If you want to challenge Canadian medicare, first you attack Canadians’ confidence that we are achieving good results with the expenditure of our health tax dollars.

When Christine Elliott, Ontario’s Minister of Health and Long-Term Care says in a recent interview that, “The system is on life support,” Canadians must start to wonder whether medicare’s days are numbered.

When the Ontario Premier’s Advisory Council on Improving Healthcare and Ending Hallway Medicine warns that on an average day in Ontario hospitals, there are “1,000 patients waiting for a hospital bed in an unconventional space,” Ontarians can be forgiven for asking if we can afford to add capacity that will stabilize our hospitals.

A 2018 article published in the Journal of the American Medical Association (JAMA) comparing health spending in 11 wealthy countries offers real insight into the challenges facing Canadian medicare today.

The relatively limited amount of public money that JAMA shows we spend on health, especially considered in the context of political events in Ontario and Dr. Brian Day’s court case to allow private pay health care in British Columbia, all suggest that medicare is at risk in this country.

Despite our supposed commitment to medicare, the JAMA analysis of 11 countries shows Canadians spend the second lowest amount on publicly funded health services at 7.4 per cent of GDP. Americans actually spend more public health dollars (8.3 per cent of GDP) than Canadians.

JAMA also shows we spend less than any other country on social services, 1 per cent of GDP less than Americans. We are at the bottom of the barrel in spending on the social determinants of health, such as secure housing and income.

Recognizing that we spend less in total on health and social services than other wealthy countries, where do we spend those precious dollars?

Canada has the lowest number of hospital bed days and the lowest hospital discharges per 100 population of any country. We have the second lowest number of hospital beds per capita.

Our hospitals have responded to underinvestment by becoming hyperefficient. However, most provinces are now suffering from hospital overcrowding that has been a focus for the new government in Ontario.

Are there areas where we might be overspending? Our drug prices overall are higher than most other countries, especially for drugs purchased through private insurance. Our publicly funded drug purchases are cost-effective, showing the impact of pan-Canadian drug purchasing, but private insurance is not as efficient.

What then, shall we do? Clearly, investing in hospitals, home care and nursing home capacity to reduce hospital overcrowding is essential, along with lowering drug costs.

To invest in capacity, we need to spend more money. Will governments find the political will to make the publicly funded investments that JAMA suggests we need? This is where our current medicare model may start to crumble.

Right wing voices will insist that we already pay too much tax, that we have huge provincial debt and that any incremental funding for health services should be provided from private sources (supported by private insurance) with preferred access in return for private pay. The usual argument is that allowing private payments for enhanced access to additional services will “reduce demand on the public system.”

The battle for medicare’s future will play out in Ontario amidst the system change proposed by the new government whose health minister says medicare is “on life support.” The potential resultant chaotic environment may enable the start of two-tier funding models with the pretense of helping to balance Ontario’s budget deficit while “reducing demand on medicare.”

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And it will also eventually play out in the Supreme Court of Canada, where Dr. Brian Day, and supporters who see opportunity for private insurance markets if Day wins, will test the constitutionality of our single payer system.

Medicare is only 50 years old and it remains fragile. Supporters of medicare need to carefully evaluate the current rhetoric influencing medicare’s future and remember the words of John Lennon that sometimes, “paranoia is just a heightened state of awareness.”