The Peculiarities of Canadian Health Care

Medicare — the colloquial term Canadians use to refer to the entirety of Canada’s public health care system — is supposedly one of Canada’s defining features. Canadian celebrities are frequently asked about it on American talk shows, and it’s routinely discussed in any conversation concerning efforts to introduce a universal public health care system in the United States. What most Americans don’t know is that Canada doesn’t actually have a universal health care system. What Canada does have is a broad federal framework to guide the provision of public health care, plus thirteen provincial and territorial health ministries and departments governing multiple independent public health insurance systems.

The federal health ministry is responsible for national health policy. It ensures that the provinces comply with federal laws governing health care and the health care of indigenous people, and oversees dependent agencies responsible for food inspection, public health policy, and the regulation of pharmaceuticals. In its ideal form this setup safeguards the federal government’s close watch on the provinces, ensuring that federal standards are met, while provinces are given the autonomy to figure out the best way to individually achieve those objectives.

It’s byzantine, but this is a good demonstration of how Canadian political machinery is supposed to work. Canadian health care was as much a product of cooperation between provincial governments and the federal government as between social democrats and progressive conservatives. In sharp contrast to the privatization advocated by contemporary Canadian conservatives, the federal conservatives of the 1950s — including a supreme court justice and a prime minister — were as instrumental in implementing Canada’s Medicare system as the godfather of Canadian social democracy, Tommy Douglas (a man once crowned the Greatest Canadian specifically for his role in establishing Medicare).

Health Care’s Free Marketeers

Ironically, provincial-level public health care in Canada was introduced in two provinces — Saskatchewan in 1947 and Alberta in 1950 — that are today bastions of reactionary conservatism. They are now leading in health care privatization efforts. Ideologically motivated efforts to undermine public health care in Alberta have resulted in rural emergency room closures, overcrowded hospitals, and ambulance shortages. At the same time, the province’s conservative provincial leadership has expanded private health care services that charge patients out of pocket, in some cases by reducing what the province deems medically necessary care.

This in turn creates new opportunities for private health care in Alberta by allowing private providers to handle services that the province deems nonessential. Because these private providers can also charge patients directly for medically necessary care, their presence in the architecture of the health care system ultimately results in a dollar-for-dollar clawback of federal government health care transfer funds to the province. This doesn’t make sense from a health care policy perspective — why charge an individual to pay out of pocket for a medically necessary service whose cost would otherwise be covered by taxpayer-funded public health care? But it makes plenty of sense to people who are ideologically opposed to any form of public health care, such as Alberta’s premier, who has publicly advocated for dismantling the system.

For those ideologically opposed to public health care, this a win-win-win. New business opportunities are created, and provincial taxes are lowered (a consequence of cutting services wholesale, even if it results in major service gaps). As an added bonus, the federal government, which has a standing policy of clawing back health care transfer funds in cases where provinces allow private providers to charge patients directly, can then be blamed by populist premiers for cutbacks when privatization schemes inevitably fail.

A consistent voice leading the charge toward dismantling health care in Canada has come from the Fraser Institute. It is one of the dozen or so free-market libertarian think tanks that have steered Canada’s once “progressive” conservative party further and further to the right over the last forty or so years. The Fraser Institute, along with organizations such as the Macdonald-Laurier Institute and the Montreal Economic Institute, are partners in the Atlas Network, which has received funding from the Koch brothers.

They have spearheaded the opposition to socialized medicine in Canada in recent decades, often with pseudo-academic reports and studies that point almost without exception to privatization as the only potential remedy for the problems facing Canadian health care. Press releases announcing the findings of these reports are often published as if they were news stories in their own right by the Postmedia chain of newspapers, which serves as the primary propagandist of Canada’s federal Conservative Party as well as Canada’s conservative movement more broadly. Many of Canada’s leading conservative voices have either worked for the aforementioned think tanks or the papers of the Postmedia chain. Alberta’s current and unabashedly anti-Medicare premier, Danielle Smith, has done both.

Cutting off Health Care’s Nose to Spite Its Face

Similar to the numerous remarkable initiatives undertaken by the American federal government in the wake of the Great Depression, Canada’s drive for socialized health care emerged from the lessons learned in the same era. The effort to create a taxpayer-funded public health care system in the Canadian province of Saskatchewan in the mid-1940s came out of the realization that health care was a basic right, and that the private system that had existed up until that point simply wasn’t working. The initiative was a cornerstone of the progressive and practical “Prairie Populism” typified by the Co-operative Commonwealth Federation (predecessor of today’s New Democratic Party, Canada’s generally progressive left federal political party).

