(Policy papers 2012-2013)

Universal health care is a fundamental component of Canadian citizenship — even a national symbol that draws us together. But medicare has become less a national program and more of an uneven patchwork of services, with unacceptable variations in quality and availability. National leadership is shrinking just when the demand for health care and the confusion over private delivery are growing. Collaboration led by Ottawa must develop national standards for coverage and bring practical improvements to a public service we all depend upon.

Un des éléments fondamentaux de la citoyenneté canadienne – voire un symbole national qui nous unit – est l’accès aux soins de santé pour tous. Mais l’assurance-maladie n’est plus un programme national, il est plutôt devenu un patchwork inégal de services qui varie de façon inacceptable en qualité et en accessibilité. Le leadership national diminue au moment même où augmente la demande aux soins de santé et la confusion au niveau des prestations privées. Une collaboration menée par Ottawa doit développer des standards nationaux en matière de couverture médicale et améliorer de façon pratique ce service public dont nous dépendons tous.

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Canadians have uneven medicare coverage because we have no standards for the minimum quality and range of essential health care services that should be available across the country. The provinces have been steadily expanding their health care systems since the 1980s, revealing many grey areas in the national legislation that is meant to guide them. The Canada Health Act has five general principles — public administration, comprehensiveness, universality, portability, and accessibility — but the federal government has not been interpreting or applying them to support greater national consistency, apart from imposing an occasional penalty for extra billing.

The federal government’s decision to change the federal funding formula to a yearly lump sum equal-per-capita cash transfer to provinces is much more than a simple financial adjustment. By turning medicare into a mere accounting entry in the national budget, the federal government also made it clear that Ottawa would no longer engage with the provinces in reforming and improving medicare as in the past. Yet a healthy national health care system must be underwritten not just with federal cash but also with a substantial dose of national government leadership.

Provincial premiers have not been able to collaborate well enough on their own or as members of the interprovincial Council of the Federation to maintain equity across the country. The premiers are first and foremost responsible for provincial interests that are not necessarily compatible. They are not naturally wired to think national. Their only response to the public concerns about the federal decision to retire from any substantive role in health care policy was to establish a working group on health care innovation that is to look at everything from how many doctors and nurses should graduate each year to adopting the best clinical and surgical practices across Canada. Sadly, it is unlikely that this most recent attempt at provincial collaboration will result in a coherent national plan, and certainly not by the time of the group’s report to the annual meeting of the premiers in July 2012. At the 2010 annual meeting, the premiers announced plans to set up a national agency that would be responsible for the purchase of prescription drugs. This initiative is still languishing.

Ottawa is in the best position to lead a more cooperative and collegial effort to maintain national equity and reasonably comparable services in this critical arena of public policy. We need an intergovernmental body that is clearly and permanently mandated to facilitate compromise and consensus and to advise both federal and provincial governments on national standards for health care services, including regulation of the mix of private and public care. The Health Council of Canada could be given more powers, or a Council of Canadian Governments[2] could create a standing council on health care, as has been done in Australia.

These areas — and more — require urgent consideration and national action.

• Providing a clearinghouse for sharing health information about best medical practices, as well as medical errors, across provinces.

• Shifting the focus from hospital-based care to community-based primary care delivered by teams, not necessarily individual practitioners.

• Ensuring that every Canadian has an electronic health record and access to a central coordination point for their care, whether preventive, acute, or chronic.

• Increasing investment in prevention measures, especially for lower-income and disadvantaged Canadians.

• Expanding the availability of home care and long-term care in the community.

• Enlarging the role of pharmacists to allow them to prescribe certain medicines and the role of nurse practitioners in providing medical care.

• Ensuring that all Canadians have access to a universal prescription drug program, by expanding and coordinating the patchwork of public and private schemes that already provide drug insurance to some 22 million Canadians.

• Ensuring that all provinces participate in the Common Drug Review to address drug safety.

• Removing barriers to portability of health coverage and to the mobility of medical professionals across provincial boundaries.

• Giving the Canadian Medical Officer of Health sufficient authority to deal with a national pandemic.

• Creating a federally managed stockpile of crucial medications to be distributed when shortages occur.

Probably the most sensitive issue in medicare today is the mix of private and public delivery and payment. Those who tend to hysteria when the word “private” pops up should remember that already some 30% of the over $192 billion spent annually on health care in Canada is derived from private sources. Most delivery of health care is done by private providers: not-for-profits, for-profit businesses, and independent contractors. Canada’s hospitals and doctors are 100% publicly funded, but all other services — from drugs to home care, long-term care, and dental care — are paid for with 50% to 100% private funding.

European countries, notably France and Britain, provide useful models for mixing private and public delivery and payment. Already several provinces have experimented with increasing patients’ access to private health care when they face excessive wait times. An intergovernmental council should acknowledge that we already have a mixed model and bring a pragmatic approach to regulating it.