Restoring universality to health care imperative

The Canadian health-care system’s resistance to reform has diverged from the evidence for several years. But that may be changing.

Factors — including the new court challenge of the single-payer health system in British Columbia, the Quebec government’s ongoing reforms including the recent announcement of the elimination of auxiliary fees, and federal-provincial negotiations on a health accord — has put health-care reform atop the national agenda.

The case for reform is well-known. Canada’s health-care system isn’t only increasingly fiscally unsustainable, it’s performing poorly across indicators including wait times, access to medical technologies and supply of doctors.

Yet what’s less widely known is the extent to which the Canada Health Act is causing Canada’s health-care system to fall short of universality.

The Act sets out expectations provinces and territories must meet to receive the Canada Health Transfer. Failure to comply can cause transfer payments to be clawed back.

The Canada Health Act’s conception of “medically necessary services” is the crux of the issue. By narrowly defining these services along acute-care lines representing roughly 45 per cent of total healthcare spending and imposing it on the provinces and territories with threat of clawbacks, Ottawa has created a two-tier system.

It has frozen in time a conception of Canada’s health-care system that essentially ignores more than half of present-day health-care spending. We have universal coverage for all Canadians for roughly one-half of the system and uneven coverage based mostly on employer-provided insurance or out-of-pocket spending for the other half, including drugs, dental, vision and long-term care.

This means a significant proportion of health-care spending is neither part of our commitment to universality nor subject to public insurance irrespective of one’s means or circumstances.

The result is less affluent households, unattached individuals and senior couples spend a disproportionate share of their disposable income on health care. And it’s rising.

Quebec is an outlier to the extent that it has a public drug plan for those without private insurance. But a series of reports, including by the province’s health and welfare commissioner, has shown the plan is facing financial challenges and providing inadequate coverage.

It doesn’t have to be this way. Most jurisdictions with universal coverage are able to extend public health dollars across a wider range of services by involving different forms of patient cost-sharing such as co-insurance, co-payments or deductibles.

The goal should be to expand public coverage across a wider range of services for low- and middle-income Canadians by making coverage less generous for high-income earners, although there should be exemptions for those with chronic conditions.

This makes sense in a world of scarce public resources and changing health-care priorities. The result would be a fairer, more universal and affordable health-care system, including a strengthened public drug plan in Quebec.

But the first step must be to repeal sections of the Canada Health Act that prohibit extra billing and user fees. Ottawa’s recent pressure on the Quebec government to eliminate auxiliary fees is evidence.

The prohibition on user fees is no longer helping protect the Act’s universal aspirations. Increasingly, it’s contributed to a two-tier system.

The window for health-care reform is opening. Modernizing the Canada Health Act to better achieve universality should be a top priority.