The framework for publicly insured healthcare in Canada was established in the middle of the twentieth century with the 1957 Hospital and Diagnostic Services Act and the 1966 Medical Care Act. These statutes were consolidated in 1984 as the Canada Health Act (CHA) (1985). The key provision of this legislation was the stipulation that medically necessary healthcare provided in hospitals, or by physicians, was to be publicly insured. The point was to provide access to medically necessary healthcare independent of the ability to pay. This commentary suggests that the contours of healthcare in Canada have shifted substantially since the development of medicare and that, because of these changes, the CHA (1985) no longer facilitates either accessibility or equity. Owing to the “deep but narrow” provision of healthcare services, key aspects of contemporary healthcare (including pharmaceuticals and mental healthcare) are often not publicly insured. At the same time, because of changes in who provides medically necessary care, and where and how it is provided, many Canadians are increasingly able to access these services independently of public insurance. Somewhat paradoxically, the rigid structure of the CHA (1985) has both diminished access to publicly insured healthcare, on the one hand, and has permitted the emergence of two-tier healthcare, on the other. Achieving better access to, and equity in, healthcare provision will require a fundamental rethinking of the nexus between federal funding mechanisms and the regulatory landscape in the provincial/territorial [ PT] domain.

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