The Canada Health Act (the Act) has always seemed – to me – to be one of the most misunderstood pieces of legislation in this country.
Contrary to popular belief, for example, it doesn’t guarantee that a Canadian living in one province or territory can obtain no-charge medical care in another. Up-front medical fees may be charged to a patient from another province, who must then claim these charges back under their home province’s health insurance plan.
And these two jurisdictions may not provide payment for medical acts at the same rates, or with the same level of health insurance coverage. Due o these discrepancies, an out-of-province medical emergency may result in un-reimbursable personal costs to a Canadian patient; the difference between the cost of care billed in the province or territory they were visiting, versus the amounts covered in their home jurisdiction.
There’s also no guarantee, under the Act, that Canadians will have covered access to same types of health or medical care between regions of the country. Post-surgical physiotherapy might be provided under one province’s health insurance, at 100% for 10 sessions. A neighbouring jurisdiction may cover only 5 sessions, at only 50% – or none at all.
The Act does little to create any single system of healthcare for all Canadians. Our public health insurance coverage can – and does – differ across provinces and territories. There’s also the issue of Canadians who fall under federal health insurance programs, for example members of the military.
Most Canadians are unaware that the Act specifically excludes health coverage for members of the Canadian Forces (the CF; our military). Canada’s Constitution Act instead renders the federal government responsible for providing medical care to CF members, leaving the CF to operate yet another Canadian health insurance plan. One that must cross provincial, territorial, and national borders.
I know this first-hand, having been an officer in the Canadian Air Force (Reserve). The CF is meant to provide its members with healthcare which is comparable to that of other Canadians under the Act. Yet the question for the CF has always been: Comparable to which other Canadian jurisdiction?
All the Act does is set out five fairly basic principles that each province or territory must respect, in order to receive certain types of healthcare funding from the federal government. Read my post on the Canada Health Act for more on this topic.
A recent report summarized the Act in one phrase; it “requires public insurance of hospital and medically necessary physician services but does not require public funding of anything else”.(1)
A 2011 report published by the Canadian Medical Association (CMA) summed up the Act’s emphasis on public insurance of medically necessary and hospital care in even less favorable terms. It stated that the Canadian
health care system is very good at providing acute care – short-term care for illness or injury – or what one participant aptly called ‘Humpty Dumpty medicine.’ But for the elderly and others with longterm, or chronic, illness our system is much less effective”(2).
And the situation is much worse for Canadians living with chronic conditions or diseases which fall under the umbrella term of ‘rare diseases’. At the outset, this may not seem to be much of an issue for bioethics, healthcare policy, or medicine.
“After all,” I can imagine many folks thinking, “if a condition’s rare then it can’t affect all that many Canadians”. Although only a handful of individuals in this country may be diagnosed with a particular rare condition, there are literally thousands of recognized rare diseases.
Yet despite the vast differences between many types of rare conditions, patients very often face similar challenges. It’s estimated that 1 of every 12 Canadians has a rare disorder, yet lacks “equitable access to services between provinces” (2).
According to the CMA,
patients with rare disorders often get differential treatment across Canada because their care is a provincial responsibility…. there must be a return to the basic principle of universal access for these patients, regardless of where they live.”(2)
To be clear what it is that I mean by a rare disease, this is “defined by the Canadian Organization for Rare Disorders (CORD) as one which affects less than 1 person in 2,000” in Canada (3).
In the United States, a different definition is used:
Some rare diseases affect only a few hundred people, and by FDA’s definition, each one affects no more than 200,000 people in the U.S. Yet taken together, about 7,000 rare diseases afflict about 30 million Americans and a similar number in Europe. In much of the world, they go undiagnosed. Often, they are debilitating or deadly. Many are genetic, so children are often victims” (4).
So what’s being done in Canada? Last year our government’s Standing Senate Committee on Social Affairs, Science and Technology released a report stating that:
On 3 October 2012, Health Canada announced two initiatives to address the unique needs of Canadians affected by rare diseases; a framework to support the development and authorization of orphan drugs, and a Web portal to facilitate access to information.”(3)
Although laudable, this joint focus on orphan drug development and information sharing does little to address the current and on-going issues affecting Canadian rare disease patients. This includes the lack of equitable access to medical care, from province to province, noted above.
Their medical care and treatment remain under provincial jurisdiction, with no real incentives for inter-provincial – let alone all-province – collaboration or efforts to work on best practice approaches to diseases for which no true clinical guidelines exist.
Within Canada – between provinces and other healthcare jurisdictions – we should adopt an approach that focuses not only on research but also on improving equitable access to on-going medical care required by rare disease patients.
Collaboration is critical. Rare disease resources, including experts, are so limited that we cannot afford to waste a single moment by duplicating work or failing to share promising developments.”(4)
References:
(1) Watts, Michael. Debunking the Myths: A Broader Perspective of the Canada Health Act. Macdonald-Laurier Institute Sep 2013. Web (PDF): https://www.macdonaldlaurier.ca/files/pdf/MLICanadasHealthcareCrisisSeries2-V8.pdf
(2) Voices into Action: Report on the National Dialogue on Health Care Transformation. Canadian Medical Association. 2011. Web (PDF):
https://www.cma.ca/Assets/assets-library/document/en/advocacy/HCT_townhalls-e.pdf
(3) The Honourable Kelvin K. Ogilvie, Chair, and The
Honourable Art Eggleton, P.C., Deputy Chair. Canada’s Clinical Trial
Infrastructure: A Prescription for Improved Access to New Medicines. The
Standing Senate committee on Social Affairs, Science and Technology. Government
of Canada. Nov 2012. Web (PDF):
http://www.aihealthsolutions.ca/media/Senate-report.pdf
(4) Needleman, Katherine. Rare Diseases Without Borders: An international Strategy. FDA Voice (Government of the United States of America). 28 Feb 2013. Web: https://blogs.fda.gov/fdavoice/index.php/2013/02/rare-disorders-without-borders-an-international-strategy/