Our current approach to medication, dental care, and extended health coverage is leaving low-income, working-age Canadians behind – in particular racialized, immigrant, and female workers who face significant barriers to good jobs with benefits. With government programs (of varying levels of adequacy) targeted primarily at seniors, children from low-income families, and adults receiving social assistance, most working-age people in Canada are expected to rely on employer-provided health coverage. This results in inequitable benefit coverage. The provincial and federal governments need a better plan to improve health and health equity for all.
The old normal
Despite a universal public health care system, the reality is that about 30 per cent of overall health spending in Canada is private – meaning people are paying out of pocket or relying on private insurance. Since long before the pandemic, many did not have adequate coverage for important health care services, such as dental care, medication, and mental health supports that are still not covered by public health coverage programs, such as the Ontario Health Insurance Plan (OHIP). While OHIP provides public coverage for visits to family doctors, walk-in clinics and emergency rooms, as well as many medical tests and surgeries, employer-sponsored health benefit plans have long existed and filled the gaps in OHIP coverage for some.
However, many do not have extended health coverage. As of 2018, over a third of Canadians did not have dental insurance. Wellesley Institute found that in 2015-16 even among those in employment, one in five (or 1.5 million) workers in Ontario did not have medication coverage. Part-time, newcomer, racialized and younger workers were all more likely to not have drug coverage.
This gap means that people who do not have an employer-sponsored health insurance or an often expensive private plan can experience financial barriers when going to a dentist or paying for prescription drugs and other needed services. Those with lower incomes and without insurance were four times more likely to avoid visiting a dental professional and two and a half times more likely to decline recommended dental treatment due to cost.
In Ontario, a patchwork of publicly-funded programs address some of these gaps for select groups. For example, in 2019, the Ontario government launched the Ontario Seniors Dental Care Program to provide free dental care for low-income seniors. In 2018, the OHIP+ Program began to cover many prescription drugs for all children and youth age 24 and under, which was later amended to only cover those without a private plan. These programs in no way amount to comprehensive health coverage for all Ontarians and in particular leave out many working-age adults. Further, they do not provide coverage for many other necessary health services that are typically included in private insurance plans, such as counselling or vision care. OHIP covers some physiotherapy and eye exams for targeted eligible individuals but working-age adults are mostly excluded. Beyond Ontario, coverage for extended health services also varies widely across the provinces and territories.
This heavy reliance on private insurance, often provided through employers, raised even greater concerns as Canadians experienced significant job and income loss as a result of the COVID-19 pandemic. Between February and April 2020, over 3 million Canadians lost their jobs and an additional 2.5 million Canadians had lost over half of their hours due to COVID-19.
While the pandemic has affected all Canadians, its economic impacts have been unequal. Racialized, immigrant, and female workers faced many challenges in the labour market before the pandemic, but COVID-19 has led to greater and prolonged job loss for these already marginalized workers. Recent CCPA analysis shows that unemployment rates are much higher for Black, Indigenous and other racialized workers because they are more likely to work in the industries that have been hard hit by the pandemic. COVID-19 is also having a disproportionate economic impact on women, particularly immigrant women.
The job losses left millions of Canadian workers without employer-provided health coverage. As workers in Canada lost jobs, income, benefits and savings, affording out-of-pocket health services became increasingly unaffordable. The eventual end of federal income support programs during the pandemic, like CERB and CRB, will put many more at increased risk of not meeting their health needs.
A new normal for equitable access to health benefit coverage
COVID-19 will continue to have far-reaching impacts. Racialized, immigrant, and female workers will likely continue to bear the brunt of unemployment and underemployment, and consequently experience more financial barriers to accessing needed health services. To ensure equitable access to health benefits and health outcomes, every government’s COVID-19 recovery plans requires new commitments to address the gap in medicare.
A new normal should ensure barrier-free access to a wide range of necessary health services, covering mental health supports, pharmacare, dental care and other services. Access should be given to everyone in Canada, regardless of age, income, immigration status, and employment status. When needed, everyone should be able to visit a dentist, a psychologist, a physiotherapist, or a pharmacist without worrying about cost, just as we currently do when visiting family doctors or emergency rooms.
What it would mean for our health & recovery
Extended health care coverage for all Canadians will provide enhanced access to appropriate health care services based on individual needs for care, not based on ability to pay. While Canadians report great pride in Canada’s universal health care system, many are too often unable to afford needed health care because of its gaps. This is contrary to the primary objective of Canadian health care policy, which is “to protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers.”
