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For years – sorry, decades – Canadians have argued over how to improve the health of Canada’s health care system. Supporters of the medicare status quo, on the centre and left of the political spectrum, tend to think the problem is lack of money. Medicare doesn’t need a rethink. It just needs more resources.

In contrast, critics on the right often want to blow up universal health care, or at least let people with deep pockets buy their way around it. But their proposed solutions, when you eyeball them closely, also often assume that the main problem with Canadian health care is … a lack of money.

When this second group of critics says that the way to deal with long health care waiting lists is to allow people to buy their way to the head of the line, they aren’t really advocating health care reform. Just like status quo advocates, they want billions more dollars put into health care – albeit with funds coming from, and benefits flowing to, those able to pay.

It’s like arguing that reselling marked-up tickets to a sold-out concert creates more concert seats. Absent some other reform – moving the show to a bigger arena, adding extra dates, shrinking the size of the chairs – extra cash adds not one new seat. What changes is who gets to sit in them.

Those who defend the status quo have different ideas about where the money should come from, and where it should go. But they, too, are very focused on shoving new dollars into the old sausage grinder.

Consider the long-standing provincial demand: a massive increase in federal health transfers. They don’t want the feds telling them how to spend, and they have limited plans for transforming the management and incentives of the highly top-down system. The provinces mostly want more money to do what they’re already doing, with extra cash (hopefully) buying some extra doing.

Canadians need to consider the possibility that what ails Canadian health care is mostly not lack of money.

Among 11 highly developed peer countries, Canada is an above-average health care spender. In 2019, Canada devoted 10.8 per cent of gross domestic product to health care. That is far less than the United States: The world’s most incompetent health care setup spent 16.8 per cent of GDP, while delivering mediocre outcomes. Canada also spent less than Germany, Switzerland and France. But it spent more than Australia (9.4 per cent), New Zealand (9.1), the United Kingdom (10.2), the Netherlands (10.2) and Norway (10.5).

With the exception of the U.S., every one of those countries does better than Canada on the non-partisan Commonwealth Fund’s regular comparisons of health care system performance. And the top four performers – Norway, the Netherlands, Australia and the U.K. – all spend less than Canada.

That’s why Canada needs to think about system reform, not just about spending more on the status quo.

But rethinking isn’t about getting rid of universal health insurance. It doesn’t mean allowing doctors and patients to act like resellers and bidders for sold-out concert tickets. That won’t deliver cheaper health care, or better health care, or a better society.

Rather than tearing down universal insurance, Canada needs to reform its structure and its incentives. At the same time, our country should expand – yes, expand – the list of insured health services.

Ottawa is moving forward on the second of those needs, with a federal plan for guaranteed dental insurance for low- and middle-income families. It also promises to (eventually) create national drug insurance. This page has long supported both ideas – because the one place where Canadian health care looks like the American disaster is when it comes to the widespread lack of insurance for dentistry and drugs.

Among peer countries, the U.S. has by far the highest level of people who didn’t fill a prescription because of cost, or didn’t go to the dentist because they couldn’t afford it. Canada is an embarrassingly close second. It’s time to fix that.

But Canada also has to recognize that the world’s best health care systems cost less than ours, yet deliver more – shorter waiting lists, quicker access to a doctor when you’re sick, fewer emergency room visits, and fewer appointments cancelled during the pandemic. What can we learn from them, and copy?

Keep universal health insurance. Expand it. But rethink how it’s organized, incentivized and delivered. That’s what our more successful peers did.

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