Canadians have been subjected to a string of recommendations from think tanks, lobbyists and some media outlets that the health-care system is not sustainable, that it is in crisis and that some form of privatization is the answer.

Canadians have likewise been bombarded for the last few years with gloomy news stories of hospital closings, nursing shortages, crises in the emergency rooms, patients sleeping in halls, long waiting lists for surgeries, and doctors fleeing to make their fortunes in the US. Not surprisingly, Canadians believe that the quality of the health-care system has gotten worse.

That makes it all the more remarkable that Canadians remain deeply committed to the present system. It would have been easy for many Canadians, particularly well-off Canadians, to throw up their hands and say to themselves, “Well, we’d better start privatizing the system to ensure that we have access to the best quality health care.” But in fact most Canadians haven’t said that. Instead they’ve said, “fix it.”

Canadians do not agree with the sustained language of crisis and privatization. Despite the blandishments of a gloriously improved system through the introduction of for-profit options, Canadians haven’t signed on. The population is deeply attached to the system, and Canadian governments undermine the publicly funded, universal, national system at their peril. How governments handle the issue over the next five years will determine their longevity, and while Canadians are prepared to accept primary care reform, some hospital closures and improved accountability measures to discourage unnecessary use of the system, they are not prepared to compromise on the core principles of the system.

Canadians speak very clearly through the polls on a number of issues. First, they are very attached to and proud of their health-care system. Second, they are very supportive of the principles of the Canada Health Act and what they understand to be the core elements of medicare, namely that the system is national, publicly-funded and that it provides Canadians universal coverage and medical care on the basis of need. Third, Canadians have perceived a marked deterioration in the quality of the system during the past decade; they are particularly concerned about waiting times for specialists, waiting times at emergency rooms, the availability of the best technology and adequate numbers of doctors and nurses. Consequently, Canadians have become very worried about the future of the health-care system and are thus prepared to consider modifications.

Canadians have reached a mature, settled public judgment, based on decades of experience, that the Canadian health-care model is a good one that should be preserved. This public judgment is reflected in the fact that the overwhelming response to perceived deterioration is not to destroy the model but to call for governments to fix the system through better collaboration and management, by injecting more funds and by making small modifications. Canadians are aware of the challenges facing the system and are increasingly open to some experimental modifications, but policy debate on potential changes must be predicated on the presumption that Canadians like the Canadian health-care model, have an attachment to the present system and would like improvements designed to reinforce the system with which they are familiar, not undermine it through radical change. Regarding proposed reforms, Canadians prefer those changes that support the basic model and principles.

Canadians believe that access to medical care should be guaranteed by government. Recent surveys have shown that 91 percent believe care should be based on need; 72 percent believe medicare embodies Canadian values; only eight percent believe the American system is better than the Canadian system. The attachment Canadians have to their health-care system is not just symbolic: to the extent they know about other systems, they prefer Canadian system.

Canadians are worried about the system’s future and do not believe that all is well. Only 37 percent agree with the statement that medicare is just fine the way it is, a remarkably low percentage considering the great attachment Canadians have to the system. In 1989, only two percent of Canadians said they had not been able to get the medical care they needed; this number jumped to 15 percent in 2001. Most Canadians (88 percent) believe there is or will be a funding crisis in the short-term, but most do not believe the system can be fixed simply by injecting more funds.

Only about one-third of Canadians say they support two-tiered or privatization models, with most Canadians strongly opposed to these proposals. This strong opposition to a two-tiered system is at odds with Canadians’ belief that individuals should be able to use their money as they see fit to protect their own health. Canadians are sensitive to the fact that many patients are ready to spend their own money if they face a lengthy wait for treatment. While there is strong opposition to people paying to jump to the front of the line for medical procedures, when Canadians are faced with the proposition, “Should Canadians be allowed to have the option of using private facilities with their own resources if they cannot get timely access in the public system?” 73 percent say yes. This is a crucial value tension: Canadians want to nurture the public system, but they fully sympathize with those who want to spend their own money to get the care they need.

