Canada’s health-care debate has long been trapped between two options: the system we have, and the American system we fear.
Experts say that binary thinking is costing us. Dozens of countries offer universal care, and many do it more efficiently and with better health outcomes than Canada.
“There’s a false dichotomy often in Canadians’ heads, this idea that there’s only two ways to do health care in the world, the Canadian universal way … or the American non-universal way,” said Nadeem Esmail, director of health policy at the Fraser Institute, a think tank.
“There are far better ways to deliver universal access to health care.”
The Commonwealth Fund report, which compares 10 high-income countries’ health system performance, highlights the possibilities.
In the fund’s most recent report, Canada ranked seventh. “The three top-performing countries in 2024 are Australia, the Netherlands, and the United Kingdom,” the report says.
Over a series of articles, Canadian Affairs will dig into the report’s findings, with a specific focus on Australia’s system and why it consistently ranks at or near the top.
Australia is a good country for Canada to benchmark against, and not only because Australia is a world leader in health care.
“We love Canada … we have so many similarities,” said Mark Cormack, a professor and health‑system policy expert at the Australian National University.
“In my current area of research interest, which is the health workforce, we would share and collaborate more with Canada than any other country in the world,” said Cormack, who has represented Australia at the OECD and World Health Organization.
Canada’s ranking
The Commonwealth Fund is a private, U.S.-based foundation that focuses on improving access to health care.
The fund has published its Mirror, Mirror reports since 2004, typically releasing a new report every two to three years.
The foundation uses patient and physician surveys and standardized international health data to assess health systems across five categories: health outcomes, access to care, care process, administrative efficiency and equity.
The report cites health‑care spending for context, but does not include it as a factor in the rankings. Australia spends the least as a percentage of GDP, at 9.8 per cent; Canada is in the middle of the pack, spending 11.2 per cent.
The report identifies some specific deficiencies with Canada’s system.
“Canadians face longer wait times and more difficulty getting timely access to primary care than top-performing countries,” reads the report.
These findings match other recent Canadian data. Roughly half of Canadians do not have a family doctor or struggle to see the doctor they have, according to a February poll. Canadians also wait longer than Americans and Europeans to access life-saving medicines.
The Commonwealth Fund report shows Canada also performs poorly on income equity, which refers to “how people with below-average and above-average incomes differ in their access to health care and their care experience.”
Lower equity scores are linked to higher out-of-pocket costs, gaps in private coverage, and experiences of unfair treatment or not being taken seriously by health professionals.
High-ranking health care
Australia delivers health care at lower cost and achieves better health outcomes than Canada, while maintaining comparable levels of health equity.
Esmail, of the Fraser Institute, identifies four policy features that help explain Australia’s strong performance.
One factor is modest co-payments. Like Canada, Australia provides universal primary care coverage through its Medicare system, but certain services require small co-pays, which encourage patients to use care thoughtfully.
“The basic principle is we all spend our own money more wisely and more carefully than we spend someone else’s,” said Esmail.
Another factor is private competition in hospital delivery. In Australia, private hospitals perform roughly two-thirds of elective surgeries. In Canada, by contrast, hospitals are overwhelmingly managed by provincial health authorities.
Hospitals are also funded differently. In Australia, the funding model is activity-based, where hospitals are paid for each patient treated. In Canada, hospitals typically receive a fixed annual budget.
Australia also delivers much of its publicly funded services through private providers, giving patients more choice and easing pressure on public services.
“We have a very strong private system, and in primary care, most of the health care that is funded through the Medicare arrangement is delivered by private businesses,” said Cormack.
Esmail made similar observations. “It’s a system that really perceives the private sector as a partner and as part of the system, as opposed to something to be regulated out of existence, like we do here in Canada,” he said.
Lastly, Australia’s Pharmaceutical Benefits Scheme, a system of publicly funded drug coverage, ensures affordable access to a wide range of medicines, with low co-payments and income-sensitive safety nets.
Why Australia?
In the coming weeks, Canadian Affairs will dig into these features of Australia’s system in more detail.
Australia is a country Canada is well-positioned to learn from, in part because there are numerous structural similarities between the countries.
Both have comparably sized populations and federal systems of government, where national and state or provincial governments share responsibility for health care.
Both countries have high levels of immigration and large rural and remote populations, which can affect access to care and health outcomes.
“Australia has this peculiar population distribution: 80 per cent of the population live in a small number of major cities, and then 20 per cent of the population is dispersed across unimaginably vast areas, exactly as you have in Canada,” said Don Nutbeam, executive director of Sydney Health Partners, a research collaborative.
Both countries also provide universal public health coverage supplemented by private sector care for non-urgent services.
And in both countries, poorer and less educated populations tend to have greater health needs.
“Generally speaking, just like Canada, the people that tend to need more health care and have more things wrong with them tend to be those that are poorer and less educated,” said Cormack.
Esmail says Australia’s system offers many lessons for Canada.
“We can see clearly that it has given them a more efficient, more accessible health-care system for lower cost than the Canadian system.”
Moving to the Australian health care model makes so much sense to me because I believe so much money is wasted in our current system. Using private healthcare providers integrated into our system would provide so much more opportunities for improving the quality of healthcare in Canada.
