Season 3: Episode 3 - Tommy!

Health care in Canada is a mess. It is also one of the largest sectors of the economy. In this episode, I will make the case that our antiquated constitution is a major reason why we don’t get the quality we pay for. There is a solution.

Transcript

3  Tommy!

I’m Patrick Esmonde-White. Welcome to Canada Re-imagined, season three. After the Cataclysm

This episode: Tommy!     

In this episode, let me put aside the drama that is Trump, and turn to the challenge of delivering good government to Canadians.

Health care in Canada is a mess. It is also one of the largest sectors of the economy. Ahead, I will make the case that our antiquated constitution is a major reason why we don’t get the quality we pay for . On this issue, happily, constitutional renovation may not be the only solution.

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Canadians all know what needs to be fixed. Long wait times and the shortage of family doctors are two well-known symptoms.  Health care under the provinces is costly, inefficient and wholly inadequate.  We can do better. 

The BNA Act gave health to the provinces, never imagining that it would become a service that every Canadian would rely on quite so much. Pioneers in the Canadian colonies went to barber surgeons, apothecaries, midwives and herbalists for medical help. Doctors were few and far between. 

Medical schools had been created several decades earlier, but the profession was just becoming established. Science in medicine was only in its infancy. 

The Fathers of Confederation certainly had no knowledge of modern health care, or that it might one day consume one in every eight dollars in the economy. 

Much has changed in medical science since 1867, and access to medicine is now considered a public good. This evolved slowly, starting in the provinces. In 1966, building on the depression-era success of Saskatchewan under Tommy Douglas, Canada created a national system. It was a unique Canadian compromise: Ottawa would help fund a single-payer system; but it would be run by the provinces. 

Ottawa agreed to send money to the provinces; in return, all Canadian citizens would get quality healthcare under a single payer system. The federal Health Care Act let the provinces run their systems, and to set standards and fees.

At first, Ottawa paid half the cost.  Today, Ottawa pays about a quarter. 

Every province runs health care differently. There is no national health care system, owned by taxpayers. Most doctors are in private practice, and bill the province. Hospitals are seldom owned by the provinces, but by a mix of non-profits, corporations and health authorities. Some provinces also promote and American-style privatization. It is all incredibly complicated.

Canada’s total health care spending is now around 344 billion dollars, twenty times more than it was fifty years ago. It is almost 13% of GDP.  

This said, the cost in Canada is typical of other advanced democracies. There are shortages of doctors and nurses in many countries, and demand is growing everywhere as populations age. 

Some people argue that artificial intelligence and skilled nurses can fill the gaps. We know Doctor Google.  At some point AI can help. But it will take time to get everything right.  In the meantime, patients need care. 

Is the Canadian system too expensive?

Canada’s cost is at the high end compared to similar advanced democracies, but not by a great deal. Some of the higher costs can be easily explained. Our geography makes it hard to deliver world-class services across a vast land.  Canada is naturally inefficient. But this is a rationalisation… it hides the truth. 

Other statistics tell a different, and more worrisome story.  

Compared to most developed countries, Canada’s overall satisfaction with health services is at the very low end of the scale. According to one survey, in 2024 confidence in Canadian health care dropped during the previous five years from 79% to 64%.

Approximately six and a half million Canadians, 22% of the adult population, do not have a family doctor. Provinces now use statistics that include both family doctor and nurse practitioner.  It makes the picture look better.

In France, only 11% lack a family doctor.  In England, virtually everyone has one. 

One reason is the number of doctors.  The OECD average is 3.7 doctors for every thousand people. In Canada it is 2.7. Looking ahead, the staff shortage is only going to get worse. By 2031, it was estimated that Canada will face a shortage of 78,000 doctors, and of 117,000 nurses.  

Canada’s medical schools cannot keep pace.

Look at the length of time it takes to get treated in a hospital emergency room. The countries with the highest level of satisfaction average just over half an hour from when a patient goes through the door to when the patient sees a doctor.  In Canada the wait time typically starts at 1.5 hours.

Canada lacks facilities. France has fifteen operating rooms per 100,000 people. Italy has twelve. England six.  Canada less than three. Between the shortage of doctors, and of operating rooms, getting sick is a bad idea.  

It is small wonder that the Medical Tourism Association estimates that 432,000 Canadians sought medical care abroad in 2025. That is money for health care, paid by desperate taxpayers, that is not spent in Canada.

As an aside, the Americans are the real outliers. As a share of GDP, the USA spends about 50% more than Canada. The American system is superb for those who have full access, and terrible for those who do not.  

Here’s the deal. Canadian health care is a contradiction.  Canadian medicine is generally excellent. Our doctors and nurses and researchers are among the best in the world. But the shortcomings of the system are evident. We spend enough, but do not get great results.  The question is why?

