It is no accident that health care is Canada’s best-loved social program, even though it has become increasingly meaner and leaner. But we have failed to learn from its success and have so far fallen short in our efforts to build a universal public system for today.

When we talk about national public health care, we are mainly talking about the hospital and physician care covered by federal legislation. There are three pieces of legislation that set the frame: the Hospital Insurance and Diagnostic Services Act of 1957, the Medical Care Act of 1966, and the Canada Health Act, passed in 1984.

Unlike the United States, which began federal programs by targeting those defined as poor and old, Canada followed Tommy Douglas’s lead in Saskatchewan by providing universal access to health care services without fees. This approach gained several significant benefits. The most obvious is that many more people had access to health services, and this was particularly the case for the poor as well as for the many without insurance.

But there were more advantages that were less obvious. There was no need to sort the deserving from the undeserving or to set up a bureaucracy to do the sorting or assess detailed billing, thus promoting equity while reducing costs. That hospital care included all services, equipment, medications, and treatments, including private rooms if they are medically necessary, also prompted equity while reducing bureaucracy and billing. Similarly, care by doctors included all that was medically necessary, promoting diagnosis and treatment based on need rather than ability to pay. Moreover, when all classes share the same services, the rich have as much interest as the poor in ensuring high quality care.

The national legislation also benefited those who do health care work. The Canada Health Act requires “reasonable compensation” for medical doctors (and dental surgeons in hospitals). Although many doctors resisted the Saskatchewan plan and the federal legislation that followed, research showed how much their positions improved. They no longer had unpaid bills or paid staff to bill each patient. With more secure income, many had reduced hours of work. While the legislation does not talk about pay for other health care staff, the significant expansion in hospital and doctor services that followed the legislation meant much more paid work, most of which went to women. Brought together in large numbers, these women joined unions and successfully fought for improvements in wages and conditions. In addition, the provision of paid care helped reduce the unpaid care provided by women outside the health care system, especially in households where incomes were low and private insurance unavailable.

The portability provision in the Canada Health Act meant that people could get emergency care in another province or territory. It had the potential to coordinate care to allow residents of one jurisdiction to seek out specialized services in another jurisdiction. The portability provision also made health coverage portable from job to job. The universality of the system allows people to change jobs as well as jurisdictions in Canada, without fear of losing their coverage (unlike the case in the United States).

The money, and the way it was provided, is another benefit of the federal legislation. When hospital and medical insurance were introduced, the government offered stable funding amounting to half the provincial and territorial costs of specified services. The money was conditional on meeting the standards set out in the legislation and required annual reporting from the provinces to ensure that the money was spent on such services.

Within four years after hospital insurance was introduced, all the provinces and territories had signed on. It took longer with medical insurance but within six years all jurisdictions had universal physician and hospital insurance plans administered by a non-profit agency. The stable funding allowed them to plan for expansion, and the number of hospital beds grew rapidly. The standards and funding made conditional on demonstrating the standards were met provided some consistency in access to care across Canada while allowing each jurisdiction the flexibility to organize their own systems.

These federal initiatives have built support for public health care because they demonstrated the benefits of sharing risks and resources, of solidarity in addressing health care. And by beginning with universal access to specified services, they avoided the politics of envy that have emerged in the US.

Of course, the health care services that were created were not perfect or perfectly equitable. But they did have enormous benefits that we should not forget in moving forward, even as we have become so accustomed to them that they are often invisible. At the same time, we need to recognize the limits in and problems with the legislation, their implementation, and the health care systems they shaped.

Where we went wrong

The biggest failure of federal governments is the failure to “take the necessary legislative, organizational and financial decisions to make all fruits of the health sciences available to all residents without hindrance of any kind,” as the 1964 Royal Commission on Health Services (the Hall Report) recommended. The Commission’s list, in addition to medical services, included prescription drugs, homecare services, prosthetic services and both dental and homecare services for specific groups. It was missing nursing homes, perhaps because at the time nursing homes provided few if any medical services. There has been no new federal legislation since the 1984 Canada Health Act setting out terms and conditions for the services listed in the Hall Report, let alone for the new services that have merged since then. Meanwhile, the initial federal cost sharing program encouraged as much care as possible was delivered through hospitals and physicians.

