, which aligned with international ocean travel for goods, services and passengers.
Canada’s journey toward a publicly funded health-care system started with universal public hospital coverage in Saskatchewan in 1947. Coverage expanded to include physician services, again starting in Saskatchewan, in 1962.
By 1966, all provinces followed suit and the federal government agreed to cover half of the costs of insured hospital and physician services.
The cost-funding agreement between Ottawa and the provinces evolved through time. The Canada Health Act of 1984 now governs health transfer payments, which are Ottawa’s contributions toward provincial insured health-care costs.
The federal government has increased health-care transfer payments annually. Since 2017, the payments have been tied to the gross domestic product; they are projected to be more than $49 billion in 2023-2024.
Despite the increases, federal health-care transfer contributions have not kept pace with escalating health-care costs. Federal transfer-payment contributions have incrementally declined from 50 per cent and now amount to approximately 22 per cent of total public health-care spending, according to the Canadian Medical Association. The provinces want more money; Ottawa wants strings attached.
The here and now – health-care crisis
Health care has become the top concern for Canadians, beating out inflation, environmental issues and jobs, according to a Nanos Research poll conducted this month.
Last August, Nanos reported that 70 per cent of Canadians feel that access to health care is worse after the COVID-19 pandemic, about 50 per cent believe we are in a health-care crisis and 38 per cent don’t trust either federal or provincial governments to fix the problem.
Canadians are suffering while waiting years for elective surgery, enduring hours of waiting to be seen in emergency departments and then waiting for days to be admitted to a ward. More shocking is the increasing number of patients dying while waiting in the emergency department.
Last July, provincial and territorial premiers met in Victoria and their message to Ottawa was clear – increase health-care transfer payments from 22 per cent to 35 per cent and make the increase permanent.
Ottawa questioned the provinces’ math and countered that Ottawa’s overall health-care funding contributions amounted to 27.9 per cent of provincial health-care costs; when bilateral deals for long-term care, home care and mental health are included, Ottawa’s contribution increases to almost 39 per cent.
I suspect that pragmatism will slowly, and eventually, win out over ideology in all provinces.
The Prime Minister says Ottawa is willing to some extent but not without conditions. According to some reports, Ottawa and the provinces’ are close to an agreement on a 10-year funding deal that would increase federal health transfers, along with bilateral financial agreements in specific areas of health care.
Ottawa is offering “top-up” funding for five priority areas:
- Easing diagnostic, treatment and surgical backlogs and adding health-care workers,
- access to family care services,
- long-term care and home care for seniors,
- mental health and substance use and,
- health data and virtual care.
Expanding the health-care workforce is the top priority for Canadians, according to a Nanos poll published last month.
I suspect that pragmatism will slowly, and eventually, win out over ideology in all provinces given the gravity of the health-care crisis and mounting public pressures on elected leaders.
It is time to stop normalizing our broken health-care system. Political leaders need to quit bickering about who pays for what and get on with actually fixing the problem.
The constant political jousting between the provinces and Ottawa on health-care funding continues to erode public confidence. Even with a 10-year agreement, the back-and-forth finger-pointing over health care will only be put off for a while.
One solution, though it comes with its own political hurdles, would be to opt for a single-payer system and decide who this single-payer will be.
Although cost estimates are not published, the administrative costs to run the Canada Health Transfer program are undoubtedly substantial. Efficiencies could be had with a system under which either the federal government or the provinces both fund and deliver health care, instead of shuffling responsibilities between them.
From a constitutional point of view, it would be easier for the provinces to take full control of health-care funding, as they already have the jurisdiction for its delivery.
An agreement among provincial health ministers for a harmonized set of “essential health services” would be required. This would hold provinces accountable to their electorates to fund and deliver health-care services, eliminating finger pointing at Ottawa.
Moving to a national health-care system would require constitutional amendments, which are possible but unlikely to be agreed upon by all the political players any time soon.
Expand the field
Until now, doctors and health-care services provided in hospitals have been preferentially funded at the expense of all other health-care providers and services.
This has resulted in a “physician-centric” model of health-care funding and service delivery. Public funding must be expanded to cover other independent, and regulated, health-care providers, such as dentists, optometrists, physiotherapists, occupational therapists, chiropractors, nurse practitioners and, based on recent policy decisions, pharmacists.
Drugs now account for about 14 per cent of total health-care spending. Report after report has recommended that Canada adopt a national pharmacare program. From an economy-of-scale perspective, centralizing negotiations for a national drug plan between big pharma and Ottawa would lower drug prices. The Canadian Health Coalition estimates that $5 billion a year could be saved on prescription drugs with a national pharmacare program. This would justify such a program, no matter whether the provinces or Ottawa were funding health care.
A redistribution of existing public health-care funding to various health-care providers beyond physicians, choosing either the provinces or Ottawa to fund public health-care, and savings from a national pharmacare program will all bring us closer to financially sustainable health care.