Medicare is often referred to as the highest beacon of Canadian values, a great equalizer among people of all walks of life. While for many this is the story of “Canada the Good,” and a history linked to the narrative of Canada, for others the truth is more complex.
This latter perspective can best be seen in the story of the former CCF premier of Saskatchewan and Canada’s first NDP leader, Tommy Douglas, credited as the “father of medicare.” The common narrative is that of a man moved to champion publicly funded health care as his life’s work due to his own brush with the cruelty of the former system.
As a child, Douglas suffered from osteomyelitis, and avoided amputation of a leg only because a surgeon agreed to offer care for free, in exchange for using his case to teach medical trainees. Later as an adult, Douglas spearheaded the creation of medicare, our publicly funded health-care system, which provides hospital and physician care on the basis of medical need, not ability to pay.
Much less convenient to Canadian mythology is the history of Douglas as a young graduate student who endorsed eugenics in his masters’ thesis titled “The Problems of the Subnormal Family.” Douglas later recanted these views and went on to oppose eugenics laws. Nonetheless, the embodiment of opposing philosophies in one man is a powerful metaphor for the contradictions in the narratives and histories of our health-care system.
One such contradiction is in how systemic racism is both woven into medicare as it exists today, as well as how medicare can be wielded as a tool for racial and social justice.
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The term itself is used by some to colloquially refer to our entire health-care system. More accurately, it refers to a very specific component – the public funding and universal coverage of physician and hospital services, jointly financed by federal and provincial governments, and codified through the Canada Health Act (CHA). Its current iteration (at least for now) excludes many services vital to good health, including prescription drugs, dental care, long-term care and psychotherapy. Notably, medicare pertains to the funding of services alone, not how they are delivered.
Gaps within medicare
There are several ways in which systemic racism manifests in the financing of hospital and physician services in Canada. Determined not by federal legislation, but by provinces and territories, there is no single definition for insured persons, thereby systematically excluding many communities from our publicly funded system. Some groups, such as refugee claimants, members of the Canadian Armed Forces and those in federal prisons, are not insured under medicare, but have insurance via the federal government.
There are now an estimated half-million people completely uninsured in Canada. This includes new immigrants and returning Canadian citizens in Ontario, British Columbia and Quebec, who are subject to a three-month waiting period for coverage; temporary foreign workers who work part-time or have lost their jobs; and people who are or become undocumented, many of whom work precarious jobs in industries like construction. It is no coincidence that the majority of those who are uninsured and face major barriers to accessing care are also racialized, and that their exclusion from coverage is made all the more problematic by their increased vulnerability to poor health.
Early in the pandemic, in response to community advocacy, governments in Ontario, Quebec and B.C. expanded, to varying degrees, coverage for uninsured people. Many of these work in essential services including the industrial food sector, delivery services and long-term care. Recognizing the need to reduce barriers to combat a highly contagious virus and acting out of self-interest, it was nonetheless an important step forward for stigmatized and systematically isolated communities. Challenges remain in the implementation of these policies, and threats to coverage being rolled back have already begun.
Canada has also historically created a parallel system of coverage of health services for Indigenous people, characterized by jurisdictional battles of who will pay for care. For example, the CHA omits First Nations and Inuit peoples, Métis and non-status or off-reserve Indigenous peoples. Instead, it is the 1867 Indian Act that defines Indigenous health as a responsibility of the federal government. Yet, neither the Indian Act nor any subsequent related legislation outlines any obligations to act on this responsibility through funding services.
Federal coverage is provided through the non-insured health benefits (NIHB) program to Indigenous people who qualify as “status Indians,” a term that is itself fraught with issues about who can access it. Associated with the NIHB program are a series of barriers related to access, including excluded services, denial of coverage and lack of knowledge around coverage. The challenges are most present in rural, remote and northern communities. These include a lack of locally available, funded services, which then means people must pay prohibitive transportation costs to go to larger communities for care
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In its calls to action, the Truth and Reconciliation Commission offers a series of specific measures to address a number of these challenges. These include implementing the health-care rights of Aboriginal people as identified in international law, constitutional law and under the treaties, as well as sustainable funding for healing centres.
Gaps outside medicare
Medicare’s universality with respect to services is also limited to only hospital and physician care. Implemented in the late 1960s, medicare’s corresponding legislation was brought into force at a time when health care was predominantly focused on managing acute conditions in hospital settings. Today, health care is increasingly driven by chronic disease management, with services such as outpatient prescription drugs, physiotherapy, dental care, optometry care, long-term care, home care and much of mental health care falling outside its umbrella.
With respect to excluded services, the status quo reliance on private insurance and out-of-pocket payments is an unrealistic and unsustainable remedy, not to mention inherently inequitable. Universal publicly funded systems will disproportionately benefit those in precarious economic situations, and thereby benefit racialized communities disproportionately.
Reforming long-term care requires a diversity and equity approach
For example, outpatient prescription drugs have been historically excluded from medicare. A recent poll showed that Canadians who identify as a “visible minority” are more likely to report having no insurance or only partial coverage for prescription drugs. This confirms prior work done in Ontario showing that while approximately 20 per cent of white workers do not have a prescription drug plan, that figure is approximately 30 per cent for workers who are racialized. Thus, implementing a universal, public drug plan – as an increasing number of health policy experts, patient and civil society groups have been calling for – can also be seen as a tool for racial justice.
A similar pattern is seen for dental care. Approximately six million Canadians avoid visiting the dentist annually because of the cost. An overwhelming majority of dental care, 94 per cent, is paid for privately, a mirror image of funding for medicare. Racial and ethnic disparities are rife. South Asian, Latin American, Black and Arab children have lower rates of dental insurance than those who are white.
Notably, the recent Liberal-NDP confidence and supply agreement offers includes promises for both prescription drug coverage and dental care. It should be approached with cautious optimism. Federal commitments to a public, universal drug plan have been characterized by lofty rhetoric and unfulfilled expectations. The agreement’s dental plan will greatly expand public coverage, but on a means-tested basis, not a universal expansion of medicare.
A strong foundation on which to build
Expanding the basket of publicly insured services is often framed as an expansion of medicare itself, with good reason. Though the status quo must be improved upon, medicare’s core principles offer a strong foundation.
For example, when comparing racialized communities in Canada to those in the U.S., racial disparities in health-care coverage for those in Canada are significantly smaller than in the United States. Even within the U.S., where multiple state and federal health systems exist, differences are apparent. The Veterans Administration operates a single-payer health-care system for military veterans. Within this system of universal public coverage, Black Americans have equivalent or better outcomes for cardiovascular disease than those who are white.
Despite these benefits, there are some in Canada attempting to use the courts to unravel existing universal public coverage. If successful, systemic racism would only worsen in our health-care system.
People in Canada have good reason to be proud of the values that medicare embodies, but we must acknowledge how gaps in coverage have disproportionate impacts on racialized communities. Much like the story of Tommy Douglas, the narrative is not as tidy as it first appears but has the potential for tremendous good. Reconciling racial inequities between already insured people, as well as expanding the definition of both who is eligible for public coverage, and what they are eligible for beyond hospitals and physicians, is a vital step toward achieving true universality, and supporting racial justice in the process.