Healthcare in Canada

Health and aging in Canada

By July 2020, there were 6,835,866 who were 65 years old and older and 11,517 centenarians.^[32] The same data reported that by July 2020, 16% of Canadians were 14-years-old or under, 66.5% were between the ages of 15 and 65, and 17.5% were 65 years and older.^[32]

Canada's population is aging, like that of many other countries^[34]—by 2016, there were about six million seniors in Canada, which then had a population of approximately 39 million.^[35] While this significantly influences Canada's healthcare services,^[34] by 2019, Canada's aging population represented a modest increase in healthcare costs of about 1% a year.^[7]

Since the 2010s, Statistics Canada health research on aging has focused on "chronic diseases", "social isolation" and senior's mental health needs, and "transitions to institutional care" including long-term care.^[34] The eight chronic conditions that are prevalent in one out of ten seniors include high blood pressure, arthritis, back problems, eye problems, heart disease, osteoporosis, diabetes and urinary incontinence, with many seniors having multiple chronic conditions.^[34] Those with chronic conditions are "associated with higher use of home-care services and need for formal-care providers."^[34]

Ninety percent of Canadians agree that Canada should have a "national seniors strategy to address needs along the full continuum of care."^[35]

In 2016, individuals who are from 55 to 64 years old—which represented about 55% of the population—did not have enough savings to cover even one year's expenses.^[36] Canadians who are 65 years of age or older have access to Old Age Security (OAS), Guaranteed Income Supplement (GIS), Allowance and, Canada Pension Plan (CPP) based on certain criteria for eligibility.^[37]

Benefits and features

Health cards are issued by provincial health ministries to individuals who enroll for the program in the province and everyone receives the same level of care.^[45] There is no need for a variety of plans because virtually all essential basic care is covered, including maternity but excluding mental health and home care.^[46] Infertility costs are not covered in any province other than Quebec, though they are now partially covered in some other provinces.^[47] In some provinces, private supplemental plans are available for those who desire private rooms if they are hospitalized. Cosmetic surgery and some forms of elective surgery are not considered essential care and are generally not covered. For example, Canadian health insurance plans do not cover non-therapeutic circumcision.^[48] These can be paid out-of-pocket or through private insurers.

Health coverage is not affected by loss or change of jobs, cannot be denied due to unpaid premiums, and there are no lifetime limits or exclusions for pre-existing conditions. The Canada Health Act deems that essential physician and hospital care be covered by the publicly funded system, but each province has reasons to determine what is considered essential, and where, how and who should provide the services. There are some provinces that are moving towards Private Health Care away from Public Health Care. The result is that there is a wide variance in what is covered across the country by the public health system, particularly in more controversial areas, such as in-vitro fertilization,^[49] sex reassignment surgery,^[50] or autism treatments.^[38]

Canada (with the exception of the province of Quebec) is one of the few countries with a universal healthcare system that does not include coverage of prescription medication (other such countries are Russia and some of the former USSR republics^[51]). Residents of Quebec who are covered by the province's public prescription drug plan pay an annual premium of $0 to $660 when they file their Quebec income tax return.^[52][53]

Due to changes in the past two decades, at least some provinces have introduced some universal prescription drug insurance. Nova Scotia has Family Pharmacare, introduced in 2008 by Rodney MacDonald's Progressive Conservative government.^[54] However, residents do not automatically receive it through their health care as they must register separately for it, and it covers a limited range of prescriptions. No premiums are charged. A deductible and out-of-pocket maximum for copayments are set as a percentage of taxable income of two years before.^[55]

Pharmaceutical medications are covered by public funds in some provinces for the elderly or indigent,^[56] or through employment-based private insurance or paid for out-of-pocket. In Ontario, eligible medications are provided at no cost for covered individuals aged 24 and under.^[57] Most drug prices are negotiated with suppliers by each provincial government to control costs but more recently, the Council of the Federation announced an initiative for select provinces to work together to create a larger buying block for more leverage to control costs of pharmaceutical drugs.^[58] More than 60 percent of prescription medications are paid for privately in Canada.^[38] Family physicians ("General Practitioners") are chosen by individuals. If a patient wishes to see a specialist or is counseled to see a specialist by their GP, a referral is made by a GP in the local community. Preventive care and early detection are considered critical and yearly checkups are recommended for everyone.

