POLI321
ISSUES: CANADIAN PUBLIC POLICY
Mehri Ghazanjani
Weeks 8, 9, & 10: Health Care
 Marchildon, G. (2022). Canadian medicare as a
policy success. EA Lindquist, M. Howlett, G. Skogstad,
G. Tellier, & P.‘t Hart (Eds.), Policy success in Canada:
Cases, lessons, challenges, chapter 2.
WEEKLY
READINGS
 Lavoie, J. G. (2018). Medicare and the care of First
Nations, Métis and Inuit. Journal of Health Economics,
Policy, and Law, 13(3-4), 280-298.
 Daw, J. R., & Morgan, S. G. (2012). Stitching the gaps in
the Canadian public drug coverage patchwork? A
review of provincial pharmacare policy changes from
2000 to 2010. Health Policy, 104(1), 19-26.
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OUTLINE
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A.
Background
B.
Canada Health Act
C.
Indigenous Health Care
2
A. BACKGROUND
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 Built step by step, roots in Saskatchewan (Tommy
Douglas, CCF)
 1946: Saskatchewan Hospitalization Act: free hospital
and diagnostic services
 Provincial success prompted federal engagement
 Hospital Insurance & Diagnostic Services Act
(HIDSA) (1957)
 50–50 federal–provincial cost-sharing
 Provinces must provide services to all residents
 Spread universal hospital coverage nationally
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 1961: Saskatchewan insures community physician services.
 Triggered opposition from organized medicine.
 Physicians feared reduced autonomy and weaker bargaining power.
 Disputes escalated into strike:
 Compromise: physicians remain independent contractors.
 Government mainly pays bills and doctors bill fee-for-service.
 What are some consequences of physician independence?
National expansion: Medical Care Act (1966)
 Required provinces receiving federal funding to cover hospital & physician services.
 Late 1960s: Canada achieves its core Medicare structure.
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B. CANADA HEALTH ACT
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 Response to extra-billing & inequity
 Prohibits user charges & extra-
billing
 Five CHA principles:
 comprehensiveness,
 accessibility,
 universality,
 public administration,
 portability
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 Federal transfers are contingent on CHA compliance.
 Original aim was to make the Act a foundation for broader public health system.
 1964 Royal Commission recommended early inclusion of prescription drugs.
 Key question: what services are publicly funded?
 CHA limits: “medically necessary” hospital services, “medically required”
physician services.
 In practice: largely determined by physician judgment.
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 Physicians bill via approved fee codes.
 Fee codes are negotiated annually between provincial medical associations and
insurers.
 Contrast with with National Health Service (NHS) in the UK.
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 CHA operates at federal–provincial interface.
 So there is no direct patient appeal process
 Courts defer to legislatures
 Example: Auton v. BC → no obligation to fund all beneficial treatments
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 The main challenge is to expand the basket to include necessary services (drugs,
community care, etc.)
 Balancing two goals:
 including the full range of truly medically necessary health goods and services
 focusing on cost-effective and beneficial treatments
 The system needs flexibility: add new services, remove low-value services
 Political resistance limits delisting
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 What do we need to do to modernize the CHA?
 Is public financing the main cause of inefficiency?
 Is privatizing hospitals and physician services a better solution?
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C. INDIGENOUS HEALTH
CARE
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1.
Section 91(24) (Constitution Act, 1867): federal jurisdiction over “Indians and
lands reserved for Indians.”
2.
Section 109 (Constitution Act, 1867): reinforces federal authority over reserve
lands.
3.
Section 35 (Constitution Act, 1982): constitutional recognition and protection of
Aboriginal and treaty rights.
4.
Section 25 (Constitution Act, 1982): protects Indigenous rights from being
overridden by Charter interpretation.
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 Federal responsibility under section 91(24), Constitution Act, 1867
 1920s onward: nursing stations, clinics, hospitals on/near reserves
 Parallel system to provincial Medicare
 separate staff, facilities, funding
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 Hospital Insurance and Diagnostic Services Act (1957) and Medical Care Act (1966) did
not explicitly address Indigenous peoples living on reserves.
 1968: “Health Plan for Indians”:
 provinces provide hospital/physician care and the federal government would serve as the
“payer of last resort”
 Structural divide: federal primary/community care vs. provincial clinical services
 Coordination challenges: delayed discharge, service denials, unmet needs
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 !970s-80s: federal policy sought to reduce direct service delivery and promote
Indigenous participation in health governance .
 Self-governance: Health Transfer Policy, regional boards (e.g., James Bay, BC First
Nations Health Authority)
 What are the advantages and disadvantages of this approach?
 In many cases administrative control has been transferred, but federal oversight
and funding remain
 Persistent fragmentation: multiple actors, unclear jurisdiction
 Equity gaps: limited on-reserve continuing care, geographic and financial barriers
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