Lewis: Canada’s dying Liberal government may have saved medicare

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It is not unthinkable to envision the end of medicare. The system has two potentially fatal symptoms: a massive access to care crisis and poor value for money.

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One in five adults has no regular source of care and wait times to see specialists stretch on for months and even years. The division of labour is inefficient, which reduces capacity, frustrates providers and increases costs. Private options beckon and business seems brisk.

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The Canada Health Act, now 40 years old, sets out the conditions by which Ottawa transfers $50 billion annually to the provinces. The act forbids charging patients for “medically necessary” services, defined as services provided by a physician.

For every dollar physicians bill patients directly for services, Ottawa is supposed to take a dollar back from its transfer payments.

It has long been an open secret that many other professions can and do provide what common sense would define as medically necessary services. Among them are nurse practitioners, midwives and pharmacists. But they have never been fully integrated into the primary care system.

For the most part, physicians are still the gatekeepers to the system, and retain their near-monopoly on the provision of services covered by medicare.

There have been occasional breeches of the medical fortress. Some provinces have funded nurse practitioner-led clinics, in the face of stiff opposition from organized medicine. Pharmacists can independently prescribe a limited range of drugs for certain conditions.

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But since the Canada Health Act prohibits direct patient billing only for doctor-provided services, some nurse practitioners have set up private clinics to serve patients without a regular doctor and charge them whatever the traffic will bear.

The federal government viewed the access problems and creeping privatization as violations of the spirit if not the letter of medicare, and sought a remedy. Opening up or even replacing the act would spark fiery debates fuelled by relentless interest group lobbying.

So Health Minister Mark Holland instead consulted with his counterparts across the country to find a Canada Health Act compatible way forward.

On Jan. 10, Holland sent a letter to provincial/territorial ministers of health outlining changes to come into force by April of 2026.

The new interpretation is that the act covers services provided by “physician equivalents,” a phrase that drives a stake through the heart of the physician monopoly over primary care.  (Look for a spike in the number of doctors treated for apoplexy.)

Furthermore, “patient charges for medically necessary services, whether provided by a physician or other health care professional providing physician-equivalent services, will be considered extra-billing and user charges under the (act).”

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The changes are significant, but hardly a radical foray into treacherous territory. They are a long-overdue response to system breakdown largely attributable to an obsolete care model that demands too much of doctors and undervalues other professions.

The surprise lies not in the removal of barriers to common sense reforms, but in how long it took. The new interpretation opens the door to innovation, but doesn’t guarantee it.

Resistance must be overcome, implementation must be negotiated, and getting the most out of an expanded range of primary-care providers will require sound policies and wise but firm diplomacy.

Fragmentation is a risk, and governments should use their leverage to mould providers into real inter-professional teams who train and practise together.

The fundamental breakthrough is to base scope of practice on demonstrated competencies, not occupational identities. Monopolistic guilds serve themselves, not the public interest. Health care changes constantly; people learn new skills. It’s high time they got to use them.

If and when we see major change — for example a province that quadruples its nurse practitioner training spaces and drastically cuts the number of orphaned patients — knock-on reforms might soon follow. Family medicine could reinvent itself to repatriate work from specialists.

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Specialists could delegate routine procedures to nurses and technicians. Wait times would shrink.

For decades, Ottawa has tried and failed to attach meaningful conditions to its health-care funding. This is its best shot to date at pulling health care back from the abyss. If it kickstarts real and rapid change, a Liberal government seemingly on its deathbed just might have saved medicare with a desperate final gasp.

Steven Lewis spent 45 years as a health policy analyst and health researcher in Saskatchewan. He can be reached at [email protected].

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