Mental health

The Canada Health Act covers the services of psychiatrists, medical doctors with additional training in psychiatry. In Canada, psychiatrists tend to focus on the treatment of mental illness with medication.^[59] However, the Canada Health Act excludes care provided in a "hospital or institution primarily for the mentally disordered."^[60] Some institutional care is provided by provinces. The Canada Health Act does not cover treatment by a psychologist^[61] or psychotherapist unless the practitioner is also a medical doctor. Goods and Services Tax or Harmonized Sales Tax (depending on the province) applies to the services of psychotherapists.^[62] Some coverage for mental health care and substance abuse treatment may be available under other government programs. For example, in Alberta, the province provides funding for mental health care through Alberta Health Services.^[63] Most or all provinces and territories offer government-funded drug and alcohol addiction rehabilitation, although waiting lists may exist.^[64] The cost of treatment by a psychologist or psychotherapist in Canada has been cited as a contributing factor in the high suicide rate among first responders such as police officers, EMTs and paramedics. According to a CBC report, some police forces "offer benefits plans that cover only a handful of sessions with community psychologists, forcing those seeking help to join lengthy waiting lists to seek free psychiatric assistance."^[65]

Oral health

It is said that among the OECD countries, Canada ranks approximately second to last in the public funding of oral healthcare. Those who need dental care are usually responsible for the finances and some may benefit from the coverage available through employment, under provincial plans, or private dental care plans. "As opposed to its national system of public health insurance, dental care in Canada is almost wholly privately financed, with approximately 60% of dental care paid through employment-based insurance, and 35% through out-of-pocket expenditures [7,8]. Of the approximately 5% of publicly financed care that remains, most has focused on socially marginalized groups (e.g., low-income children and adults), and is supported by different levels of government depending on the group insured [9]."^[66] It is true that compared to primary care checkups, dental care checkups are highly relied on the ability of people being able to pay those fees. While viewing studies done in the cities of Quebec as well as Ontario a few interesting facts were seen. For example, studies in Quebec showed that there was a strong relation among dental services and the socioeconomic factors of income and education whereas in Ontario older adults heavily relied on dental insurance with visits to the dentist. "According to the National Public Health Service in 1996/1997, it showed a whopping difference of people who were in different classes. About half of Canadians aged 15 or older (53%) reported having dental insurance (Table 1). Coverage tended to be highest among middle-aged people. At older ages, the rate dropped, and only one-fifth of the 65-or-older age group (21%) was covered."^[67] Attributes that can contribute to these outcomes is household income, employment, as well as education. Those individuals who are in the middle class may be covered through the benefits of their employment whereas older individuals may not due to the fact of retirement.

Under the government healthcare system in Canada, routine dental care is not covered.^[68][69] There are a couple of provinces that offer child prevention programs such as Nova Scotia and Quebec.^[70] Other provinces make patients pay for medical dental procedures that are performed in the hospital. Some dental services that are possibly not covered by Medicare may include cavity fillings, routine dental check-ups, restorative dental care, and preventive care, dentures, dental implants, bridges, crowns, veneers, and in-lays, X-rays, and orthodontic procedures.

Physiotherapy, occupational therapy, and massage therapy

Coverage for services by physiotherapists, occupational therapists (also known as OTs) and Registered Massage Therapists (RMTs) varies by province. For example, in Ontario the provincial health plan, OHIP, does cover physiotherapy following hospital discharge and occupational therapy^[71] but does not cover massage therapy. To be eligible for coverage for physiotherapy in Ontario, the insured individual has to have been discharged as an inpatient of a hospital after an overnight stay and require physiotherapy for the condition, illness or injury for which he or she was hospitalized, or be age 19 or younger or age 65 or older.^[72]

Other coverage limitations

Coverage varies for care related to the feet. In Ontario, as of 2019, Medicare covers between $7–16 of each visit to a registered podiatrist up to $135 per patient per year, plus $30 for x-rays.^[73] Although the elderly, as well as diabetic patients, may have needs that greatly exceed that limit, such costs would have to be covered by patients or private supplemental insurance.

As of 2014, most, but not all provinces and territories provide coverage for sex reassignment surgery (also known as gender confirming surgery) and other treatment for gender dysphoria.^[74] In Ontario, sex reassignment surgery requires prior approval before being covered.^[75]

There are wide discrepancies in coverage for various assistive devices such as wheelchairs and respiratory equipment in Canada. Ontario, which has one of the most generous programs, pays 75% of the cost for listed equipment and supplies for persons with a disability requiring such equipment or supplies for six months or longer.^[76] The program does not have age or income restrictions. As with other health coverage, veterans and others covered by federal programs are not eligible under the provincial program. Only certain types of equipment and supplies are covered, and within categories only approved models of equipment from approved vendors are covered, and vendors may not charge more than specified prices established by the government.^[77]

Private health insurance

In Canada private health insurances is mainly provided through employers.^[88]

By 2016, "health care dollars from private insurance were $788 per capita" in 2016, which represents an annual growth rate of 6.4% from 1988 to 2016.^[85]

According to a 2004 OECD report, 75% of Canadians had some form of supplementary private health insurance.^[88]

Out-of-pocket expenses

From 1988 to 2016, the amount of out‑of‑pocket expenses paid by individuals had grown by about 4.6% annually. By 2016, it amounted to $972 per capita.^[85]

