Abstract

This excerpt on a Call for Reforms in Healthcare is from the upcoming Healthcare Policy Volume 19 Number 3 Editorial to be published April 30, 2024.

Effective reforms to provinces’ and territories’ healthcare delivery systems are needed to generate meaningful changes in population-based health and well-being outcomes in Canada. These reforms include transformations that slow the decline of health and improve the quality of life – such as those relevant to long-term care and aged care – and are expansive enough to include prevention and health promotion.

From the perspectives of many, including mine, the adoption of effective policy reforms can be frustratingly slow but is long overdue (Sutherland 2021). For instance, why can’t people and their healthcare providers access a single electronic medical record shared across providers, sectors and settings for both publicly and privately insured services? The technology exists, and the business case is strong (CCA 2023). Even highly visible and expensive reforms by provinces’ and territories’ ministries of health have struggled to gain traction – for example, using higher payments to improve access to primary care (Farmer 2023; Islam et al. 2023).

Even when the policy path is clear, solutions well-articulated and expected outcomes beneficial to thousands, effective reforms have been slow in coming. This is the case with surgical waitlists. Provinces and territories have been slow to develop policies that have been shown to be effective at improving wait times and access to elective surgery, such as centralzing waitlists (Blythe and Ross 2022; Office of the Auditor General of Ontario 2021).

These examples highlight that reforms to provinces’ and territories’ healthcare delivery systems that meaningfully raise population-based health and well-being outcomes are uncommon. Opportunities abound and span all aspects of healthcare, including service delivery models, clinical governance, procurement, clinical information integration, payment policy and provincial or territorial health insurance programs. Recent reforms are modestly incremental, targeting dental services for uninsured children and the elderly through the Canadian Dental Care Plan (Government of Canada 2024). The other is the much-ballyhooed national pharmacare program, now scaled down to include only diabetes therapies and reproductive care and already panned as a “pilot” for expanding drug insurance programs (Picard 2024b).

Governments face policy choices. They are not making the hard choices for meaning- ful and effective reforms in healthcare that raise population-based health and well-being outcomes. Lack of policy innovation by provinces and territories could be overlooked by the public if provincial and territorial health systems were high-performing. However, they are not. Incrementalism is not cutting it.

I am not the first to say that reforms are needed (Drummond and Sinclair 2021; Picard 2024a). The health systems that governments regulate and fund clearly need big ideas and innovation. Here are some ideas.

Thinking Big

Re-writing the Canada Health Act for expansion

A re-imagined Canada Health Act (CHA) (1985) would build from provinces’ and territories’ forays into other sectors not covered by the CHA. They would expand their insurance pro- grams to include publicly funded access to under-insured and uninsured physical and mental health services, therapies and products.

Currently, the CHA (1985) outlines the minimums required by provinces and territo- ries – free access to medically necessary hospital, physician and diagnostic services. Beyond this minimum guarantee of access and public administration, provinces and territories have latitude regarding which other providers, sectors, settings, services or technologies are publicly insured. Provinces and territories already selectively offer programs that insure select groups of residents, such as drug insurance for the aged, long-term care for residents who lack the ability to privately pay and access to human immunodeficiency virus drugs.

Significant reform that expands provincial and territorial health insurance programs would encompass and subsume what is currently privately paid or commercially insured services, technologies and products, including drugs, vision and hearing care, physical therapies and mental healthcare services. This reform would remove financial barriers to accessing physical and mental health services from audiologists, physiotherapists, dentists and counsellors. Expansion of provincial insurance programs of this magnitude has been unheard of since the introduction of provincial insurance programs decades ago.

Yes, expanding provincial and territorial health insurance programs would be complex because of the number of stakeholders involved – each vested and invested in the current structure and process of healthcare delivery. Each of the physician associations, nursing unions, allied health providers, healthcare organizations, pharmaceutical and technology companies, patients and caregivers would deserve a say.

