Time for a new Canada Health Act

It seems almost paradoxical that in these times of unparalleled economic prosperity, reduced personal taxes and national budget surpluses most developed countries are worried about the sustainability of their health and social programs. In Canada, discussion of the sustainability of medicare has become the national pastime.

Some of the concern has arisen because of a chronic disregard by the federal and provincial governments of the need to provide adequate capital investment; for example, Canada ranks near the bottom of Western nations in terms of MRI devices per population.1 Although this shortfall urgently needs correction, both in the short term with an injection of funds and in the long term with a better method for financing capital investment, it is not the main threat to sustainability.

The real worry is that with ever- increasing privatization of health care (the private component of total health care expenditures has increased from 25% to 30% in the past decade) the principles of the Act — public administration, universality, portability, accessibility and, most problematically, comprehensiveness — may not be sustainable. Comprehensiveness embraces "all insured (medically necessary) health services provided by hospitals, medical practitioners or dentists, and where the law of the province so permits, similar or additional services rendered by other health care practitioners."2 This is a broad and perhaps unaffordable definition.

The medical commons is not only being overgrazed, it is expanding.3^,4 When national hospital insurance was introduced in Canada in the late 1950s we were answering the question posed by physicians and private hospitals at the time: "Your son needs an appendectomy. Do you have $300?" By the late 1960s our collective answer was "Yes," and national health insurance became, as they say, part of the social fabric. Now the question is, "You need surgery if you want to play a better game of tennis. Can you wait 6 months?" Or, more importantly, "Your mother needs long-term care for her Alzheimer's disease. Can you afford $2000 per month?" The boundaries of "comprehensiveness" are enlarging both because of scientific advances and because expectations about what is medically necessary — home care, chronic care, drugs and preventive care, for example — are increasing. Some have argued that reducing inefficiency (by increasing the use of effective, preventive measures5 and avoiding expenditures related to ineffective treatments and manoeuvres6) would reduce costs. Although this and the more effective deployment of nonmedical staff would improve productivity, neither will stop medical and technological advances or the inflation of public expectations.

It is time to re-examine the principles of the Canada Health Act and to be more precise in our notions of comprehensiveness and medical necessity. The public, physicians and health care administrators want some clarity. Establishing new boundaries must certainly be based on evidence of effectiveness, but at the end of the day it will require social and political action. It is time to revisit the Canada Health Act. — CMAJ