Informed by the evidence, Emmett Hall argued that covering the full range of services would ensure that people were treated in the appropriate place, in the process improving the efficiency of health care services in ways that would increase access while controlling costs. Instead of following this advice by expanding services and by maintaining the formula of combining cash contributions of 50 percent with accountability that had been so successful in increasing access to hospital and medical services, federal governments began in 1977 to limit its share by reducing the cash component and transferring tax points.

As the federal cash share declined through Established Program Funding and subsequent adjustments such as the Canada Social Transfer that brought together all social programs in one lump payment, so did their ability to hold provinces and territories accountable. The 1984 Canada Health Act did make funding conditional on meeting five principles and two conditions. It did for a time at least prevent extra billing and has continued to shape aspects of hospital services. However, provinces and territories for the most part have been allowed to go their own way and spend those tax points where they wished. From 2000 on, federal governments did expand their financial contributions through agreements with First Ministers and provide some more stable funding. Money was targeted to primary health care, home care and catastrophic drug coverage. There was some requirement for public reporting on wait lists in five areas, but no real enforcement of agreements. According to the federal government’s current website, “there was less necessity for the rigorous and comprehensive reporting and auditing required on the part of the federal government.” The focus is instead “on accountability to the public rather than to other levels of government,” whatever that means.

There was no plan after the federal government moved away from shared cost, stable funding with monitored conditions. The number of hospital beds were dramatically reduced, dropping from 4.4 per thousand in 1997 to 2.2 in 2020, well below the international average. As COVID-19 has taught us, these numbers are dangerously low especially when it comes to surge capacity. Many supported a reduction in hospital beds, arguing that they reflected an overmedicalization of care and that hospitals are dangerous places. And technology made it possible to shorten patient stays and provide more out-patient surgeries, as did pressure to cut public expenditures under neoliberal austerity programs at all government levels. However, just as the closure of psychiatric beds was promoted by many progressives, the failure to provide alternative services left many without care and transferred more care to the household where women were pressured to take up the work without pay, equipment, or training.

Moreover, moving care out of the hospitals shifted costs as well as access to care. As soon as care moves out of the hospital, the Canada Health Act prohibition against fees disappears except for physician-provided medical services. Long-term residential care provides the most obvious example. Everywhere in Canada there are fees for residential care even when the care home is publicly owned and funded. Chronic care and psychiatric hospitals were closed while acute care has been redefined to cover only narrowly defined medical issues. This has left few alternatives for those with heavy daily care needs except places like long-term care homes that charge fees.

The move out of hospitals without other safeguards also provided many opportunities for profit. There are many positive things about the Canada Health Act but it failed to address the matter of ownership. The prohibition against profit applies solely to the administration of the insurance plan, not to provider organizations. The movement out of hospitals, the growth in day surgeries, the shift to home care and long-term care all offer opportunities for profit even when the money comes from the public purse. While hospitals have remained not-for-profit, many services within hospitals are contracted out to for-profit firms.

Federal governments have also failed to develop a strategy for a health care labour force, despite multiple recommendations and efforts to do so. And the Canada Health Act did not specify much about working conditions. Each province and territory sets its own standards for many health care occupations and we don’t even have common titles for many jobs, so moving among jurisdictions can be difficult. The shortages revealed and exacerbated by COVID-19 have been a long time coming. Absences due to illness and injury are highest in health services and highest among those lowest in the many-layered hierarchy that itself is a product of for-profit managerial strategies. Turnover is higher than in other industries as ‘just-enough care’ strategies make it more and more difficult for workers to provide the care they know should be provided. According to a recent Ontario staffing study, pre-pandemic, a quarter of the personal support workers who provide most of the direct care in nursing homes leave within two years and half within five.

Things got worse with the pandemic. “In the first quarter of 2021,” according to StatsCan, “the health care and social assistance sector experienced a larger year-over-year increase in job vacancies than all other sectors,” and this happened despite the enormous growth in demand for workers in this sector.

Various international organizations like the OECD, the ILO and the WHO warned before the pandemic of severe shortages unless governments stepped in to improve the valuing of the work and the conditions under which the work is performed. Those conditions have been made worse by for-profit ownership and by the the adoption within the public sector of managerial strategies taken from the for-profit sector. Staffing has been reduced to a minimum, technical control over workers has increased, full-time employment has declined and precarity increased, especially for those who are racialized and or newcomers to Canada.

And these are only the biggest failures.

How do we start fixing it?

