<html><head><meta http-equiv="Content-Type" content="text/html charset=utf-8"></head><body style="word-wrap: break-word; -webkit-nbsp-mode: space; -webkit-line-break: after-white-space;" class=""><div style="font-family: Helvetica-Light;" class="">The Lancet</div><div style="font-family: Helvetica-Light;" class="">February 22, 2018</div><div style="font-family: Helvetica-Light;" class="">Canada's universal health-care system: achieving its potential</div><div style="font-family: Helvetica-Light;" class="">By Danielle Martin, MD, Ashley P Miller, MD, Amélie Quesnel-Vallée, PhD, Nadine R Caron, MD, Bilkis Vissandjée, PhD, Gregory P Marchildon, PhD</div><div style="font-family: Helvetica-Light;" class=""><br class=""></div><div style="font-family: Helvetica-Light;" class="">Key messages</div><div style="font-family: Helvetica-Light;" class=""><br class=""></div><div style="font-family: Helvetica-Light;" class="">* Canada's universal, publicly funded health-care system—known as Medicare—is a source of national pride, and a model of universal health coverage. It provides relatively equitable access to physician and hospital services through 13 provincial and territorial tax-funded public insurance plans.</div><div style="font-family: Helvetica-Light;" class=""><br class=""></div><div style="font-family: Helvetica-Light;" class="">* Like most countries that are members of the Organisation for Economic Co-operation and Development (OECD), Canada faces an ageing population and fiscal constraints in its publicly funded programmes. Services must be provided across vast geography and in the context of high rates of migration and ethnocultural diversity in Canadian cities.</div><div style="font-family: Helvetica-Light;" class=""><br class=""></div><div style="font-family: Helvetica-Light;" class="">* In 2017, the 150th anniversary of Canadian Confederation, the three key health policy challenges are long waits for some elective health-care services, inequitable access to services outside the core public basket, and sustained poor health outcomes for Indigenous populations.</div><div style="font-family: Helvetica-Light;" class=""><br class=""></div><div style="font-family: Helvetica-Light;" class="">* To address these challenges, a renewal of the tripartite social contract underpinning Medicare is needed. Governments, health-care providers (especially physicians), and the public must recommit to equity, solidarity, and co-stewardship of the system.</div><div style="font-family: Helvetica-Light;" class=""><br class=""></div><div style="font-family: Helvetica-Light;" class="">* To fully achieve the potential of Medicare, action on the social determinants of health and reconciliation with Indigenous peoples must occur in parallel with health system reform.</div><div style="font-family: Helvetica-Light;" class=""><br class=""></div><div style="font-family: Helvetica-Light;" class="">* Without bold political vision and courage to strengthen and expand the country's health system, the Canadian version of universal health coverage is at risk of becoming outdated.</div><div style="font-family: Helvetica-Light;" class=""><br class=""></div><div style="font-family: Helvetica-Light;" class="">Canadian lessons for a global world</div><div style="font-family: Helvetica-Light;" class=""><br class=""></div><div style="font-family: Helvetica-Light;" class="">Canada's most important accomplishment by far has been the establishment of universal health coverage, which is free at the point of care, for medical and hospital services. The preservation and enhancement of Medicare are due largely to Canadians' pride in caring for one another—an expression of equity and solidarity that runs core to Canadian values. Hinging on a social consensus of equitable access to health care, the simplicity of the system—no variable coverage, no means testing, and no co-payments—is easy for Canadians to understand and support.</div><div style="font-family: Helvetica-Light;" class=""><br class=""></div><div style="font-family: Helvetica-Light;" class="">But universal health coverage is an aspiration, not a destination. All countries must continuously consider the depth and scope of coverage that is politically achievable and fiscally feasible. In Canada, that necessary work has not been done for more than 40 years. The Canadian experience thus offers a cautionary tale on incrementalism. In the absence of bold political vision and courage, coverage expansion can be very difficult to achieve, with the result that the Canadian version of universal health coverage is at risk of becoming outdated.</div><div style="font-family: Helvetica-Light;" class=""><br class=""></div><div style="font-family: Helvetica-Light;" class="">A powerful mechanism such as a single-payer insurance system is only as good as the willingness of system leaders to use it for reform. In turn, reform requires a willingness on the part of governments to pursue change, rather than simply managing the status quo. Clear mechanisms are lacking to consistently realign resources to meet population needs, promote evidence-based care, reduce variation, and contain costs. Health care is ultimately a local affair, and no patient or provider wants the payer in the examination room. However, much of the potential benefit of a single-payer structure is lost when institutions are independent, with little accountability. The potential of the system is further limited by the fact that physicians function alongside but outside the system, rather than as accountable participants through employment or other contractual means. Co-stewardship and accountability should be recognised as integral parts of payment systems rather than avoided or grafted on afterwards.</div><div style="font-family: Helvetica-Light;" class=""><br class=""></div><div style="font-family: Helvetica-Light;" class="">Conclusion</div><div style="font-family: Helvetica-Light;" class=""><br class=""></div><div style="font-family: Helvetica-Light;" class="">When Tommy Douglas first established public health insurance in Saskatchewan in the late 1940s, his goal was to begin by creating insurance models that would eliminate the financial barriers to care. He intended to follow that with a second reform of health service delivery that would focus on population health needs, with an emphasis on the reform of delivery models and on the social determinants of health. His government, and subsequent governments, provincially and federally, managed to overcome fragmented institutional structures and decentralisation of power to make the first stage of his vision a reality, but not yet the second. To achieve that second stage in the 21st century, determined action on the social determinants of health and a joint effort by governments, health-care providers, and the public in achieving health system reform will be needed. With bold political vision and courage, this ambitious goal is within reach.</div><div style="font-family: Helvetica-Light;" class=""><br class=""></div><div style="font-family: Helvetica-Light;" class=""><a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30181-8/fulltext" class="">http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30181-8/fulltext</a></div><div style="font-family: Helvetica-Light;" class=""><br class=""></div><div style="font-family: Helvetica-Light;" class="">PDF version</div><div style="font-family: Helvetica-Light;" class=""><a href="http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(18)30181-8.pdf" class="">http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(18)30181-8.pdf</a></div><div style="font-family: Helvetica-Light;" class=""><br class=""></div><div style="font-family: Helvetica-Light;" class="">===</div></body></html>