By Nadeem Esmail
While running for the job of leading the country, Prime Minister Carney promised to defend the Canada Health Act (CHA) and build a health-care system Canadians can be proud of. Unfortunately, to have any hope of accomplishing the latter promise, he must break the former and reform the CHA.
As long as Ottawa upholds and maintains the CHA in its current form, Canadians will not have a timely, accessible and high-quality universal health-care system they can be proud of.
Consider for a moment the remarkably poor state of health care in Canada today. According to international comparisons of universal health-care systems, Canadians endure some of the lowest access to physicians, medical technologies and hospital beds in the developed world, and wait in queues for health care that routinely rank among the longest in the developed world. This is all happening despite Canadians paying for one of the developed world’s most expensive universal-access health-care systems.
None of this is new. Canada’s poor ranking in the availability of services—despite high spending—reaches back at least two decades. And wait times for health care have nearly tripled since the early 1990s. Back then, in 1993, Canadians could expect to wait 9.3 weeks for medical treatment after GP referral compared to 30 weeks in 2024.
But fortunately, we can find the solutions to our health-care woes in other countries such as Germany, Switzerland, the Netherlands and Australia, which all provide more timely access to quality universal care. Every one of these countries requires patient cost-sharing for physician and hospital services, and allows private competition in the delivery of universally accessible services with money following patients to hospitals and surgical clinics. And all these countries allow private purchases of health care, as this reduces the burden on the publicly-funded system and creates a valuable pressure valve for it.
And this brings us back to the CHA, which contains the federal government’s requirements for provincial policymaking. To receive their full federal cash transfers for health care from Ottawa (totalling nearly $55 billion in 2025/26) provinces must abide by CHA rules and regulations.
And therein lies the rub—the CHA expressly disallows requiring patients to share the cost of treatment while the CHA’s often vaguely defined terms and conditions have been used by federal governments to discourage a larger role for the private sector in the delivery of health-care services.
Clearly, it’s time for Ottawa’s approach to reflect a more contemporary understanding of how to structure a truly world-class universal health-care system.
Prime Minister Carney can begin by learning from the federal government’s own welfare reforms in the 1990s, which reduced federal transfers and allowed provinces more flexibility with policymaking. The resulting period of provincial policy innovation reduced welfare dependency and government spending on social assistance (i.e. savings for taxpayers). When Ottawa stepped back and allowed the provinces to vary policy to their unique circumstances, Canadians got improved outcomes for fewer dollars.
We need that same approach for health care today, and it begins with the federal government reforming the CHA to expressly allow provinces the ability to explore alternate policy approaches, while maintaining the foundational principles of universality.
Next, the Carney government should either hold cash transfers for health care constant (in nominal terms), reduce them or eliminate them entirely with a concordant reduction in federal taxes. By reducing (or eliminating) the pool of cash tied to the strings of the CHA, provinces would have greater freedom to pursue reform policies they consider to be in the best interests of their residents without federal intervention.
After more than four decades of effectively mandating failing health policy, it’s high time to remove ambiguity and minimize uncertainty—and the potential for politically motivated interpretations—in the CHA. If Prime Minister Carney wants Canadians to finally have a world-class health-care system then can be proud of, he should allow the provinces to choose their own set of universal health-care policies. The first step is to fix, rather than defend, the 40-year-old legislation holding the provinces back.
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