Health Minister Mark Holland rises during Question Period, on Dec 2, 2024 in Ottawa.Adrian Wyld/The Canadian Press
In a letter to his provincial and territorial counterparts, federal Health Minister Mark Holland declared that “physician-equivalent services” provided by nurse practitioners (NPs), pharmacists and midwives should be covered by publicly funded health insurance programs.
This rare “interpretation letter” about the Canada Health Act means these services now would be considered “medically necessary” and, if patients are charged fees, provinces and territories could face financial penalties.
It would also mean that NPs, pharmacists and midwives would be able to bill health plans directly, the way physicians do.
Formally recognizing that primary care services can be provided by practitioners other than physicians is a good thing, and long overdue. There is no doubt that the current definition of “medically necessary” in legislation is terribly outdated. But, if some of the work of NPs, pharmacists and midwives is to be considered essential, what about psychologists, physiotherapists and other allied health professionals?
And while we’re at it: Should everything doctors do be considered medically necessary and covered by medicare?
Answering these questions requires a much larger conversation, and maybe some fundamental rethinking of medicare itself. But, in true Canadian fashion, we prefer to fiddle around the edges with timid letters while the system crumbles. None of the 6.5 million Canadians without access to a primary care practitioner are better off today because of this new policy.
The law itself has not changed. The minister has simply provided an interpretation – a polite suggestion to the provinces and territories to change their ways, if you will.
It’s a legally dubious interpretation, at that. The Canada Health Act clearly states that “physician services” and “hospital services” are covered by medicare. There is nothing about “physician-equivalent services.” In fact, the only mention of “other health care providers” is a section saying their services should be publicly insured “where the law of the province so permits.” Provinces and territories already have the power to allow non-physician health professions to bill public plans directly and, for the most part, have not done so.
Will the vague threat of financial penalties change their minds? Doubtful. (Especially since the new policy only comes into effect in April, 2026, and provinces don’t have to report on fees charged to patients until 2028.)
In 2018, then-health-minister Ginette Petitpas Taylor issued an interpretation letter warning provinces that patients should not be charged for diagnostic scans.
But private diagnostic clinics have flourished, even if the provinces (principally Quebec) have been punished repeatedly, with diagnostic imaging clawbacks across provinces and territories reaching $72-million last year. On federal health transfers of $49.4-billion, that’s petty cash.
The larger problem with Mr. Holland’s interpretation letter, however, is that it only addresses a sliver of the ever-troublesome issue of private billing.
There aren’t many NP-run clinics, and even fewer that charge fees. There are some pharmacists that charge for services that could be considered “medically necessary,” but how many is unclear. Likewise, midwifery services are already covered in some provinces, but not in others.
What is far more common, and growing exponentially, is Canadians paying for virtual care. About 10 million Canadians now have access to virtual care, mostly through their employer-sponsored private insurance. Is that a bad thing?
Mr. Holland has promised more guidance on virtual care some time in the future. He has also vowed to address the issue of Canadians travelling to other provinces to get surgery in private clinics.
The Canada Health Act does not prohibit duplicate private insurance, or any private provision of care for that matter. What the law is supposed to do is help ensure the fundamental philosophy of medicare – that no one is denied essential care because of an inability to pay – is respected.
The Canada Health Act came into being in 1984 because of a political crisis sparked by physicians charging user fees to patients. All four “interpretation letters” that have been issued over the years have also related to user fees and private payments.
At some point, federal, provincial and territorial legislators – and Canadians more broadly – will have to determine the place of private insurance in our largely publicly funded system. Every health system in the world has a mix of publicly and privately insured care. Getting the mix right to ensure fairness and equity in access is ultimately what matters.
You only get do that if you address the issue head-on instead of punting it forward indefinitely while ignoring the overall health of the system.