The Path to Health Care Reform: Policy and Politics

André Picard

Conference Board of Canada, 2013

Reviewed by Johny Van Aerde, MD, MA, PhD, FRCPC


In The Path to Health Care Reform, André Picard analyzes the Canadian health care system in an historical, political, and reflective context. Throughout the entire monograph, the health journalist highlights the fact that we cannot address the “how” questions without first answering “what.” What is it that we want from our health (care) system and what is that system supposed to be anyway? Surprisingly, there is no concrete description of Canadians’ expectations and, because there are no precisely defined goals or outcomes, we have not seen substantial changes or improvements for decades. What business or organization would be successful and feel good about itself without goals and objectives?


Many of today’s difficulties are embedded in the history of the health care system and in Canadian culture, as evidenced in the first six chapters of the book, which look back as far as the 17th century when health care was established in Quebec. Picard comes to the conclusion that many promises have been left unfulfilled, resulting in a health care system today that simply reflects political and policy choices made over the last half century. Many inquiries and commissions have been struck, many documents have been written, but very limited action has resulted, not least because health care system reform takes longer than the short election cycles or the high turnover rate of health ministers. Top


Of the promises made in the 2004 health accord — A 10-year Plan to Strengthen Health Care — the only significant accomplishment was an improvement in access to cancer treatment, cardiac procedures, diagnostic imaging, joint replacement and cataract care, resulting in reduced wait times for those specific items. Politically, that was important, but the $41-billion price tag was huge and the system did not really become more efficient.


With supportive facts, Picard argues that the other nine promises in the accord were barely touched on, mainly because no clear measures and outcomes were defined at the onset. That is reflected in reports by the now-abolished Health Council of Canada, which, on one hand, shared information on innovation across the country but, on the other, did not have much to report on the implementation of the health accord. Top


Picard also highlights the positive points of the Canadian health care system. It provides jobs for 1.1 million people and is a stabilizer of the Canadian economy, especially during a recession. He acknowledges that medical care and new offerings have constantly improved; however, it is the structures used to deliver the care that have certainly not improved.


Lack of change to the system is attributed to the lack of political leadership, vested interests, and the cultural fear of change. The lack of political leadership is inherent in the system of short election cycles and the tendency of politicians to hide behind constitutional and legislative myths around prohibition of health care reform. The vested interests of hospitals and other players in the health care sector, combined with a lack of coordination between “silos,” have led to inertia and the status quo. Finally, Canadians fear change, and that fear is further stoked by interest groups on a regular basis. Top


Picard raises several issues that need to be addressed: public versus private funding, drug costs, primary care, home care, health human resources planning, and the need to abandon the bickering between the federal and provincial governments that has resulted in inequality of services delivered in different provinces and to transform that relationship into one of real coordination and collaboration.


Picard argues that Ottawa has virtually withdrawn from any leadership role in health care and only contributes 20% of the costs for hospitals and physicians. Before we can accomplish any meaningful change or address barriers, some of the fundamental questions to be answered are the “what” questions: What is medically necessary? What is the evidence? What is not medically necessary? What do we mean by “sustainable”? What will we pay for? Once those questions have been addressed, we can ask “how”: How will we pay for these services? How can the public purse support our medically necessary services and how can we supplement with private insurance and/or out-of-pocket options? How do we define that balance? How will we measure effectiveness and efficiency of the services delivered?


On several occasions, Picard mentions that the health system cannot be everything to everybody; a fair balance has to be struck between the needs of the individual and those of the population, including the socioeconomic need for health. Everything in the health care system is about balancing competing interests while keeping universality of necessary care central.


This monograph is a page turner; it can be downloaded electronically from the Conference Board of Canada’s web site: (