This is a very interesting conversation. I’m looking forward to reading more and hope political leaders are following as well. The comment about “spending our own money more wisely and more carefully than we spend someone else’s” really hits home. Politicians and bureaucratic leaders seem to spend “our” money less wisely and less carefully for that exact reason…it’s not theirs. I don’t mind paying taxes, but we all want value for our money and less waste.
There are some very good lessons to be learnt from Australia and others. Perception by Canadians of private delivery because of what we see in the US is a significant hurdle. Our model of funding primary care doctors is a blend of private practice funded by the government based on work volume. Expanding this to many other services gradually is the route to go. Forcing hospitals etc to develop a business sense and better use the dollars allocated. Can we change the way a hospital gets funded to the way we pay doctors?
I am all for a co-pay system, which we used to have in some provinces. It doesn’t stop you from accessing healthcare, but it will mitigate those nuisance visits for care that could readily be provided at home. I don’t remember ever going to the doctor as a child. Bruise, bumps, nosebleeds, cuts, cold and sniffles were all looked after by self or family. A small fee would help maintain a woefully underfunded healthcare system without putting a huge burden on the patient. As a medical expense it would be tax exempt, and there could be an income minimum for those who cannot pay.
For years I have been wondering why they don’t charge us a small co-pay when we see a doctor. Who couldn’t afford five or $10, yet imagine the difference it would make in the healthcare budget of the country! Personally I have figured out that I could easily pay $25 to see my doctor even though I am living on Canada’s old age pension system. Some people could afford less maybe but we would all think twice about calling them clinic for an appointment.
When Canadian “free” (of personal out of pocket charges) medicare came into existence, my father said to me, “For now it’s a good thing. But we who have established this system also know what it costs to visit a doctor, or hospital, etc.
“The next generation will have no idea, and soon everyone will consider it a ‘right’, not a ‘privilege’, paid for by everyone who pays taxes. They will forget how to address minor health challenges at home. You’ll see people running to the doctor’s office with every sniffle, sneeze and cough. We’ll lose our reliance on ourselves, and we’ll lose ‘common’ knowledge, thus becoming dependents on a system, rather than managing it!”
I believe I have seen and do witness the fulfillment of his prophetic warning.
We do well to STOP tinkering at the cosmetic edges of a ‘sacred cow’ which cannot survive. We should redesign, from scratch, a new efficient, limber and lithe model — asking patients and professionals what ought to be envisioned/incorporated — while devising a wise intentional transition plan, to implement over 2-5 yrs.
People and professionals will buy into a plan they have built together – they will also contribute to the management model more personally, responsibly.
Meanwhile, health care will be better for most, if not all, facilities and equipment will be adequate, cutting edge and available, while minor concerns will take up less bandwidth in the total time management.
We spend alot of money having paramedics waiting in the hallways of emergency departments. There must be a better way
I’m a former RN and a senior now. I have always been grateful for and proud of our Canadian public health system. I appreciated that it wasn’t free. However, somewhere over the years I lost the depth of awareness of that. Then one day I laid eyes on a copy of an invoice for the surgery and hospital care I had received the previous year. I was shocked to my core to realize how much I had been taking for granted.
When I was born, before 1950, a hospital birth and 7 day stay in hospital probably cost less than $100. If we actually knew what it costs the government today to provide our healthcare services, I think it would change a lot of attitudes.
Universal, free public healthcare is a hard-fought right in Canada. But must we continue to be kept ignorant of the true cost of each of these services we use personally?
The choice to use Australia seems very sound, and I look forward to reading the in depth articles. This kind of information is badly needed for Canadians to better understand how our system might be improved. Right now I think that Canadians fall into on of three perspectives on our health care. 1. Fear of any private involvement as it would mean that we are moving towards as US-like system. 2. Total disgust with our current system and wait times, meaning that we should move to a US system. 3. A fiscal view that would allow pay for the privilege of skipping the line. I think that the answer is more complex.
I had two major surgeries in BC that were publicly funded but managed end to end by a private provider, and the experience was excellent.
I forgot to mention that I read somewhere that privately delivered hip replacement surgeries in Ontario were billed to the government at twice the price of publicly delivered surgeries. Has anyone heard of this, or know if it is true?
My lived experience as a Canadian Australian, who spends many months each year in Canada, is not as rosy as pictured. A small co payment to visit the doctor? The Australian government has increased incentives to medical practitioners to bulk bill – i.e. charge no co-payment. Nevertheless, my doctor in downtown Melbourne belongs to a corporate practice that charges $108 for less than 20 minutes, $194 for 20-40 minutes, of which the patient pays $64 and $109 after the medicare rebate. On the bright side, there is not usually much of a wait for appointments. If I want to use the private hospital system I would need health insurance that would cost me around $1800 per year, except that I would qualify for less of a government subsidy, as punishment for not currently having insurance, and would be loaded with 70% more.
I fear that Canadians would find neither the co-payments nor the insurance premiums palatable, in spite of the desperate need for improvements to the health care system. Australians who must use only the public system, due to financial constraints, are subject to many of the same issues that my Canadian friends and family complain of. Public hospitals here are also under stress with ambulance ramping and extended wait times.
This is terrific and I will look forward to the series. Is there any data about how many Canadian health care visits can be considered unnecessary? I wonder what physicians say about this, and I wonder how many unnecessary cisits – and how many necessary visits – would be deterred by a co-pay.