When you or a family member falls gravely ill or suffers a serious injury, the learning curve is steep.
One of first and cruelest lessons is having your eyes opened to the limitations of medicare.
Break your leg and the X-ray and cast will be covered, but you will need to pay for the crutches. Break your jaw and it will be wired at no cost; break your teeth and you will pay the dentist. Get cancer treatment at the hospital and there will be no charge; take the same oncology medication at home and you will pay dearly. Suffer from severe depression and your hospitalization will be covered, but psychological care and medications will not be covered by public insurance after you’re released. If you have diabetes and live in Quebec, many more of your drugs and supplies will be covered than in neighbouring New Brunswick. Need trauma care while visiting another province, and you could get stiffed with a big air ambulance bill. Live out your final days in a hospital and the state will pick up the tab, but do so in a nursing home and you will pay.
The list of inconsistencies and absurdities is a long one. Coverage often depends on where you live, where you work, your age – but more than anything, public coverage is limited by historical accident.
In Canada, medicare (the name we give provincial health-insurance programs) covers “medically necessary” care, which is defined as hospital and physician services. Provinces have also opted to cover some other health services but the decisions have been largely haphazard and politically motivated. (The recent decision by Ontario’s government to make prescription drugs “free” for seniors just weeks before an election is a case in point.)
So how do we bring some order and sense to the basket of publicly insured services?
A new report, which examines the role of federally funded health agencies, recommends the creation of a new entity, the Canadian Council for Health Equity, to “develop a methodology, based on the best international practices, to review and update the list of services covered by medicare.”
The inconsistent coverage of mental health care (and psychological services in particular), home care and prescription drugs has been the subject of much debate, but it’s just the tip of the iceberg.
If we are going to have a semblance of a national health system across 13 provinces and territories – without forgetting the large federal health system – it’s important to have equitable (not equal) access for all Canadians. Yet, the variations in coverage between jurisdictions have never been more pronounced.
Having a transparent way of determining what is covered by medicare is also increasingly urgent, especially with the influx of costly but unproven drugs and treatments like gene editing.
The new report, titled Fit For Purpose, is getting a lot of attention because it recommends scrapping or revamping some well-known agencies like the Mental Health Commission of Canada. But it is not getting enough attention for the smart, forward-looking solutions it is proposing.
The Canadian Council for Health Equity is one such innovation. But it would not work alone. The report recommends a Canadian Drug Agency and Connected Data Canada, which would play key roles in evaluating drugs, devices and other health technologies, as well as making better use of data to make funding decisions.
Medicare cannot provide all care to all people at all times. We need to make tough choices on what is, and isn’t, in the medicare basket of services. We need to eliminate obsolete and wasteful practices, and embrace only new ones that are cost-effective.
We have the tools to do so. But good evidence isn’t enough. As the report notes, we need to “translate the language of science and evaluation into the language of decisions and public policy.”
We also need to change the culture of health funding, to remove the political micromanagement and partisan promises from the process and to promote co-operation between jurisdictions.
That’s a tall order, but the only way to ensure Canadians not only get equitable access to necessary care, but the best bang for their health care buck.