Open this photo in gallery: Illustration by Marley Allen-Ash The federal election campaign has so far focused on cost of living and the trade war. Health care – an issue that touches the lives of every Canadian – was notably absent from the leaders’ debates, although the Liberals, Conservatives and NDP have made a number of promises on that front in recent days, including to add more family doctors. Last week, The Globe and Mail hosted a webcast panel – Election 2025: Steps to heal Canada’s health care system – to discuss the current landscape, possible solutions and what to look for when casting your vote on April 28. Hosted by health reporter Kelly Grant, the panelists included Kevin Smith, president and chief executive officer of University Health Network; Tara Kiran, family physician and scientist at Unity Health Toronto; Joss Reimer, president of the Canadian Medical Association; and André Picard, health columnist at The Globe and Mail. The conversation has been edited for length. Grant: One thing that all the parties have made a promise of is access to family doctors and primary care. What do you want to see the next government do to help guarantee every Canadian access to primary care? Dr. Kiran: I’m glad that parties are recognizing that this is an issue. But what I would like to see is all of the parties committing to three things. One, more money. Two, more accountability for access. And three, a co-ordinated national strategy that ensures the minimum standard for access. When we look to our peer countries across the globe, we know that they, on average, spend a greater proportion of their total health budget on primary care than we do in Canada. So it’s clear that we need to shift our spending. We probably have to grow the whole health pie, but we also need to, within that pie, put enough dollars for primary care and what we call upstream issues – trying to prevent people from having problems, to prevent them from having to get into a hospital, for example. Grant: You mentioned the consequences if people don’t have access to a family doctor. One of the consequences over the last few years has been this rise in virtual care. In a lot of cases, we’re looking at for-profit companies who are charging things like membership fees for medically necessary services. If we can’t provide people with enough doctors through the public system, should people be allowed to pay out of pocket, especially for something as convenient as virtual care? Dr. Reimer: That’s a really important question, because access to care, like Dr. Kiran said, is such a fundamental issue for Canadians. We hosted a series of conversations across the country, and between those conversations and surveys we talked to 10,000 Canadians, and they told us that their No. 1 concern was access to care – but that access should not be determined by whether someone has the ability to pay. We also did a literature review and a jurisdictional scan, and found that, broadly speaking – and there are lots of caveats – the private care tended to be more expensive and have worse outcomes. That’s not to say we shouldn’t have private services in our health system. But it does mean that we need to be really cautious when we’re looking at private solutions. We’d love to see virtual care also being considered part of that public purse – that whether you’re seeing your doctor in person or you’re seeing them virtually, you should have the expectation that that is provided by your tax dollars. Dr. Smith: An example of where digital or virtual care worked well during COVID is at University Health Network. We went from about 200 virtual visits a month to over 11,000 a month, and it was good for everyone. It was, of course, within the public pay system. Afterwards, as we came out of that and we changed the fee schedule, we no longer rewarded virtual care in the same way. It’s important to recognize that we have the system we incent, and if we follow the incentives, we sometimes better understand the behaviours. We’re fortunate to be doing some work with the province of Nova Scotia in virtual care, where urgent and primary care is available using technology with a UHN physician. What’s been fascinating is that 90 per cent of the people who are coming to be seen don’t require a visit to a hospital or clinic. The physician or nurse practitioner can order lab tests, drugs et cetera, and co-ordinate with those who do have a primary care provider. Grant: Some of these innovations, be it in drugs or technology or the way the system is governed, do wind up adding costs. Do you think we have the ability as a country to have the public purse keep pace? Dr. Smith: When people poll and say, ‘Do you want to pay more taxes?’ not a lot of hands go up. But when you say, ‘Do you want more access to high-quality health care?’ a lot of hands go up. For our political colleagues, that’s challenging. What we are recognizing is, perhaps could we use those resources more effectively? Obviously. And should we be looking at other forms of revenue that already exist in the system? Grant: André, do you think we’re underfunding health care in Canada? Picard: I’m not sure. I’m not sure we know what we’re funding or why. So I think that’s a fundamental issue. I think what is clear is we don’t get value for money for what we spend. We have the least universal, universal health care system in the world. We fully fund hospitals and doctors, but everything else is really all over the map. Our system was built in the 1950s and sixties. It was built for a population at that time. We could certainly spend more money, but first and foremost we have to spend it better and smarter. Grant: A way in which we could modernize the system would have to do with how we handle medical records. Our colleague Chris Hannay just wrote a piece about the frustration people have getting to see their own records. I wonder, André, if you see that as something that Canada could improve on, and why it is that it has been such a hard problem for us to solve? Picard: We have to remember [that in] the Canadian health system, the principle means of communication is still the fax machine. The last government had legislation, Bill 72, to ensure that systems are interoperable so they speak to each other. That’s our biggest problem. We have a lot of systems, way too many of them. There’s maybe 30 electronic medical records in Ontario alone, and most of them don’t talk to each other. Dr. Kiran: Many countries have legislated the right for patients to be able to have their own record. Until we legislate, the private companies, even public institutions, don’t have an incentive to enable that interoperability so that everybody can have that record right at their fingertips. Grant: I’ve been getting questions from the audience. I’m going to direct this one to you, Dr. Reimer. What is being done to streamline the provincial regulatory approval of doctors, and how could the federal government play a role there? Dr. Reimer: Health is a provincial jurisdiction overall, [but] there’s lots of roles for the federal government. I’ve seen a clinic that is newly opened in Halifax, where they are doing something they call practice-ready assessments, meaning they do several months of supervised practice. It’s like a teaching clinic: They have internationally trained physicians