Similar efforts developed in various provinces until Medicare was formally adopted and became federal law in 1968. A subsequent federal regulation — the Canada Health Act of 1984 — was the last major accomplishment of the “nation-building” government of Pierre Trudeau. Pierre, Justin’s father, served as prime minister for a nearly uninterrupted sixteen-year stretch from 1968 to 1984. The Canada Health Act formalized public health care in Canada, establishing guiding principles for its administration and delivery as well as the conditions for federal funding to provincial health systems.

Within a decade Canada’s provinces had already begun severe cutbacks to their provincial health care systems. During the 1990s, Ontario, Quebec, and Saskatchewan, notably, implemented a series of hospital closures and consolidations. These measures aimed to reduce public expenditures amid a period of economic sluggishness and widespread acceptance of neoliberal economic policies, which targeted various components of the social safety net — Medicare first and foremost among them.

Provincial cuts, already bad enough, were then met with additional reductions to federal health care transfers, beginning in 1995. Health care spending in Canada then dropped below 10 percent of GDP. Between 1986 and 1995, the number of the country’s hospitals decreased by 14 percent, while the number of approved beds dropped by 11 percent. The number of staffed beds per one thousand people dropped from 6.6 to 4.1 during the same time.

At the start of the pandemic, the number of hospital beds had fallen further, to 2.55 beds per one thousand Canadians. While some provinces moved forward on expanding certain aspects of Medicare — such as Quebec’s introduction of a mandatory pharmacare program in 1997 — most Canadian provinces were busy moving in the opposite direction. Alberta started the trend by allowing private hospitals in 2000. Just a couple years later the seminal Romanow Report was released. A cross-country public inquiry into the future of health care in Canada, the report reflected the desires of the Canadian public, putting it at odds with the privatization endeavors pursued by both the medical profession and the provincial governments.

Out of the Frying Pan Into the Fire

The Romanow Report recommended a federal Health Council of Canada to “facilitate collaborative leadership in health” and “new approaches to primary health care.” It also recommended stable and predictable long-term funding, a national drug agency to lower the cost of prescription drugs, a home care and rural health care strategy, among other suggestions.

The first ministers of the country signed a health accord in 2003 that addressed the funding issues highlighted in the Romanow Report, but it failed to bring about any accountability measures to ensure health care funding transfers would be used to improve provincial health care services. Ten years later, after a decade of consistent legal challenges to Medicare, the Conservative federal government of Prime Minister Stephen Harper terminated funding for the Health Council of Canada. This step was taken in spite of the council’s successes at reducing patient wait times and its efforts at developing systems to improve the accountability, oversight, planning, and national coordination of Canada’s health care systems. The Health Accord expired in 2014, ending government oversight on provincial health care spending.

Research from the Canadian Health Coalition in 2016 indicated a possible health care budget shortfall of as much as $43.5 billion by 2024. The health care funding agreement signed by Justin Trudeau and the provinces earlier this year was more than $46 billion. While the shortfall may have been resolved, the issue of overseeing the allocation of provincial funding is very much alive.

Though it was clear that Canada’s health care system was in trouble for many years before 2020, decades of government cutbacks left the system severely weakened, such that the COVID-19 pandemic pushed much of Canada’s health care system over the edge. It resulted in arguably the worst crisis since Medicare was signed into law in the late 1960s.

Hospital emergency rooms are perennially overcrowded, an increasing number of Canadians have no access to a family physician, and burnout is endemic across the health professions. During the early stages of the pandemic, 50 percent of nurses and 20 percent of physicians working for the McGill University Health Centre (one of Montreal’s two primary hospital networks) indicated that they were ready to quit their profession. The situation has not improved despite generally lower COVID caseloads: according to a recent report by the Canadian Medical Association Journal, the amount of overtime worked by Canadian health care professionals in 2021 was equivalent to over nine thousand full-time jobs.

