Medicare marks 60-year milestone in Saskatchewan. What’s next?
The launch of Medicare in 1962 was marked by strong controversy, political division, striking doctors, a “red scare,” and spying by the federal government. But with time, people increasingly welcomed a health care system based on need rather than the ability to pay. By 1972, every province in Canada had adopted the Saskatchewan Medicare model. Medicare became a much beloved system that was envied by other nations. But where’s it at today?
One of the key features of Medicare, legislated by the Canada Health Act, was comprehensiveness. “Medicare was supposed to be comprehensive. The vision of Medicare that Tommy Douglas had was never to limit it just to doctors and hospitals. That’s where it started,” says Steven Lewis, health policy analyst, research consultant and Adjunct Professor of Health Policy at Simon Fraser University.
To truly deserve to be called a comprehensive system, the system should add services, he says. “Medicare reached its highwater mark probably in the late 70s to early 80s and it hasn’t added a whole lot of services since then. It’s still mainly focused on physician and hospital care from the standpoint of public financing,” says Lewis. There was a move in the 1970s to expand in some areas. Saskatchewan had a foot care program, and home care began to expand in the 70s, Lewis recalls.
There have been some notable successes in health care—technological successes, surgical successes, more effective drugs, and the population is living longer, Lewis reflects. “But there is also a huge explosion in client diseases.”
Lewis has served on a number of provincial and national health councils. Intermittent national inquiries have looked at federal-provincial relations, what the health care system needed to do to modernize itself and live up to its claim to be comprehensive, accessible, universal and portable.
Innumerable provincial reviews of the system have also taken place over the years. Lewis finds they pretty much all say the same thing: • The program should rely more on community care and less on institutional care.
It should focus more on modernizing services for seniors because the needs have changed. The population is aging; the system needs to get better at managing chronic diseases. The system could be more efficient.
While there is general consensus in most of these reports, there is very little follow through, he says.
A Commonwealth Fund 2021 report found that Canada’s health care system scored poorly against its peers: 10th out of 11 high income nations surveyed. The United States was last. Canada was ninth in access to primary care, which reflects wait times and affordability. A Fraser Institute report earlier this year noted a scarcity of key medical resources in Canada compared to peer countries with universal health care.
The system currently has 70 per cent public funding and 30 per cent private funding. The latter is high by OECD standards. The public versus private funding question remains an open debate. Lewis believes there are big risks inherent in having the government pay private clinics for medical procedures (such as MRIS or certain surgeries), “but it doesn’t undermine the public financing of medical care.”
According to the Fraser report, Canada ranked second highest in health care spending out of 28 countries. “We’re weakest in timely access to care and we get very low marks on value for money,” says Lewis. In the Netherlands, 61.5 per cent of patients can get same-day or next-day service with a call to the doctor. In Canada that number is 34.7 per cent, resulting in crowded ERS.
There were cracks in the system before the pandemic and COVID has heightened them. “The indicators that it wasn’t performing well were well known before COVID,” says Lewis.
If he’s being optimistic, Lewis suspects there may be “an increasing appetite to expand Medicare.” The deal Ottawa recently made with the NDP to maintain a majority in the House of Commons includes a dental plan. “There will be some kind of dental program on a national basis.”
Another potential area for expansion is the care of seniors. “With the crisis revealed by the pandemic in long-term care, I think there may be some political will to invest more in community care and community programming, particularly for seniors, and rely less on long-term institutional care because those were and still are hotbeds of vulnerability to pandemics,” Lewis observes. People don’t want more nursing homes. “They want to live independently on alternate models.” Restructuring would require greater investment into home care. “We’re very stingy with home care in Canada compared to European countries,” Lewis laments.
The pandemic revealed a vast need for mental health services. “There’s always been a case for including mental health care in universal care and I think it makes a mockery of the principle of comprehensiveness if mental health care isn’t a core essential service,” he says.
Other changes could involve improving working conditions, creating a more equitable distribution of care, developing an alternate payment model and forming teambased practices.
No doubt, Canadians will always want a publicly funded health care system. In this pivotal moment, it remains to be seen whether COVID will help break the inertia. “Will there be a recognition that we have to do some things fundamentally differently, so the system actually improves?” Lewis wonders.
There are good ideas from dozens of reports as well as models from other countries that haven’t been implemented. “There are lots of problems in our system about access and quality that can be solved by looking at what others have done, but it does take some courage, it takes some vision, and it takes the ability to negotiate in a respectful and trustful way with the people who have to change.”