working there, being supervised by Canadian physicians for three months or so. The idea being, at the end they will either get a check mark, yes, you’re ready to go practice in Canada, or you might need extra training in parts A, B and C, or we can get you this tailored licence where you can go and do a procedure clinic, but maybe you won’t do full-scope family medicine. It gave me some hope that we now have an example of a process where, instead of one-off assessments, international grads can go into the system, get assessed in a comprehensive way and get into practice sooner. We’re just going to need some resources, and this is something I’d love to hear from federal candidates about what they plan to do. Grant: I really love that example. I want to turn to you, Dr. Smith, to ask you also about trying to bring in doctors from overseas. UHN announced a campaign to attract 100 early-career scientists, and really you’re targeting the United States and so many of the researchers there who are concerned about what the current political climate means for their grants and for their future. What do you want to see the federal government do to make sure there is a smooth path for those people looking to move to Canada? Dr. Smith: Less red tape. So, how do they get here? In our focus, it is early-career scientists, some of whom will be clinician scientists. Some will be PhD basic scientists. For us, the excitement was in hearing all the party leaders talk about a transformation of our Canadian economy into a knowledge-based, science-based economy. If we truly mean that, then we need to think about how do we not only create science, but exploit science and build a manufacturing environment? This is something I hope whoever the next prime minister is will boldly embrace. Everyone’s talking about transformational. I’m going to be a little bit critical. Canada is not well known for transformational. We do incremental really well. I hope we hold the next prime minister accountable to build a transformational economy and start with research and science. Dr. Reimer: We have a window of opportunity with U.S. physicians wanting to come to Canada. We need to see the government fast-tracking visa applications, because that is squarely within the federal government’s control. They could eliminate the need for things like labour market assessments, because right now we have to prove that we’re not able to fill these vacancies with Canadian physicians. Dr. Smith: I’ll just add, 35 per cent of the people who’ve [expressed] interest from the United States and around the world, they’re Canadians. They want to come home. Grant: That’s bringing physicians and scientists back, but it also speaks to the idea of retention. What needs to be done to keep the health workers we do have? Dr. Kiran: I’ll start with the training part, because that’s something we’ve done a pretty terrible job with over the last three decades. When we compare ourselves to other countries, we have a lot less doctors per capita. Many of the European countries might have 1.5 times or more. This all goes back to decisions from the 1990s about restricting medical school enrolments as a cost-saving measure. We’ve had a lot of flaws in our planning process. Not only do we have an aging population where we need more doctors to be able to serve people because they’re living longer and have more complex conditions, but we also have a work force that wants to work differently. People want more flexibility, and they want to concentrate on the doctoring part if they’re doctors. We need to ensure that our federal government is planning for the future, taking population growth and work force patterns into account. Grant: I love asking this to doctors: Do you think we should be channelling a lot more of this work to other providers, like nurse practitioners or pharmacists? Dr. Reimer: I have worked in a clinic where I had nurses, a pharmacist, a dietitian, physiotherapist, social worker, and I can tell you that for me as the physician, it was so much less stressful – and it was so much better for my patients as well. That’s the type of team we want to build so that patients get access to the right provider at the right time. But the key part is that it’s a team. We don’t want isolated practitioners working where we’re not sharing information. Grant: There are a couple more topics I want to make sure we hit and one of those is pharmacare. The last Liberal government passed some legislation regarding pharmacare. They’ve done some deals with provinces that would see federal money spent on providing coverage for some birth control options and diabetes drugs. What would you all like to see the next government propose and pass as far as pharmacare is concerned? Dr. Kiran: We absolutely need a national pharmacare program. It is really frustrating and feels awful to be in a clinic room with someone and know that there are treatments available but that those treatments are going to be a challenge for them to afford. Lots of evidence shows that if we spend more as a country on publicly covered drugs, we can negotiate better and bring down costs, which is an important part of it, too. Dr. Smith: I couldn’t agree more philosophically. But here’s my challenge: We continue to see federal governments inadequately fund the broader public purse. My worry is we’ll drift into another political announcement with partial funding that, at the end of the year, will leave us scrambling for actual coverage. Many of us are fortunate to enjoy a wonderful drug program through our employer, so that isn’t something that we need to defray by public expenditure. But for those who do not, especially those who are most disadvantaged, we for sure need to consider that. Grant: What do you think about the fact that the debate organizers [chose] not to make health a theme in the leaders’ debates? Dr. Reimer: I was deeply disappointed. It makes sense that we’re talking about the economy, because we are seeing such a shifting landscape with our relationship with the U.S. and tariffs. But the economy and health are so deeply interlinked that I don’t think we can separate those. Picard: You can’t have a healthy economy without healthy people. It’s an issue where we spend a lot of money. The future of our nation is healthy children. There’s a multitude of reasons why we should be talking about this, and it’s unfortunate. Dr. Smith: It’s incredibly tragic that we’re not actually having this debate. If you look coast to coast to coast, in any media outlet every day, we see the challenges of health care, whether it’s quality of work-life, whether it’s access, whether it’s cost, you name it. If this election is about competitiveness and economic renewal and transformation, you can’t have the outcome not include addressing health care issues. Dr. Kiran: We’re at a critical juncture in health care and we know that it’s something Canadians value dearly. We also know that our health care system is struggling like it hasn’t before, and so it’s ever more important that we should be talking about it. I worry that maybe one of the reasons that political parties didn’t put forward more on health care is because they’re not sure that this is a solvable issue. That would be sad if that was the case, because I do think that there are actual, real solutions.