(Re)examining the Canadian Health Care System through an Equity Lens

Because 2024 coincidentally marks both the 50th-anniversary issue of Canadian Public Policy and the 40th anniversary of one of the most iconic pieces of Canadian legislation, the Canada Health Act (CHA), this is an opportune moment to take stock of the latter's legacy in the current Canadian health care system with regard to equity. After a review of the concepts of vertical and horizontal equity, we show that, although the CHA has in practice ensured that there are no fees for medically necessary physician and hospital services, evidence remains of a persistent negative income gradient in mortality. We also review evidence of a negative income gradient in shares of out-of-pocket household expenditures for health care services excluded from the publicly funded program. In each case, we suggest that intersectional factors correlated with income (rurality, gender, age, and race) may be important. Although this article is not meant to be a systematic assessment but rather an evocative view of equity in the Canadian health system to help motivate future research agendas, we propose possible new ways forward for investigation and consideration. These include embedding equity principles in policy processes, expanding the notion of accessibility beyond income barriers, and broadening the range of covered services with stronger principles of fairness and universality.