With Friends Like These

Despite health care consistently receiving favorable ratings in polls and being a source of pride and identification for Canadians, concerns persist regarding both the current state and future of health care in the country. Creeping privatization is also a concern. Nearly 30 percent of Canadians think that the health care system is in crisis, yet place the blame for the crisis on inadequate federal funding rather than provincial mismanagement of funds. This misapprehension is gainsaid by research indicating that Canada’s provinces are flush with cash and could be fully funding health care themselves but are instead using no-strings-attached federal funds to finance tax breaks.

The conservative premier of Ontario, Canada’s most populous and wealthiest province, has been deliberately underfunding the province’s health care system. Creating a crisis is nothing new for Canadian conservatives either. Former Ontario education minister John Snobelen was caught on film arguing that, in order to ram through reforms meant to undermine Ontario’s teacher unions and assist in the privatization of the province’s schools, public education needed to be bankrupted. The ensuing situation, Snobelen maintained, would create a “useful crisis” favorable to advancing the party’s agenda.

Ontario isn’t alone in deliberate, ideologically driven underfunding of health care. Though some headlines praised the United Conservative government of Alberta for increasing health funding in the province to “record levels,” subsequent analysis revealed that the province’s additional funding isn’t on track to meet public demand, or increases in inflation or population.

Several conservative-led provinces dealt with the pandemic by deliberating underfunding their health care systems. Canada’s conservative premiers were the least likely to introduce public health measures meant to stop the spread of infection, most likely to try to get back to normal too quickly, and quickest to blame the federal government for problems that were entirely within provincial area of jurisdiction.

Ontario premier Doug Ford was arguably the worst offender. Polls indicated that the citizens of Ontario and Alberta were the most likely to view their governments’ handling of the pandemic poorly — with disapproval ranging from 65 to 75 percent, respectively — and that more than 60 percent of respondents wanted their provincial governments to enforce stricter public health measures.

It’s Not Paranoia If It’s True

The negative effects of privatization were made crystal clear during the pandemic, as the largely privatized, for-profit long-term care (LTC) facilities of Ontario and Quebec failed under horrifying circumstances, with employees walking off the job, and residents found dead, starved, and sitting in their own feces. Canada found itself without sufficient domestic personal protective equipment production capacity and further lacking in a domestic vaccine production facility (the latter of which was privatized back in the 1980s). Subsequent federal efforts to develop a domestic vaccine capacity have largely failed, with billions of dollars of public funds sent to private companies that largely failed to deliver any vaccines.

Despite this, the Trudeau administration has so far failed to address widespread provincial health care incompetence and stand up for a health care system most Canadians still believe in. Though the Trudeau administration was able to secure the funding arrangement with the provinces earlier this year in an attempt to avoid a complete breakdown, the “no strings attached” aspect of the deal has frustrated public health care advocates. The deal fails to do anything about the ideologically motivated underfunding that laid the foundation for the crisis in the first place.

The federal government has substantial grounds to argue for exclusive responsibility in administering health care in Canada, which could garner strong support from a majority of Canadians given the ample evidence of provincial health care sabotage. Trudeau has so far failed to capitalize on the open-net goal of making his administration a champion for Medicare in Canada. Trudeau’s Liberal Party is currently supported by Canada’s New Democratic Party in an agreement that’s not quite a formal alliance or coalition but will prevent a federal election for the foreseeable future. Partially because of New Democratic Party pressure, the Liberals have managed to introduce a very modest dental care program, administrated by the federal government, that provides dental care to about nine million low-income Canadians. This deal was worked out without any provincial involvement whatsoever because a federal government agent has been tasked with its administration.

Provincial and territorial premiers have largely been silent on the issue of the dental plan, despite the federal intervention on matters of public health policy the plan entails — a jurisdictional prerogative that is typically the reserved right of the provinces. This achievement has garnered enthusiastic support from a Canadian public evidently longing for leadership on health care matters. Nevertheless, Trudeau continues to maintain a predominantly hands-off approach toward the arguably more substantial concerns of persistent provincial health care underfunding and privatization.

It’s a peculiar situation. Even with the widespread desire among Canadians for an enhanced public health care system, provincial politicians steadfastly reject considering any alternative apart from privatization. In the face of recent modest success in expanding federal health care to millions of Canadians, the federal government — an informal union of its centrist-liberal and progressive-left parties — has done almost nothing to change course from decades of deliberate defunding and creeping privatization. Canadians might be forgiven for drawing the conclusion that their political classes want health care to fail.