Trudeau's big — and underfunded — health care promises

The claim: "A re-elected Liberal government will make sure every Canadian has access to a family doctor, to mental health services, to affordable prescription drugs and to national pharmacare."

— The federal Liberals tout their promise to boost health care funding by $6 billion over the coming four years.

The facts:

On Monday, Liberal Leader Justin Trudeau unveiled his plan to close the "gaps" in Canada's health care system, promising an "additional down payment" of $6 billion to strengthen medicare and the public health system. 

The party reported the amounts — $750 million in 2020-21, rising to $1.75 billion in 2023-24 — but said a detailed breakdown of how the money would be spent will have to wait until later in the campaign.

Still, that didn't stop Trudeau from raising expectations about what he might accomplish in a second term, vowing that Canadians in every province and territory would have access to a family physician, mental health services as needed and prescription medications via a universal "pharmacare" program.

"Every Canadian, no matter where they live, who they are or what they do, should receive the care they need to stay healthy," Trudeau said during a campaign event in Hamilton, Ont.

The Liberals came to power in 2015 promising to negotiate a new "collaborative" health accord with the provinces and territories. But when the 10-year deal was finally struck in 2017, it wasn't nearly as generous as the premiers had hoped: it capped increases to the Canada Health Transfer at three per cent per year, down from six per cent under the old agreement.

Ottawa did sweeten the pot with $11 billion in funding over 10 years for improved home and palliative care, and mental health and addiction services. The Liberals have been talking about that a lot during this campaign, along with changes to prescription drug pricing that they say will save Canadians $13 billion over the coming decade.

The Canada Health Transfer in fiscal year 2018-19 was $38.6 billion, more than half of the total $75.4 billion that flowed from Ottawa to the provinces and territories.

But that remains a fraction — just 15 per cent — of overall public and private health care spending in Canada, which totalled $253.5 billion in 2018, according to the Canadian Institute for Health Information (CIHI).

Per capita health care spending has been increasing since 2014, up an average of 1.7 per cent per year, after declining by an average of 0.2 per cent a year between 2010 and 2014. In 2018, it worked out to $ 6,839 per person, or 11.3 per cent of Canada's Gross Domestic Product. That's still below the peak health care spending ratio of 11.6 per cent of GDP in 2010.

The Liberals can claim partial credit for that uptick, but if they're really intent on filling the gaps in the system, it's going to take a lot more money than they have budgeted and promised thus far.

Take Trudeau's vow to implement national pharmacare and help the nearly one million Canadians "who skimp on food and heat to be able to pay for the medications they depend on."

In June, the advisory council that the Liberals set up to look into pharmacare tabled a final report with some awfully big numbers. If, as recommended,  the government starts with a stripped-down version of the program covering only "essential'"medicines in 2022, the net annual cost would be $4.1 billion. And as the list of eligible drugs expands, along with the number of users, the price tag would grow to $15.3 billion a year by 2027. 

Michael Law, an associate professor of public health at the University of British Columbia and the Canada research chair in access to medicines, said it's hard to reconcile the Liberals' ambitions with the $6 billion sum and the multiple objectives on offer.

"It might go toward some of the groundwork to get things started," he said. "But what they are currently proposing to spend is nowhere near what they would have to spend to set up a national pharmacare program."

Trudeau's promise to improve access to mental health services — so that "Canadians can get the support they need quickly, when they need it most" — would also be costly.

Last year, the Canadian Mental Health Association (CMHA) produced a report that looked at spending on mental health versus physical health in Canada. Right now, only 7.2 per cent of the federal health care budget is dedicated to mental well-being. And the 2017 pot-sweetener that dedicated $5 billion more over 10 years barely moved the needle, increasing slightly the share of federal health spending going to mental health from 7 per cent.

Fardous Hosseiny, the CMHA's interim chief executive, said getting to nine per cent would take an additional $3.1 billion a year — which would still be well below the spending level his organization wants to see.

"More investment is always welcome," he said. "But it won't take one budget, or even one government, to right-size that funding gap."

Too many patients, not enough doctors

Then there's that Liberal pledge to provide everyone with access to a family doctor.

In 2017, Canada had 86,644 practising physicians, which works out to 234 doctors per 100,000 population. That's slightly more than Mexico, slightly fewer than the United States — but well below the levels in Argentina, Germany, France, Italy and Spain, all of which have ratios closer to 400 doctors per 100,000 population.

CIHI reports that gross clinical payments to physicians amounted to $26.4 billion in 2016-17 — a 2.8 per cent increase over the year before, with an average payment of $342,000 per doctor. 

Statistics Canada estimates that there are now 4.7 million people who don't (by circumstance or choice) have a primary health care provider. Offering them the same level of access as other Canadians would mean adding at least 11,000 more doctors — which, at current payment rates, adds up to an additional $3.76 billion a year in health costs.

And keep in mind that the country already is having difficulty finding enough residency spots for the record number of students graduating from medical schools.

A hostile provincial climate

Of course, party pledges to "fix" Canada's health care system are a staple of almost every election, provincial and federal.

"The Liberals first promised medicare in 1919 under William Lyon Mackenzie King," said Dr. Michael Rachlis, a public health physician and adjunct professor at the University of Toronto's Dalla Lana School of Public Health. "And they took until 1968 — 47 years — to pass the legislation."

Rachlis noted that these current Liberal goals come with a number of caveats and all depend on more "collaborative" negotiations with the provinces and territories — many of which are led by Conservative governments.

"If they're re-elected, they're going to face really hostile provincial governments who won't want to do any of this stuff with them," said Rachlis. "These are nice promises that the Liberals are never going to have to fulfil."

The Verdict: False. Filling the gaps in Canada's health care system will take billions of dollars more than the Liberals have put on the table, and a level of political goodwill that probably doesn't exist right now.

Sources: Liberals to boost investments in health care for Canadians, Liberal Party of Canada; Liberals promise improved access to family doctors, mental health care and prescription drugs, CBC News; A new plan for a strong middle class, Liberal Party of Canada; Divide and conquer: How the feds split the provinces in health talks, Hill Times; Manitoba signs on to Ottawa health accord for more mental health, home care funding, CBC News; Ottawa promises to save billions with tweaks to patent drug system, CBC News; Federal support to provinces and territories, Dept. of Finance; National Health Expenditure Trends, 1975 to 2018, Canadian Institute for Health Information; Final Report of the Advisory Council on the Implementation of National Pharmacare, Government of Canada; Mental Health in the Balance, Ending the Health Care Disparity in Canada, Canadian Mental Health Association; Physicians in Canada, Canadian Institute for Health Information; Density of Physicians, World Health Organization; Primary Health Care Providers, 2017; Statistics Canada; 'You feel like your world in over': Problems and solutions for medical graduates without residencies, CBC News.