Canada's health care system won’t change until we stop trying to fix it
Voters aren't open to solutions beyond more government spending. Successful reform requires a new approach.
Canadian health care is ripe for major reform but caught between the horns of policy and politics. Patient needs are greater than what any government can provide, yet voters remain intolerant of solutions beyond new government programs and spending. Successful reform requires a new approach.
After a ‘big-bang’ policy change with the passage of the 1966 Medical Care Act, Canada’s core relationships between patient, state, medical profession, and labour have remained unaltered. For 60 years, political actors promised incremental change and avoided major overhauls. Medicare might be Canada’s most change-resistant policy field.
It’s time to shift gears. Instead of drafting detailed reform plans that seek to deliver incremental change, we should use indirect methods that pursue transformation. The following is a shortened version of arguments I offer in, A winning prescription: It’s time to let innovators drive health care reform, published last month by the Macdonald-Laurier Institute. We could achieve reform with three measures: adopting a time-limited vision for growth of health care services, allowing diversity in public funding sources (not private funding), and supporting health care management reform.
The first step is committing to robust, broad-based growth of service delivery. If we insist on cautious, specific growth, we risk political infighting about what kinds of care must grow first.
If doubt remains about the need, consider a 2023 Fraser Institute report which compared Canada among 30 high-income OECD countries with universal care systems. It found Canada was first place for spending as a share of the economy but 28th for number of doctors, 23rd for care beds, 25th for MRI units, 26th for CT scanners, and last place for surgical wait times. There’s more: a 2024 report found Sweden is the only OECD country with fewer beds per capita than Canada. OECD countries average 4.1 hospital beds per 1,000 persons; Canada has 2.59. It’s clear that system-wide growth is needed.
Next, we need to diversify funding—with two vital caveats. First, there’s no discussion of patients paying for care themselves (such as co-payments, deductibles, user fees—anything that requires them to open their wallets). Diversification should emphasize this bottom line: a large majority of Canadians prefer not paying for care at point of service. Second, diversification is not simply about securing new money, but shifting the current “logic” of our funding environment. We are not looking to fund all growth. We’re seeking to work at the margins, providing small amounts of new money to shift the way we think about funding.
For example, it could start with changes to regulations around charitable donations. Current rules prohibit hospital foundations from using charitable funds for operational expenses. They can only invest in capital costs like equipment and supplies. Giving donors the opportunity to fund not only the construction of a new hospital ward, but also its operation, would transform charitable giving. And this is only a start. Diversification could encompass many approaches beyond charitable sources, as new proposals surface and public sentiment shifts. Again, the aim is to foster larger change as a by-product.
Third, we need to support health care management reform, and stop trying to design it. Managers never change behavior because someone told them to. They respond when the system changes around them. A time-limited vision for growth, with even small adaptations in funding, will spark organic change in management. It will appear by necessity as managers shift their focus from maintaining the single-payer status quo towards a new mindset of growth supported by multiple funding streams.
Finally, it’s worth noting that this approach carries one significant risk: in our single-payer system, growing service delivery means more government spending. However, in light of the urgent need to expand services, it offers an efficient and politically viable way to change health care over the next 5-10 years, without simply repeating what we’ve done for the past 50. More importantly, it would encourage a paradigm shift in the status-quo thinking and logic of the system.
This solution is simple to say but hard to do. It requires a revival of a 20th-century-style vision that was agnostic about how growth would happen. We need a commitment to growth matched with a principled eschewal of planning. It goes farther than central planners will allow and falls far short of what free-marketers want. But it offers a viable escape from the two horns of our current health care dilemma.
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Dr. Shawn Whatley is a physician, past president of the Ontario Medical Association, and a senior fellow at the Macdonald-Laurier Institute.