In the past decade, every Canadian province has published at least one health care report. Some, like the Clair Commission report in Québec (2001), have been very broad and elaborate. Others, such as the Ontario hospital restructuring commission (2000), were more specifically targeted. The more controversial reports, such as Don Mazankowski's for Premier Ralph Klein in Alberta (2002), have resonated long and loud in health reform circles.

During the same period, the federal government (under Jean Chrétien's Liberals) commissioned two major reports. The National Forum on Health (1997) was designed to find out what was right about health care in Canada. The Commission on the Future of Health Care in Canada (2002), chaired by Roy Romanow, sought to identify challenges and remedies. In the context of framing health care reform as a cost crisis issue, even the Senate of Canada flexed its political muscle by mandating the Standing Committee on Social Affairs, chaired by former Senator Michael Kirby, to survey and report on health as well (2002). And the SARS crisis brought public health to the forefront and spawned the Naylor commission as well.

Major-league commissions, extensive research budgets, thick and voluminous reports, dozens upon dozens of recommendations … to what end?

The debate over health care reform has shifted substantially in Canada over the decade, though whether this is either a result of commission activity or a reason for it is difficult to ascertain. On the one hand, the debate has become much more infused with evidence. One of the major contributions of the Romanow commission was the 40-odd research papers published alongside the report. We know more than ever before about the social determinants of health, the impact of evidence-based medicine, the structure of public opinion, and the real access issues affecting Canadians. On the other hand, the debate has polarized substantially, leading to often unhelpful dichotomies between “public” and “private”, between less and more spending, between federal and provincial roles and responsibilities.

Political leaders used to consider health care the crown jewel in the Canadian welfare state. But as one commission after another pored deeply – often with an abrasive approach – into the health care system, some of that shine rubbed off. The major shocks administered to health care during the period of austerity in the mid to late 1990s sullied the playing field even as it came under intensive scrutiny. Health care budgets were slashed and providers and patients were forced to adjust without a plan.

Public opinion polls tell us that confidence in the system has eroded over the decade and there is increased anxiety about the sustainability of public funding. There has also been an erosion in people's confidence in policy-makers, partly due to the steady drum-beat of reform-speak that persists without producing a clear consensus on the direction of change. Given that environment, it has been difficult to act on many of the recommendations put forth by commissions and much about health care has stayed the same.

Nevertheless, specific legislation has emerged in most provinces emanating from these commissions and reports, and the federal government has also taken some heed. It can also be argued that the Senator Kirby's report influenced the Supreme Court in its landmark Chaoulli ruling on private health insurance.

In Québec, the Clair commission prompted an overhaul of regional boards, sounded the alarm about an aging population, and jump-started primary care reform (although the project is still very much in progress). Pilot projects for vulnerable elderly were instituted but did not survive.

In Ontario, substantial change in hospital sector, including regionalization, followed the hospital restructuring commission report, but it is difficult to say that this was this a direct consequence of the report.

In Alberta, the Mazankowski report succeeded in changing the debate but not necessarily legislation. Bill 11, which expanded possibilities for private health care delivery, preceded the report but likely gained legitimacy following its publication.

Federally, the National Forum on Health emphasized health and medical research and prompted the creation of the Canadian Institutes for Health Research (CIHR) (replacing the Medical Research Council and other research funding groups) and the Canadian Institutes for Health Information (CIHI). It was the first to raise the importance of developing electronic health records, a goal that has not yet been achieved.

The Commission on the Future of Health Care in Canada recommended and was successful in seeing implemented a significant federal reinvestment in health spending. Multiyear funding was set at a level higher than recommended; a federal-provincial accord was signed, and specific health funds established in targeted areas such as wait time reduction and primary care. As per recommendations, a Health Council was established but its use and clout remain uncertain. Provinces have responded to calls for a renovation of primary care, though home care and a national pharmacare programme, which were both subject to recommendations in the report, still lack political traction.

