“Canada does it right” is a common enough phrase when discussing health care reform in the United States that it may rank high enough to justify its inclusion in congressional talking points bingo (other entries include “We have to pay attention to China” and “this is the red line we just can’t allow”, both of which can apply to literally anything at any time). Canada’s universal access to healthcare, enshrined nationally and administered provincially, is built upon principles of accessibility, universality of service, comprehensiveness of coverage and portability; whether an individual lives in Toronto or Whitehorse, they should have access to the same all-encompassing services and same level of care. The design of the National Medical Insurance Act and Canada Health Act were lauded as revolutionary steps towards national equity, as they well were. The issue with the Canadian system has never been its initial design, but rather it’s failure to adapt over time, and the limited resources that affect realization of its ideal within this fundamental social service.

Canadians have a different view of their medical care system than the rest of the world. A recent survey completed for the Conference Board of Canada indicated that 90% of Canadian believe health care and health care reform should be a main priority for federal decision-makers, surpassing the environment and economy as reform priorities. An annual report card published by the Conference Board of Canada sees Canada’s system rank 10th out of 17 developed economies, receiving a ‘B’, with leader Japan surpassing even the Nordic nations for overall quality. The primary reason for this is a failure to adapt a 1960s era chronic-disease care system in an age of community-based solutions and preventative medicine, as well as external drivers of increasing  costs placed upon provincial governments and a rapidly aging population.

Issues can be found at every stage of the health care chain, compounding as they proceed: the first sign of trouble emerges at the institutional design level. Designed for an era of younger and smaller populations, Canada’s healthcare system is overly reliant upon hospitals and physicians to back an original conception that health care systems were designed to protect citizens from bankruptcy issues of payment for chronic illnesses. This goal remains noble, but the incentives, financial supports and performance metrics have failed to shift alongside the social landscape. The once ‘comprehensive’ service only truly encompasses physicians and hospital care, leaving out dental, pharmaceutical purchases and long-term support care. It also prioritizes patients based on urgency – this is not unusual, and is in fact essential to any health care system. But Canada’s centralized medical care system means an individual cannot pay to bypass the line in order to see a necessary specialist, creating wait times that span years if problems such as joint replacements are deemed non-urgent (as they commonly are).

The impacts of stagnant institutional design ripple throughout; Canada’s primary care system is a pittance, with low accessibility for rural populations and only 2.2 physicians to attend to every 1000 citizens. Spending is directed towards institutions with effective treatment metrics, not those who play a role in preventing the requirement of treatment in the first place. Little focus is given to the integration of primary and emergency care systems, with patient information digitization initiatives often seen as ancillary and not fundamental towards improving inefficiencies. Accountability for patient outcomes is silo-ed and singular; 80% of healthcare costs are borne by 20% of the population, a figure easily recognizable when routine screenings and check-ups are bypassed and create a much larger strain on financial resources in hospitals further down the health care chain.

External financial issues are present to compound pressure – successive federal governments have slowly reduced cash contributions to provinces to meet national standards, and costs of hospital insurance continue to rise. Total spending on health care amounted to 11.1% of overall GDP in 2016, which constitutes a cost of approximately $6000 per citizen. The burden only looks to increase as retirees, the number of whom encompasses that of children in Canada, increase the average cost per patient at uneven rates. Atlantic provinces and Quebec are aging more rapidly than average, and without effective financial support or reform, the risks stand pronounced for these segments of the population.

Modern medical care has focused on expanding the breadth of health care mandates to not only curing disease, but encouraging the adoption of healthy lifestyles, which has the dual benefit of healthier populations and reducing the future burden on the health care system. Reform measures often follow this trend: Nurse practitioners (NPs) can provide primary care, and capacity issues could be addressed through the development of networks that allow for NPs to provide primary care service delivery to rural and under-served areas. Greater investment in digitization technologies would reduce waiting times by centralizing patient data and creating greater efficiencies between offices. Changes to compensation and performance metric measurements could focus more on patient health instead of patient treatment, empowering capacity-development in levels where it currently lacks.

Canadians understand that their health care system has its benefits, its limits and its flaws. Reform is required to redress policy gaps and return the framework towards its initial principles of effective universal coverage across the country. Contrary to popular belief, health care is not free in Canada – funding is directed through taxation on citizens and as such, they have a right to dictate terms of service and a personal responsibility to reduce the burden upon it, within the scope of what they can control. Reform shouldn’t be a term reserved for politicking bingo – it’s time to make sure that phrase becomes an automatic check on the scorecard.