People getting the care they need, when they need it, could significantly reduce rates of avoidable negative health outcomes and the use of emergency health services. For example, Canadian researchers found that covering the medication costs for just three diseases —diabetes, cardiovascular disease, and chronic respiratory conditions — would result in 220,000 fewer visits to emergency departments and 90,000 fewer hospitalizations annually — a potential savings of up to $1.2 billion a year.
Similar results exist for dental care. estimated that it would cost taxpayers at least $38 million annually when people who could not afford dental care turned to family doctors or hospital emergency rooms. Reducing financial barriers to access preventative and restorative dental care would improve individual health, and it would address this inefficient, inappropriate use of health care resources.
The Conference Board of Canada’s 2016 report found that a large proportion of working Canadians had unmet mental health care needs that prevented them from working full time or part time. This study estimated that improved access to depression treatment for workers could boost Canada’s economy by up to $32.3 billion a year. Another Canadian study found that every dollar invested in psychological services would yield two dollars in savings to society.
Equitable access to comprehensive health care coverage would mean better health outcomes for all, especially for those who have been excluded from employer-provided benefits – racialized, immigrant, and female workers. As many struggle with financial challenges, enhanced health benefit coverage will ensure that people can access needed health services without having to cut back on food, electricity, shelter, or other necessities of life. This will help more households afford what is required to live a healthy life as outlined in our Thriving in the City project.
How we get there
Governments must come together to deliver a bold plan on how to improve equitable access to more comprehensive health coverage that is needed to maintain physical and mental health.
The best way to provide equitable coverage is through universal coverage. There is considerable momentum to establish universal pharmacare. In 2019, the Advisory Council on the Implementation of National Pharmacare recommended that the federal government “enshrine the principles and national standards of pharmacare in federal legislation, separate and distinct from the Canada Health Act, to demonstrate its ongoing commitment to partnership on national pharmacare and provide for a dedicated funding arrangement.” As with medicare, the Council recommended that all residents be eligible for universal pharmacare, regardless of their employment status, age, ability to pay or where they live. The governments of Canada and Prince Edward Island have signed an agreement “to accelerate the implementation of national universal pharmacare” to cover additional drugs and lower costs to Islanders, and the Green, Liberal, and New Democratic party 2021 platforms all proposed to accelerate this work to varying degrees of funding and specificity.
There is considerable support, decades of research and advocacy work, and a clear path forward for universal pharmacare. Governments need to now deliver. Establishing national pharmacare could be a historic first step towards achieving equitable access to comprehensive health care coverage. Beyond medication, such universal coverage could be extended to include other medically-necessary health services. Indeed, both the federal NDP and Liberals have indicated interest or support for universal dental care.
As we move forward towards the goal of universal pharmacare and expanded medicare, there is more that governments at all levels could do by taking immediate, targeted approaches to improve access to comprehensive health care coverage for low-income working-age adults who are currently being left out of both existing government programs and employer-provided benefits. Health advocates and organizations, like Canadian Mental Health Association, have urged the governments to provide extended basic health coverage, including prescription drugs, vision care, and dental, to low-income workers. During recent federal and provincial elections, some campaign promises were made to address this gap.
Federally, the Liberals promised new funding for the provinces for mental health care (via the Canada Mental Health Transfer). The NDP proposed to introduce immediate mental health care and dental care for people without private insurance as first steps to universal coverage. The Conservatives proposed a modest tax credit to encourage businesses to provide mental health coverage for their employees. Provincially, Ontario NDP’s last platform proposed dental care coverage for every worker in Ontario by ensuring access to Ontario Benefits, a public dental plan, or a comparable level of coverage through an employer-sponsored private plan.
While focus has largely been on how to incorporate pharmacare and dental care into national or provincial public system, achieving health equity requires renewed commitments to improve access to other health services such as mental health, vision care, physiotherapy, and assistive devices that can be so important for health and well-being. Funding psychiatric drugs without improved funding for mental health services may create problematic incentives towards pharmacology and away from (unfunded and costly) therapy. In the wake of the mental health crisis exacerbated by the COVID-19 pandemic, a social contract for a mentally healthy Canada was signed by Wellesley Institute and 25 other organizations across Canada, calls for a system that is funded adequately to support mental health and well-being.
Individuals and civil society actors should be a part of putting this on the agenda of political actors. For some, this could mean raising the issue with friends, family, or local political representatives. For civil society, this should mean putting forward and advocating for policy proposals that would address these needs. In addition to design, funding, and paths forward, policy questions remain outstanding around how private insurance can be either included or wound down in an improved future state.
There is an urgent need to address the benefit gap particularly for low-income, working-age adults. Ultimately, there should be a guarantee that every person living in Canada be eligible for needed health services, from pharmacare, to dental care, to mental health supports, to vision care and others, based on need, not based on ability to pay – and a plan to get there.