"The State of Universal Healthcare: How Equitable is the System?"

"How universal is our health care system?" My short and quick answer is that our health care system is no longer universal for all Canadians. We simply have to look at the lack of primary healthcare (PHC) access across the country, the absence of mental health support for Canadians, the lack of culturally safe care for Indigenous persons, and the inadequacy of adult residential care (home care, nursing home care) from coast to coast. There simply is no systematic approach. Some of these topics listed above are considered "extended health care services" in the Canada Health Act (CHA).

The CHA is Canada's federal legislation for publicly funded health care insurance. It states that the aim of the Canadian health care policy is the protection, promotion, and restoration of the physical and mental well-being of Canadians. Provinces and territories do have certain criteria, qualifications, and conditions for coverage related to insured health services and extended health care services set out by the CHA that they must follow and fulfill. Qualifications include:

1. Services must be "medically necessary" and provided by a physician.

2. Services must be dentally necessary and provided by a licensed dentist in a hospital setting where required.

3. Services must be medically necessary and provided in an in-patient or out-patient hospital setting, with the goal of maintaining health, preventing illness, diagnosing illness, or treating injury or disability (Canada Health Act, 2024)

If we were to dissect the topic of PHC, physicians and nurse practitioners determine ad hoc where they’d like to settle their practice based on their own interests. Also, within the PHC system, there’s limited interdisciplinary teams found in the PHC setting. What we need is comprehensive care. I was profoundly grateful to attend a conference this past weekend in Ottawa. One of the speakers was expert Dr. Jane Philpott. She touched on the topic too. In this universally publicly funded healthcare system, private health insurance does not ensure all Canadians have access to PHC. We saw federal changes in the Canadian health system from the late 1950s, 1960s all the way up to 1984, but if you look at the 20th-century fine print it says “medically necessary,” or the procedure or service must be done in hospitals. The CHA is simply not fit for its purpose in 2024. There is a health insurance focus but not a health systems focus. Focus work is skewed to in-hospital care. As we know, with no PHC access for all Canadians, then Canadians and patients are left visiting the hospital or emergency department (ED), and by this time they’re not doing so great. If we look at evidence-based models providing care, the ones with PHC systems result in the best outcomes.

Professor Barbara Starfield (1932-2011) was a strong champion and advocate of primary health care systems worldwide. This was highlighted in her work and research from 2005 onward. One of her literature studies states: “This evidence shows that primary care helps prevent illness and death, regardless of whether the care is characterized by the supply of primary care physicians, a relationship with a source of primary care, or the receipt of important features of primary care. The evidence also shows that primary care (in contrast to specialty care) is associated with a more equitable distribution of health in populations, a finding that holds in both cross-national and within-national studies" (Starfield, 2005).

Canada has its islands of excellence; however, we require more pressure to support PHC as there is limited access for all Canadians. If we look at statistics across Canada, or more specifically at a national survey by OurCare that ran from September to October of 2022, the survey captures about 22% of Canadians who don’t have primary healthcare access, that’s almost 7 million people (OurCare, 2023). In 2019, Stats Canada captured about 15% for persons over the age of 12 without PHC (Stats Can, 2019). In some places across Canada, it’s only 1 in 3 persons that have access. There is a large gap in chronic disease support, and this leads to longer stays in hospitals, increased ED visits, and poor outcomes.

If one were to look at the country Norway, for example, we would see they do have within their legislation the right to have PHC access. Services in Norway include primary, ambulatory, mental health, and hospital care, as well as select outpatient prescription drugs (Commonwealth Fund, 2024). It’s the law, so that means if you don’t have it, you could put in a complaint with the Ombudsman within that county. The PHC service in Norway is like our Canadian school education system - everybody gets it. But unfortunately, there are gaps in the current CHA. It needs to be modernized. Including within the Act, we must first start with PHC accessibility, or we just need the creation of a Canada Health Primary Care Act. That would essentially be a sister Act of the CHA. We have to realign healthcare spending, so it’s not just physician-driven or within hospitals but more to include medical drug coverage to get the best outcome and fulfill the rest of the social contract. There needs to be more integration with the whole healthcare team. We need federal legislation for accountability to improve health outcomes, and we need the Federal Government to fund PHC so that it’s equal and equitable access for all. There are inequities across the country currently, and as I noted, there are huge troublesome gaps for indigenous health, mental health care, and adult residential care, but we must first start with PHC as a means to better support the foundation as a whole.

Curated Resources - Health

References

Government of Canada (2024, March 6). Canada Health Act. Justice Laws Website. Retrieved March 27, 2024, from https://laws-lois.justice.gc.ca/eng/acts/C-6/FullText.html

Government of Canada (2020, October 22). Health Fact Sheets Primary health care providers, 2019. Statistics Canada. Retrieved January 28, 2024, from https://www150.statcan.gc.ca/n1/pub/82-625-x/2020001/article/00004-eng.htm

OurCare (n.d.). OurCare national research survey. Https://www.Ourcare.ca/Nationalsurvey. Retrieved February 28, 2024

Starfield, B., Shi, L., & Macinko, J. (2005). Contribution of primary care to health systems and health. The Milbank quarterly, 83(3), 457–502. https://doi.org/10.1111/j.1468-0009.2005.00409.x

The Commowealth Fund (n.d.). International Health Care System Profiles Norway. Retrieved January 28, 2024, from https://www.commonwealthfund.org/international-health-policy-center/countries/norway