The perceived deterioration of the system has made Canadians more open to a variety of options than they were a decade ago, provided that the core elements of the system are preserved and that these reforms lead to real and tangible improvements in quality without damaging accessibility. Canadians are aware of inefficiencies in the system, as well as being aware of some of the incentives built into the system that perpetuate these inefficiencies and damage accountability. Most appear prepared to entertain reforms to the organization of primary health care. Any re-organization of primary care would attract more support among Canadians if it improved efficiency and accountability and eliminated waste and unnecessary procedures, all key preoccupations of Canadians. Reforms might also include the ability to buy extras or be insured for extras within the context of the core public system.

Nonetheless, there is very strong support for the public system and a willingness to pay to ensure quality, and discomfort with privatization or curtailing access to services, although support for some privatization experiments has gone up in recent years as Canadians struggle to find ways to maintain quality and access without large increases in taxes. Only about one-third of Canadians supports tax increases to fund improvements to the system.

Quality and access are key principles Canadians want to maintain, but polling data related to the trade-off between the two are very difficult to interpret because just about all Canadians are deeply committed to both principles, and most have not really thought about how to strike a balance between the two. Most older or low-income Canadians instinctively choose access because they sense that they would be negatively affected by a system that did not guarantee equal access for all, while many wealthier Canadians choose quality because they are increasingly concerned that the best available procedures and technology are not being used because of cost considerations.

Nonetheless, the two clear messages emerging from many polls are that Canadians have become increasingly concerned about the quality of care provided by the health-care system, and that quality and access can be understood as the two key principles of the health-care system to which most Canadians are deeply attached. The Romanow Commission is thus in a difficult position. On the one hand it must make concrete recommendations to improve and modernize the system; on the other it must preserve the core of the Canadian health-care model.

Canadians strongly believe that the federal, provincial and territorial governments all have a role in health-care reform; a strong majority supports collaboration between governments on the health-care file; and a majority holds both levels of government responsible for the current state of health care. Canadians very much support national standards and value the notion that there is one national system of health care. However, they would prefer to have Ottawa, the provinces and territories work together to set national standards, rather than have one order of government impose them.

Canadians very much like the health-care model in Canada and are delivering a very strong message to governments: Save medicare, preserve the system, work together, jointly set and enforce national standards, and if you mess up, you’re going to pay. But the Canadian public is delivering a second message as well: Within the framework of the public system, it is time to entertain changes that respond to new realities. These realities include a far more diverse array of health-care options, more empowered health-care users, rapidly evolving technology, health-care provided beyond the traditional network of doctors and hospitals, and a greater diversity of needs.

Any reform, however, must recognize that there remain important socio-economic differences on many questions: women, the elderly, those who are more economically vulnerable, and residents of Atlantic Canada and Ontario are especially resistant to changes that could damage accessibility or the publicly funded system.

Most Canadians, including the more economically secure, remain deeply committed to a system that guarantees all Canadians access to good quality health care.

This article is based on the author’s paper, Canadians’ Thoughts on Their Health Care System: Preserving the Canadian Model Through Innovation, prepared for the Royal Commission on the Future of Health Care, 2002.

Matthew Mendelsohn is a professor and co-founder of First Policy Response at Ryerson University and a Senior Advisor to BCG’s Global Public Sector Practice. From 2016 to 2020, he served as Deputy Secretary to the Cabinet, leading the Prime Minister’s Results & Delivery Unit and the Government of Canada’s Impact & Innovation Unit. Prior to his cabinet role, Mendelsohn was the founding Director of the Mowat Centre, a public policy think tank at the School of Public Policy & Governance at the University of Toronto. Some of his former credentials include: Deputy Minister with the Ontario government, chief architect of the 2015 Liberal election platform, and member of Prime Minister Trudeau’s transition team. Mendelsohn received his B.A. from McGill University and Ph.D. from l’Université de Montréal and was a tenured faculty member in the Department of Political Studies at Queen’s University.

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