For 40 years, the Canada Health Act (CHA) has not only protected universal health coverage in Canada but helped define our identity as sharing and caring Canadians. Today the act not only affords less protection than we may think, but could be in danger in the next few years.

We have a choice: either “spring forward” with a redesigned act to safeguard and improve medicare or continue to “fall back” and allow the further erosion of this cherished national program.

The problem

For an increasing number of Canadians, medicare has become a failed promise. It was meant to guarantee access to medically required services at the time and to the extent of need rather than ability to pay. But now 20 per cent of Canadians do not have ready access to primary care.

Emergency departments are closing for the summer. Wait lists for needed surgeries are growing again. The result is an increasing number of Canadians are simply opting out of medicare.

Those who can afford it pay out of pocket for services from private medical practices and corporations, private diagnostic clinics and private nurse practitioners. All of this is in breach of the spirit if not the letter of the Canada Health Act.

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A 2023 public opinion survey of Canadians by Angus Reid found that Canadians are of three minds when it comes to private health care.

The purists (39 per cent) believe there is no place for the private sector. The pragmatists (33 per cent) still believe in medicare in principle, but worry about themselves or their family being denied access. They feel there are practical ways for the private sector to supplement medicare and improve access. The proponents (28 per cent) have given up on publicly funded medicare programs and see the Canada Health Act as the problem.

The good news is most Canadians (just over 70 per cent if you take purists and pragmatists together) still support the principles of medicare, even if some feel access is not what it should be.

The bad news is we now have a significant minority of Canadians who no longer believe in or identify with medicare. Almost 25 years ago, a clearer majority of Canadians supported medicare and the CHA without qualification or hesitation. 

Myths versus realities

Most worrisome is that the proponents of private-sector solutions believe the act is the source of our access problems. They also have come to believe it has frozen out needed innovations in Canadian health care. These prevalent myths need to be contested.

Let’s start with the misbelief that the CHA is responsible for our current access and wait-time problems. The difficulty lies with how provincial and territorial health care is being managed or mismanaged.

Much needs to be done here, including more fundamental primary-care reforms to improve access and reduce pressure on emergency departments. Connected to this is the misconception that the act prevents the provinces and territories from being innovative in changing and improving their health systems.

Both are dead wrong.

The CHA does not constrain or direct governments and their health authorities. They have all the decision-making authority needed to improve admission to care. The act simply states that access to services must be based on medical need rather than ability to pay and ensures portability of coverage.

It does mandate deductions in federal transfers when governments allow hospitals, clinics and physicians to impose service charges on patients. In short, the current version of the Canada Health Act provides a floor, not a ceiling.

The defenders of medicare also have their myths.

Perhaps the most pernicious is that the CHA cannot be amended without opening a Pandora’s box of problems. This is not how government works, not even when it is a minority. Any decision on the CHA would be taken by cabinet in consultation with the party holding the balance of power.

In the current context, this means the governing Liberals, with support from the NDP (the party of medicare founder Tommy Douglas), could decide on needed amendments, which would be subject to debate in Parliament. A majority vote would result in the passage of the Canada Health Act 2.0.

What can we do?

These problems and perceptions require a two-front strategy. The first is for us as citizens or members of civil-society organizations to put pressure on health ministers across the country to address timeliness and quality of care, with a premium on fixing primary care. Provincial and territorial governments are ultimately responsible for how medicare works on the ground.

The second is to push the current Liberal minority government in Ottawa – as well as the NDP, which has agreed to support key bills – to draft and pass a long overdue update to the health act before the next election. The purpose would be to address anachronisms, to update and clarify insured services covered and to provide an on-ramp for denticare and pharmacare to become universally accessible services over the next few years.

The time has come to bring the CHA into the 21^st century. There is much that could be done, but the act could be strengthened immediately by:

• Including a provision for an automatic deduction (in the dollar amount) instead of discretionary deductions in federal transfers to any provincial government not recognizing the portability criterion, at least within Canada. Portability is the glue that holds our Canadian health system together.

Due to Quebec not being a signatory to the provincial/territorial reciprocal billing agreement on medical care (though it is on hospital care), out-of-province residents receiving medical care in Quebec must pay at the point of service. Quebec residents must do likewise when in the rest of Canada.

This situation is contrary to the spirit of the CHA and would be discouraged – and likely eliminated – through mandatory transfer deductions and the negative publicity accompanying them.

• Changing the definition of “insured health services” to include all primary-care providers, including nurse practitioners (NPs). There is increased evidence that NPs are setting up independent clinics for the same or similar services provided by physicians, but requiring immediate payment from patients (as we have seen recently in Ontario). It can be argued that such services, when medically required, fall within the scope of the CHA.
• Acknowledging that the ways and means of delivering health-care services have changed markedly, especially through and beyond the COVID-19 pandemic. For example, virtual care via phone or online should be clearly included in a revised Canada Health Act.

A revamped act would force all parties to declare their intentions concerning medicare in advance of the next election campaign. This strategy would require the Liberals and the NDP to be committed in a practical way to improve access and remove financial barriers.

More importantly, they would be forced to reveal their timeline to move denticare and pharmacare from highly targeted initiatives to universal and comprehensive programs.

The approach would also force the hand of the Opposition Conservatives. The party would have to vote on the changes before the election. This is not unlike how the original Canada Health Act came to be approved without a dissenting vote in 1984.

If the Conservatives were to support an amended CHA, even if it were motivated by wanting to avoid an election wedge issue, it would make it more difficult to undermine the act if the party were to form the next government. And if the party were to vote against the amendments, it would need to explain to the electorate why it is opposed and outline its intentions for the future – all fodder for the next election campaign.

The time to act is now. The future of our national health-insurance program hangs in the balance.