We are told over and over again that health care is a provincial and territorial responsibility. This mantra is used by federal governments to justify their failures in introducing more health care policies, and by the provinces and territories to resist programs that require them to meet specified standards or conditions and demonstrate that they have done so. The provinces and territories demand that the federal government just give them the money without strings, even as these governments attach strings to their own expenditures. Provinces and territories claim they know best what works for their residents, but it is hard to see evidence supporting this claim.

We desperately need a new national plan that goes beyond hospitals and medical care, to include pharmacare, homecare and long-term residential care, at a minimum, supported by a national labour force strategy. Such a plan should begin with explicit principles, based on our shared values, and developed in consultation with the various jurisdictions. The principles or criteria found in the Canada Health Act provide a critical basis for such a discussion.

Universality and accessibility together provide an essential starting point—a way to strengthen our shared values as the other federal health care programs have. But as recent times have made abundantly clear, constructing care that is accessible and appropriate for all requires addressing other structural barriers and targeting programs within the universal ones to support not only equality but also equity, especially for the most vulnerable.

Ensuring public services are comprehensive in ways that include all that is necessary to care is critical to this access, but we need a public debate about whether (and if so which parts) of pharmacare, home and, residential care should have fees attached. Portability among jobs strengthens our economy while keeping people healthy, and portability among jurisdictions, if effectively administered, could do the same.

Public administration has been important to keeping profit out of the mechanisms that each jurisdiction uses to fund hospitals and doctors, although we should think of it as a public governance criterion that can promote democratic accountability and participation.

The Canada Health Act has not, however, kept profit out of our public services. We have been steadily if stealthily marching towards for-profit delivery of publicly funded care, with very little evidence to support this direction. Money that goes to profit does not go to care. For-profit delivery does not save money for the public purse nor does it provide better care, especially when the profits are made at the expense of staff and staffing. In terms of initial capital investment, governments can borrow at lower rates, and the only benefit may be that the government in office does not have to put all its capital funds on the books each year. Private investment does cost the public purse more in the end compared to what it would pay if it financed the service directly. It does not make care more accessible, except for those with money and even then, very few are rich enough to pay for complicated care. And it may lead to an overall decline in quality as the rich resist paying for a public service they don’t plan to use and giving them little interest in maintaining the quality of public care.

At least as important is the lack of democratic control over for-profit companies as they claim the need for commercial secrecy in order to compete. Moreover, it is difficult to coordinate services among for-profit organizations. Only public services can do that. And there is no reason we cannot have innovation in the public sector, often through specialized clinics run as part of the public sector. In fact, innovations ranging from drug discoveries to streamlined work organization are most often located in the public sector.

At the same time, by not providing enough public services, we are pushing those who can afford it into paying for for-profit care. This is yet another reason why we need a national strategy that invests in care, not profit. As COVID-19 has taught us, this should include a public health plan as well as control over the production of drugs and personal protective equipment.

In addition, there is a desperate need for a national labour force strategy that addresses the conditions of work in this sector as well as support for training, including in anti-racism and other equity approaches. The Canada Health Act requires “reasonable compensation” for doctors. But the labour force is much larger than doctors and the need for standards is much greater than compensation. A labour force plan could and should address recruitment and retention, as well as opportunities for training and recognition. These provisions could be shared across the country to ensure a continuing, prepared, and supported labour force. The plan would recognize that essential care services go beyond the medical to include all those who work in care services. As the Canadian Institute for Health Information argues, we lack consistent, comparable data on the unregulated paid providers who play such a large role in long-term care in particular. We have even less on those who do the housekeeping laundry and dietary work, or on the unpaid workers, predominantly women, without whose contributions health care in its entirety would collapse.

The Canada Health Act provides one model for national strategies, but it is not the only one. There are other ways to reach agreement among jurisdictions on stable federal funding in return for demonstrating that key principles and conditions are met. Achieving public accountability on vital, enforceable standards is a complicated matter, one that should itself be a matter for public participation built into the programs and required as part of the funding.

This is only a sketch of what we have learned from community organizations, unions and research. We need so much more. What we get must be a matter of our values and of political will, informed by the relevant evidence.

Pat Armstrong is a Canadian sociologist and Distinguished Research Professor at York University. She is a Fellow of the Royal Society of Canada.

Hugh Armstrong is a Distinguished Research Professor and Professor Emeritus of Social Work and Political Economy at Carleton University in Ottawa, Ontario. Dr. Armstrong’s major research interests include long-term care, the political economy of healthcare, unions and public policy, the organization of work and family and household structures.