The latest wave of health commissions reports differ in that they raise the possibility of – and in some respects, the preference for –an array of private-sector initiatives or public-private partnerships as solutions to the challenges of health reform. For example, the Ménard report in Québec (2005) suggested drastic financial measures to respond to what was an apocalyptic projection of future health costs. The more recent Castonguay report (2008), meanwhile, recommended creating the conditions for a parallel private market by providing the insurance industry a larger role to cover a broad range of services and allowing physicians to practice both in the public system and the private market.

To some extent, these controversial reports are more a reflection of the current tenor of public debate and partisan politics than a motor of change per se. Their recommendations on financial matters are unlikely to see the light of day in the short term. For now, the Québec government has limited itself to allowing private insurance for cataract, hip and knee surgery, and did so only to comply with the Supreme Court decision in Chaoulli v. Quebec, not in response to specific commission recommendations.

There is still no consensus on the accuracy of the analysis regarding our current situation (particularly the doomsday scenarios of aging and the funding crisis) presented in the Québec reports. Interest group opposition (largely resulting from the way in which unions and professionals have invested in the public system) make it difficult to move in the direction proposed in these reports. The virulent reaction to the Castonguay report also raises the spectre of tax-payer revolt. It is one thing to ask someone in an opinion poll whether they support user fees, another thing to actually “price” the individual deductibles or sales tax increases as Castonguay did.

One of the substantive impacts of the Chaoulli ruling has been to emphasize the problems inherent in the use and misuse of evidence and comparative analysis. This is a common theme in social science literature and is well-illustrated by discussions in Kirby, Castonguay and the BC examples. In the Supreme Court deliberations on Chaoulli, it was the absence of concrete evidence about the relationship between waiting lists and private insurance in Quebec that led the Court to look for guidance in the Kirby and Romanow reports. And those reports' different interpretations of the evidence led to the Court's divided judgment on the untested notion that limiting access to private insurance is a legitimate means of protecting collective access to public health care.
Following the Court's decision, the idea that private insurance poses no threat to public health was taken up in the Castonguay and BC commissions this year, leaning on one possible interpretation of comparative analyses of other industrialized health care systems – specifically, that such examples provide evidence that privatization and universality can co-exist. Again, there is no consensus that this is in fact the case, or indeed that the co-existence of private markets for health care has contributed to cost control in the comparator countries.

Recommendations from key health care commissions

ACTIONS

1997 National Forum on Health preserve public funding and single payer model expand public funding to include home care and drugs reform primary care establish transition fund to support pilot projects increase information and research to enable evidence-based decision-making 1998 Reassessment of Barer-Stoddart physician supply projections of 1991 (which prompted a 10% decrease in medical school enrollment) raises concerns about physician shortages 2000 Ontario Health Services Restructuring Commission (Duncan Sinclair, Chair) restructure Ontario's hospitals, close many make other parts of health care work like a system develop health information management system implement a new model of primary health care 2001 Clair Commission in Québec (Michel Clair, Chair) family practice groups to provide 24/7 service loss of autonomy insurance fund allow private clinics to provide services to hospitals emphasize merit as well as seniority in health sector contracts establish body to define basket of insured services 2001 Commission on Medicare in Saskatchewan (Kenneth Fyke, Chair) 24/7 access to primary care district contracting with specialists establish quality council reduce number of regional health authorities. 2002 Premier's Advisory Council on Health for Alberta (Donald Mazankowski, Chair) provide time guarantees for health services redefine comprehensiveness for publicly insured services establish multi-year contracts between government and regions blend of public, private and not-for-profit service delivery allow regional health authorities to raise additional revenue 2002 Committee of the Senate of Canada (Senator Michael Kirby, Chair) enact a health care guarantee to ensure patients receive treatment within a specified maximum time expand public health care insurance to include coverage for catastrophic prescription drug costs, post-hospital and palliative home care strengthen federal contribution to health care technology, health system evaluation, human resources and academic health science centres federal use of incentives and/or penalties to encourage country-wide standards continued adherence to efficient and effective universal health care insurance 2002 Royal Commission (Roy Romanow, Chair) common declaration of commitment to universally accessible, publicly funded health care system establish Health Council of Canada to provide national leadership modernize CHA to expand insured services to home care, drugs, diagnostic services include dispute resolution mechanism in CHA make dedicated funding contingent on respect for CHA principles include a built-in escalator and immediate booster funding in the CHST implement catastrophic drug coverage form a national drug agency to evaluate and approve new drugs form an Aboriginal Health partnership protect public health services in trade agreements 2006 Alberta Health Policy Framework (Premier Ralph Klein) expand choice in both public and private delivery systems use private facilities in training replace prohibitions on doctors opting out promote flexibility in scope of practice base compensation models on health outcomes and quality indicators revise services that are publicly funded 2008 British Columbia’s Conversation on Health (Premier Gordon Campbell) as reported in Throne Speech health reform vision commitment to single public payer private and public service delivery tie funding to performance; encourage competition between service providers create tax sheltered Independent Living Savings Account for future home care and supportive housing needs expand scope of practice for nurses and pharmacists clarify certification of health professionals and create restricted license category establish Safety Councils and Quality Review boards in each region 2008 Québec working group on health care financing (Claude Castonguay, Chair, with Joanne Marcotte (ADQ) and Michel Venne (PQ) systematically review what is publicly covered accelerate 24/7 access to primary care allow physicians to work in public and private care, within certain limitations provide home care for frail elderly on means-tested basis disengage government from health care provision and empower regions to become purchasers of services replace global budgets by service-based formula for hospitals increase workplace dynamism impose a means-tested annual fee based on health care utilization use 1% of Quebec sales tax for health care creation of National Institute for Excellence in Health to assess new drugs and technologies

