Many Canadians may not think very deeply about the health-care system until they are forced to use it. And even when they are, not everyone will consider the nuts and bolts of how different components of the health-care system interact.
Although tariffs and the ongoing trade war with the United States has dominated political discourse over the last several weeks, reports show that Canadians still view health care as one of the three most important issues facing the country in this federal election.
But how much control will the ruling federal party have over the kind of health care that Canadians receive? How different is the quality of care between different provinces and territories? And what are each of the parties prioritizing when it comes to the future of Canadian health care?
With voters heading to the polls on April 28, we figured it’s time for a refresher on how health policy is made and where the parties stand.
What control does the federal government have over the health-care system?
The biggest tool that the federal government has to influence health care is through funding to the provinces and territories. This happens primarily through the Canada Health Transfer, or CHT.
CHT payments are made on an equal per capita basis to the provinces. The aim of the CHT is to create a comparable standard of care across the country, regardless of where someone lives (though this doesn’t always stand up to scrutiny in practice, but more on that later).
The federal government can also exert control through the withholding of CHT payments when, for example, provinces are found allowing extra-billing or otherwise engaging in practices that violate the Canada Health Act (CHA).
What does the Canada Health Act have to do with health care?
Well, pretty much everything. The CHA is federal legislation that outlines the basis for Canada’s public health-care system.
It was passed under Prime Minister Pierre Trudeau in 1984, replacing the 1966 Medical Care Act, and sets out the primary objectives of Canadian health-care policy. It establishes a framework for the CHT and outlines five main criteria that provinces must meet to uphold the values of the CHA (and receive CHT funding).
Those five principles are: public administration, comprehensiveness, universality, portability and accessibility. You can find more on the five principles of the CHA here.
What else does the federal government control when it comes to health?
In addition to providing funding to the provinces, Ottawa regulates the production of food, pharmaceuticals, cosmetics, medical devices and more.
It can also fund health research, track disease monitoring and prevention, and provide tax credits such as for people with disabilities, to cover certain medical expenses and provide support for caregivers and disabled dependents.
The federal government also provides direct health-care services to certain groups, namely First Nations living on reserve, Inuit, members of the Canadian Forces, inmates incarcerated in federal prisons and some refugee claimants.
What are the issues surrounding Indigenous health care?
The quality and availability of health-care services provided to Indigenous populations has been the subject of much controversy throughout the history of Canadian medicare.
Although the scope of the legislative issues and care-related injustices are too vast to do justice to here, to put it briefly, some experts have called the health of Indigenous people in the country “an embarrassment to Canada and our health-care system.”
The Truth and Reconciliation Commission’s Report outlines reasons for this “embarrassment,” including but not limited to a lack of clear government accountability and frequent disputes between federal and provincial governments over who is responsible for paying for various health services for Indigenous peoples.
While the CHA outlines certain conditions required of provincial health insurance programs, generally speaking the health of Indigenous people falls under federal responsibility. However, the absence of clear criteria for the delivery of that care (and which specific aspects of care fall under the responsibility of whom) has led to deadly bureaucratic delays and created significant gaps in care for Indigenous people.
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Where do the parties stand on health policy?
Not all parties have released official platforms on health policy at the time of publication. But this is what we know so far:
The Liberal Party: At the time of publication, the Liberals have yet to release an official platform on health care for 2025. What has been released on Mark Carney’s individual campaign site focuses on strengthening the Canadian economy and improving health care by “streamlining credential recognition [for health-care workers] across provinces and territories.” In power, the Liberals have emphasized investing in public health care by targeting health-care worker recruitment and increased conditional funding for provinces. Ottawa also developed long-term care national standards but stopped short of making them mandatory.
The Conservative Party: At the time of publication, little has been released regarding the Conservative Party’s official health platform, but it won’t cut pharmacare or dental care programs if elected. Conservative leader Pierre Poilievre recently vowed to invest $1 billion in drug treatment for 50,000 Canadians. He added that he would cut federal funding to existing harm reduction programs while allowing the exemption for programs like overdose prevention sites to expire. This would shift the approach to mental health and addictions almost entirely towards treatment. Experts say it is unclear whether the refusal to renew the exemption would shutter existing programs, but speculate there may be a court challenge if so.
The New Democratic Party: The NDP has proposed to prevent the “Americanization” of public health care by cracking down on “cash-for-care” clinics that charge for publicly insured services and to ban American companies from buying Canadian health-care assets. NDP leader Jagmeet Singh has also promised that if his party is elected, every Canadian will have a family doctor by 2030 and recently promised the expansion of full, universal pharmacare. Singh has been critical of Conservatives for backing the expansion of for-profit care and of the Liberals for allowing “provinces such as Alberta and Ontario to expand the use of private-care models.”
Bloc Québécois: The Bloc is against the federal government imposing conditions on transfers to provinces. It has proposed increases in the federal health transfer to 35 per cent of total costs, amounting to a roughly $40 billion increase in federal health spending. Bloc leader Yves-François Blanchet said the party would use this increase to address the “fentanyl crisis,” taking aim at improving “deficient provision of mental health care, rehabilitation centre spaces … supervised consumption sites and harm reduction,” as well as border control measures in collaboration with the U.S. and Mexico. The Bloc would also ask the federal government to transfer oversight of the Canadian Dental Care program to Quebec.
The Green Party: The Greens have proposed to invest more heavily in the public health system. The party wants to expand the scope of CHA to include universal pharmacare, provide greater access to dental care for lower income Canadians and cover mental health care. It proposes to “provide stable, long-term funding to provinces and territories, hire more health-care workers, expand home care and community care, ensure access to reproductive care across Canada and invest in public health instead of allowing for-profit corporations to take over more health services.”