The answer may be very simple.  Tommy Douglas said it decades ago. Canada does not have one health care system: it has over a dozen.  This is the biggest difference between Canada, and countries with great health care. 

In Canada, each province has its own bureaucracy, its own system, its own standards, its own billing system, and so on. All the administration is done a dozen times, a dozen ways. There is no efficiency of scale. 

Ottawa negotiates with provinces, and typically asks them for data to demonstrate results. The provinces resist.

Québec even has two parallel health care systems, English and French. Québec seems to see hostility towards English-speaking doctors as part of a nationalism strategy. But I digress.

The Canadian Institute for Health information estimates that about 26% of the overall health budget is spent on hospitals, and about 14% each for doctors and for drugs. That leaves about 45% of the health budget for other stuff, much of it absolutely essential. Public health, for example. Or home-based health support for the elderly or disabled.  Buried in all this are the administration cost. The variety of provincial systems means no efficiency of scale.

The best European systems, by contrast, are government owned and operated, or use mandatory insurance that covers services from tightly regulated providers.  

Consider medical education.

Each province establishes its own medical schools, and determines the number of students to be trained in the province.  Most train fewer doctors than the province will need. They hope to get more doctors from outside… from other provinces, and other countries. Ontario’s Premier Doug Ford even said he hoped to poach doctors from other provinces.

There is no plan to ensure there are enough doctors in each specialty for Canada as a nation. Or, for example, to ensure there are enough family doctors whose first choice is to serve remote communities, or their traditional First Nations. 

Nurses face a similar problem.  When nurses graduate, they enter a system that is underfunded and overworked.  

At the root of the overall problem, health is a provincial responsibility.  The provinces jealously defend this jurisdiction. They then plead poverty and demand more federal funding. They blame Ottawa. 

But the overall numbers suggest money is not the problem. The province-run mini-systems fails to deliver.  They duplicate each other’s work in IT, HR, billing, and public health. This comes at the expense of doctors, nurses, and operating rooms. With less bureaucracy, more could go to training and hiring doctors and nurses, building hospitals, buying equipment and medicine at wholesale pricess.

This is where constitutional renovation could help fix the problem. It could address the two obstacles that Tommy Douglas and Mike Pearson could not overcome as they created a single-payer health care system those decades ago. 

First, the high-quality medical services that Canadians deserve would be easier to achieve if the entire health care system was a responsibility of the federal government.  Second, most doctors would become employees, with full benefits. It would be a nation-building change. 

The design of a new national system would draw upon best practices found in the provinces, and from other developed countries. It would meet the unique needs of patients spread across a vast Canadian landscape. It would have less bureaucracy, more efficiency, and universal service standards. It would seek efficiencies of scale in data management, purchasing, research, approvals of new drugs and equipment, and a host of other areas. It would look for ways to use technology, including artificial intelligence, to empower doctors as they meet the needs of patients.

Doctors and nurses who immigrate to Canada could have transparent process to recognize, or update, their credentials. A national plan for medical education could be designed to meet the health care needs of the nation, with secure funding.   

The caveat is that a separate system would be needed to ensure services for Francophones.   

The clean and simple way to get positive change would be to amend the constitution, and make health care a federal responsibility. But constitutional renovation is never clean and simple.  

There is another option. Health care reform could be achieved step by step. Parliament could study what is required, and propose a concept that incorporates best practices from provinces and successful European countries.  Ottawa could pass legislation to design the national system as a concept. Legislation could be passed to offer provinces the ability to opt into the proposed system. Provinces that opt in would get extra help. This that do not participate would miss out on the funding. This would allow renovation without actual constitutional amendment. 

As a political manoeuvre, this is what Obama did in the United States. He brought in Obamacare, a plan that did not force states to join, but enticed them. 

With a concept such as this, provinces would have incentives to participate, and to pass supporting legislation to opt in. This would make it a permanent accord. Provinces would no longer pay for health, and could use provincial funds elsewhere. They could invest in infrastructure and housing and economic development without needing to beg for federal money.     

From a pragmatic perspective, this step by step approach is more likely to succeed, given the diversity of political opinion across Canada. Some provincial leaders would resist.  However, provincial voters might make the national health plan a ballot-box issue. 

One way or the other, few citizens care about constitutional issues: they care about results. They want and need better health care. If an antique constitution is getting in the way of health care results, and there is a better solution, voters will demand change. 

It is time to bring the dream of Tommy Douglas into the 21st century.

You have been listening to Canada Re-imagined, season three: After the Cataclysm

I’m Patrick Esmonde-White, totally responsible for this podcast. My theme music is by Tom Plant. My thanks to the Harbinger Media Network for their support.

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