2000 FPT Health Accord increases Canadian Health and Social Transfer (CHST) after 5 years of cuts dedicates new funding to medical equipment, health IT, the Health Transition Fund and pilot projects in primary care reform 2000 Alberta Health Care Protection Act (Bill 11) defines how insured services can be provided by hospitals or designated surgical facilities opens door to regions contracting (with Minister's approval) from private sector 2003 Patient Safety Institute (Dr. John Wade, Founding Chair) founded after Baker-Norton report on patient safety "Patient Safety and Healthcare Error in the Canadian Healthcare System," revealed the extent of adverse events and related deaths 2003 First Ministers' Accord on Health Care Renewal establishes a Health Reform Fund to support primary health care, home care and catastrophic drug coverage increases general funding and directed funding for diagnostic and medical equipment, EHRs and telehealth equipment performance Indicator Working Group established by provinces, territories, Statistics Canada, CIHI and Health Canada 2003 Health Council of Canada (Michael Decter, Founding Chair) created to monitor provisions of the 2003 Accord on Health Care Renewal 2004 First Ministers Accord "10-year Plan to Strengthen Health Care" provides new federal money for wait time reduction, indicator development, benchmark wait time development, medical equipment, aboriginal health and to speed progress on home care and catastrophic drug coverage demands from provinces meaningful reduction in wait times for specific areas demands plans for provincial coverage of short-term acute home care, as well as affirmation of provincial support for the principles of the CHA and the single-payer system the CHST becomes the Canada Health Transfer (CHT), with base funding set above amounts recommended by Romanow and an annual escalator of 6% 2004 Wait Times Alliance established to track progress on wait times reductions 2004 Ontario Commitment to the Future of Medicare Act prohibits physicians from opting out of the public system (some few exceptions) 2005 Chaoulli Decision the Supreme Court of Canada rules than Québec's ban on private health insurance for medically necessary services violates provincial human right law: "Access to waiting lines is not access to care." 2006 Alberta Health Policy Framework rejected by Albertans attracts warnings from Federal Health Minister Tony Clement, that allowing dual practice jeopardizes the accessibility requirement of the CHA 2006 Québec passes Bill 33 allows the private sector to supplement public services without additional costs to patients allows limited involvement of private insurance for specified services and private medical centres to act as providers of service for hospitals describes a framework for specialized private medical centres under which services can be provided by opted-in or opted-out physicians