The People’s Party: The People’s Party proposes to repeal the CHA and “create the conditions for provincial and territorial governments to set up mixed private-public universal systems.” It also proposes to do away with the CHT and instead focus on payments through the transfer of tax points. It also has outlined a number of policies targeted at “gender ideology,” including outlawing the use of puberty blockers and gender affirming surgery on minors. It also proposes to repeal Bill C-16, which added gender identity or expression as grounds for protection against discrimination.
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What do the provinces and territories control?
Most of the on-the-ground regulation and implementation of health care is the responsibility of provinces and territories.
Under the CHA, they are responsible for the management, organization and delivery of “all medically necessary” services. However, the exact definition of “medically necessary” is not laid out in the CHA and is therefore subject to interpretation by provinces and territories.
While this allows for some necessary flexibility to address the health needs of diverse populations, critics have highlighted that this is also a contributing factor to a number of gaps within the system.
Generally, “medically necessary” refers to hospital services like emergency care, surgery and anesthesia, lab tests, X-rays and ultrasounds, as well as any medications, treatments or procedures provided in hospitals.
Provinces are also required to cover visits to family doctors, specialists and walk-in clinic costs. But disparities exist between what is covered in each province, for example in-vitro fertilization is fully covered in Ontario, Quebec and British Columbia, but not covered at all in Alberta and Saskatchewan.
Each province or territory has a ministry of health, or a government department that oversees health regulations. The ministry implements health programs and oversees health-care facilities like hospitals.
The provinces also set standards and guidelines in several areas including home and community care, health planning, administrative services and governance.
Who pays how much and for what?
More than 70 per cent of health-care spending is publicly funded through general taxes, whether provincial or federal. But how much funding is provided by the federal government versus what should be paid for by the provinces has been the subject of debate since medicare was first established.
Negotiations around the CHT have consistently made headlines. Though provinces often claim the federal government has not been pulling its weight in terms of health spending, analyses revealed that over the past 20 years federal transfers mostly have outpaced increases to provincial health budgets.
In 2023, the Liberal government pledged a $196-billion health deal that would increase the CHT by 61 per cent over the next decade. Despite much debate, the provinces eventually agreed to the deal in addition to signing their own one-on-one agreements with Ottawa.
Between 2023 and 2024, the federal government paid nearly $50 billion to the provinces and territories via CHT, representing about 22 per cent of provincial and territorial health-care spending.
Despite the financial transparency of this most recent health deal, getting a clear view of who is paying for Canada’s health care isn’t always so straightforward. No government is collecting health spending data on a national scale and exact federal contributions can be difficult to pin down, particularly as Ottawa often includes tax point transfers (a system by which the federal government lowers its tax rates for things like personal income so provinces can increase theirs) when calculating its contributions to provinces.
Historically, the CHT has had few strings attached aside from general adherence to the five principles of the CHA. But in the most recent 10-year spending deal, Ottawa set a series of criteria to be met by provinces and territories, including various accountability measures such as progress reports aimed at improving access to family health services, mental health and substance use treatment and expanding the health-care workforce.
Organizations like the Canadian Medical Association (CMA) have called the measures an “excellent first step” but have made calls for increased accountability of health spending and the appointment of a Chief Healthy Accountability Officer.
What types of health care are not covered in Canada?
To date, the CHA still does not include provisions for universal pharmacare, mental health services, non-emergency dental care or long-term/home care. The recently passed Canadian Dental Care Plan is not part of the CHA and covers only eligible Canadians.
However, the fact that some services are not included in the CHA does not preclude the provinces from offering them through their own insurance plans should they choose to do so.
What types of drug, mental health and dental coverage are available (and to whom) through provincial plans vary widely based on where you live.
The federal government could feasibly change the CHA to include any number of these services, making them mandatory and accessible across the country and many have advocated for such reforms over the years.
The private vs. public care argument
There are many aspects of our public health-care system today that are handled by private companies (most, but not all, Canadian medical laboratory tests outside of hospitals, cataract surgeries, community-based rehabilitation, etc.). This means that private companies receive public funds to provide a service.
Other private services provided by private, for-profit companies, but charged to the patient – for example dental care, massage therapists and some telehealth services – fall outside of public insurance and are paid out-of-pocket if not covered by private insurance.
There have been calls from the CMA to cautiously embrace a mix of private and public health care in an already-mixed system to meet growing demand.
However, organizations like Canadian Doctors for Medicare argue that increasing our reliance on private, for-profit companies will only further weaken the public system and increase costs.
The 2020 Cambie Surgeries Corporation vs British Columbia decision, which was upheld in a 2022 appeal, is often regarded as a major victory for the public system.
The plaintiffs had wanted B.C. courts to allow for extra billing and user fees for faster access to private care when wait times were too long in the public system. In effect, this would have allowed those who could pay more to “jump the line” for surgeries.
B.C. Supreme Court Justice John J. Steeves dismissed the challenge, saying he saw nothing to suggest that unrestrained private health care would reduce wait times in the public system, adding that it actually would worsen wait times.
Despite wins like the Cambie case, experts have highlighted that practices that violate the CHA are on the rise and have been for some time, including dozens of instances in which clinics have charged extra fees for “upgraded services.” When these fees are assigned to things that are otherwise covered by the public system, it is known as “extra-billing” and is currently against federal and provincial law.
Very helpful overview. Thanks. One complication to achieving accountability and transparency for healthcare delivery not mentioned is that some provincial jurisdictions fold federal government CHA transfers into general revenues, rather than into health ministry budgets.
The federal government is responsible for the abysmal state of health care for indigenous people. I always find it amusing when people want the federal government to do more in the health care field given their abysmal track record in indigenous health (and their not much better job of providing health care for our military and their families).