Yes, publicly insuring healthcare services, technologies and therapies that are currently under-insured and uninsured would be expensive. The governments’ bold policy reforms into publicly funding under-insured and uninsured physical and mental health services, technologies and therapies would signify that provincial and territorial governments are focused on reducing wealth-based disparities in health and well-being among their residents. However, it is also not a panacea and involves[8] big trade-offs. Serious problems that governments largely ignore would remain unaddressed, including the effectiveness or appropriateness of services or products and quality problems that plague current healthcare delivery models.

Re-writing the CHA for compulsory health insurance in a government-regulated market

With changes to the CHA (1985) and other legislative efforts, the market for health insurance could be opened by provinces and territories. This reform would allow private health insurers to offer health insurance to residents in a government-regulated health insurance market where public or private insurance is compulsory for individuals. This reform may or may not include services currently mandated by the CHA (1985).

Regulated health insurance markets exist in other high-income countries. In theNetherlands, “coverage schemes” (p. 3) are health insurance programs provided by private insurers and are compulsory for residents (noting there is a separate single-payer system for long-term care) (OECD and European Observatory on Health Systems and Policies 2021). Germany also has compulsory health insurance, with many health insurers referred to as “sickness funds” (Blümel et al. 2020: xxii). The Netherlands and Germany are acknowledged by many experts to have better-performing health systems than Canada (Schneider et al. 2021).

Hybrid variants of Dutch and German health insurance models have been implemented elsewhere. Optional private health insurance runs alongside the public system in Australia and Ireland. In these latter countries, private health insurance is not compulsory for residents. The well-publicized experience of Australia has shown that this approach is not a panacea (Angeles et al. 2023), although Australia’s health system reportedly consistently performs better than Canada’s on important markers of access (Schneider et al. 2021).

There is also the case of the US, where many consider the health insurance market to be a failure for population-level health and well-being outcomes, noting the important distinction that neither is health insurance compulsory nor do public insurers – such as state-based Medicaid programs (https://www.medicaid.gov/) – have a mandate or budget to provide health insurance to all residents.

A government-regulated mandated health insurance model is not inconceivable in Canada. Many Canadians already experience multi-payer insurance with workplace-based extended health benefits.

Such an abrupt change, however, would be dizzyingly complex owing to the constitutional entanglements, technically challenging to legislate and enact. It is not clear whether provinces, territories or the federal government have the skills to develop and manage a regulated health insurance market – which may or may not operate alongside the public system.

There is scant relevant international evidence to guide large-scale reforms in the context of provinces and territories.

Would this be expensive? More expensive for whom is the trickier question, but we would likely experience higher total healthcare spending, public and private. The publicly borne costs would depend on how far governments developed regulated and compulsory health insurance markets – whether the current publicly funded provincial health systems were maintained in parallel, whether governments stepped away from public provision of health services and “paid” private health insurers premiums that are now spent on healthcare or yet-to-be-conceived other options.

A heavily regulated and compulsory market for private health insurance that does, or oes not, include services described in the CHA (1985) might shake off the stasis that has gripped provincial health systems.

Thinking big is not without outsized risks, but painfully slow incrementalism has left provinces’ health systems standing last in league tables, above only the US.

Thinking Medium

Compulsory insurance for physical and mental health services outside the CHA

In this hybrid reform, provinces’ residents would be obligated to carry “extended” health insurance to cover the currently under-insured or uninsured healthcare services and products, such as drugs, dental, vision and mental health services. As noted earlier, many Canadians already experience multi-payer care for physical and mental health services not insured by provinces and territories but offered by their employer.

Through compulsory extended health insurance, reforms could increase access to under-insured or uninsured services and products by removing financial barriers. Necessary steps would include minimizing or eliminating premiums among residents with low income and wealth. Obviously, public spending would increase. For this more limited option, the juice might be worth the squeeze if health and well-being outcomes improved meaningfully, especially among those currently unable to access the needed physical and mental health services and products due to affordability.

Being Bold for the Sake of Improving Performance

If the past is a guide, Canada’s provinces and territories have conditioned the public to be accustomed to a small or no change approach to health policy reforms. There is a need for provincial and territorial premiers, ministers of health and their deputy ministers to innovate in their health systems. Out-of-the-box thinking is needed, and reforms are overdue for an aging population’s health and well-being outcomes.