Polls suggest that most Canadians strongly support the five principles laid out in the 1984 Canada Health Act — universality, accessibility, portability, comprehensiveness and public administration. While the Act has achieved iconic status, it only defines insured health services as “hospital services, physician services and surgical dental services provided to insured persons”. These are the only services subject to the five principles in the Act. It is also often suggested that the strict interpretation and application by the provinces and territories of its definitions and principles impedes modernizing medicare.

As patients receive less of their health care in hospitals, which is covered by the Act, and more in home and community settings, which is not, the Act’s authority is diminishing. In 1984, physician and hospital services represented 57% of total health spending, compared to 42% in 2009.

Although Canadians report that they are highly satisfied with the care they receive once it is delivered, they all too often have to wait for services such as diagnostic tests and surgery. Justifiably, they are not only increasingly concerned about long waits for services covered by the Act, they also worry about the financial costs of care that falls outside medicare, such as out-of-hospital pharmaceuticals and home care.

For all of these reasons, the Canadian Medical Association (CMA) believes that it is time to update the five principles of medicare laid out in the Canada Health Act and to add two more principles: patient-centred and sustainability. The overall goal would be to better focus the health care system on patients’ interests.

Below are the modernized principles for Canada’s health system as recommended by the CMA:

Universality
All Canadians must have access to the full range of necessary health care services regardless of ability to pay. This fundamental commitment to equity must include meeting the needs of vulnerable populations who may not be able to access services due to geographical, socio-economic and demographic barriers.

Accessibility
All Canadians must have timely access to the full array of health care services over their lifespan, from primary care, including health promotion and illness prevention, through institutionally-based secondary and tertiary care, to community- and home-based services that promote rehabilitation and health maintenance, to palliative care. There should be clear, measurable wait-time targets/benchmarks for access to care, with publicly-funded alternatives available when timely care is not locally available to patients in need.

Comprehensiveness
All Canadians must have access to the full complement of health services, with incentives in the system to encourage illness prevention and optimum health while addressing the factors affecting health and disease. Comprehensive prescription drug coverage is a critical part of this continuum. A defined set of nationally comparable, publicly funded core services should be available to all Canadians. Access to medically necessary health services across the country should be monitored for comparison purposes.

Portability
All Canadians should be covered within Canada, even if they are outside their home province or territory. This principle must apply to all levels of necessary care.

Public administration
Services must be appropriately, efficiently and effectively delivered. Care must be well-coordinated among providers and between levels (i.e., physician to hospital, hospital back to home, etc.), and supported by a secure electronic health information system.
Timely, high-quality care should be rewarded with incentives, such as activity-based funding of hospitals (i.e., payment on the basis of services provided), and pay-for-performance measures for health care providers, based on valid measures. The system would use both public and private service providers.

The system must be able to demonstrate good value for money. Accountability mechanisms and performance measurements must be in place for monitoring and managing system performance at all levels with regular public reporting required. Societal health goals and targets will be set and monitored. Health care providers and the community will be actively involved in system decision-making.

Patient-centred
The system must be patient-centred, providing seamless access to the continuum of care in a timely manner, based on need and not the ability to pay. Such care would take into consideration the individual needs and preferences of the patient and his/her family, and treats the patient with respect and dignity.

Sustainability
The system must be properly resourced in a sustainable manner. It must be resilient, capable of withstanding or accommodating demand surges and fiscal pressures. It must have the capacity to innovate and improve. Monitoring and documentation of emerging health needs and the burden of illness must be undertaken on an ongoing basis. Strategies must be developed and implemented to meet those needs properly.

Whether one considers the Canada Health Act iconic or incomplete, there can be no doubt that the federal government must reinterpret its vaunted principles so that they can meet the needs of Canadians in the 21st century. This is the next logical step in the evolution of Canadian medicare.

Dr. Jeffrey Turnbull is the President of the Canadian Medical Association.