Major healthcare expenses

The highest health expenditures were hospitals—$51B in 2009 up from $45.4B, representing 28.2% in 2007, followed by pharmaceuticals—$30B in 2009 up from $26.5B, representing 16.5% in 2007, and physician services—$26B in 2009, up from $21.5B or 13.4% in 2007.^[89][90]

The proportion spent on hospitals and physicians has declined between 1975 and 2009 while the amount spent on pharmaceuticals has increased.^[91] Of the three biggest health care expenses, the amount spent on pharmaceuticals has increased the most. In 1997, the total price of drugs surpassed that of doctors. In 1975, the three biggest health costs were hospitals ($5.5B/44.7%), physicians ($1.8B/15.1%), and medications ($1.1B/8.8%).^[90]

By 2018, drugs (both prescription and non-prescription) had become the second largest expenditure representing 15.3% of the total, hospitals at 26.6% represented the largest sector by expenses, and physician services represented 15.1% of the total.^[29]

Healthcare spending and an aging population

By 2019, Canada's aging population represented a modest increase in healthcare costs of about 1% a year.^[7] It is also the greatest at the extremes of age at a cost of $17,469 per capita in those older than 80 and $8,239 for those less than 1 year old in comparison to $3,809 for those between 1 and 64 years old in 2007.^[111]

Comparing healthcare spending over time

Healthcare spending in Canada (in 1997 dollars) has increased each year between 1975 and 2009, from $39.7 billion to $137.3 billion, or per capita spending from $1,715 to $4089.^[112] In 2013 the total reached $211 billion, averaging $5,988 per person.^[113] Figures in National Health Expenditure Trends, 1975 to 2012, show that the pace of growth is slowing. Modest economic growth and budgetary deficits are having a moderating effect. For the third straight year, growth in healthcare spending will be less than that in the overall economy. The proportion of Canada's gross domestic product will reach 11.6% in 2012 down from 11.7% in 2011 and the all-time high of 11.9% in 2010.^[114] Total spending in 2007 was equivalent to 10.1% of the gross domestic product which was slightly above the average for OECD countries, and below the 16.0% of GDP spent in the United States.^[115]

Since 1999, 70% of Canada's total health expenditures is from the public sector and 30% from the private sector.^[7][8] This was slightly below the OECD average of public health spending in 2009.^[116] Public sector funding included most hospital and physician costs with the other 30% primarily paid by individuals through their private or workplace insurance or out-of-pocket.^[117] Half of private health expenditure comes from private insurance and the remaining half is supplied by out-of-pocket payments.^[7][8]

There is considerable variation across the provinces/territories as to the extent to which such costs as out of hospital prescription medications, assistive devices, physical therapy, long-term care, dental care and ambulance services are covered.^[118]

Canadian per capita health care spending by age group in 201X^[111]

Total Canadian health care expenditures in 1997 dollars from 1975 to 2009^[119]

According to a 2001 article in Annals of the Royal College of Physicians and Surgeons of Canada, applying a pharmacoeconomic perspective to analyze cost reduction, it has been shown that savings made by individual hospitals result in actual cost increases to the provinces.^[120]

Healthcare spending by province

The planning and funding of most publicly insured health services are the responsibility of provinces and territories. There is a regional variation in health system characteristics.

Healthcare costs per capita vary across Canada with Quebec ($4,891) and British Columbia ($5,254) at the lowest level and Alberta ($6,072) and Newfoundland ($5,970) at the highest.^[111]

Total health spending per resident varies from $7,378 in Newfoundland and Labrador to $6,321 in British Columbia. Public drug spending increased by 4.5% in 2016, driven largely by prescriptions for tumor necrosis factor alpha and hepatitis C drugs.^[121]

According to a 2003 article by Lightman, "In-kind delivery in Canada is superior to the American market approach in its efficiency of delivery." In the US, 13.6 percent of GNP is used in medical care. By contrast, in Canada, only 9.5 percent of GNP is used on the Medicare system, "in part because there is no profit incentive for private insurers." Lightman also notes that the in-kind delivery system eliminates much of the advertising that is prominent in the US and the low overall administrative costs in the in-kind delivery system. Since there are no means tests and no bad-debt problems for doctors under the Canadian in-kind system, doctors billing and collection costs are reduced to almost zero.^[122]

Wait times

In a May 28, 2020, report by the Organisation for Economic Co-operation and Development (OECD) that examined wait times in member nations—all of which are democratic countries with high-income economies with a very high Human Development Index (HDI), found that long waiting times for health services was an important policy issue in most OECD countries.^[150] In 2017, Canada ranked above the average on OECD indicators for wait-times and access to care, with average scores for quality of care and use of resources.^[15]

In the 1980s and the 1990s, wait times for certain surgeries, such as knee and hip replacements, had increased.^[151][152] The year before the 2002 Romanow Royal Commission report was released, in 2001, the Ontario Health Coalition (OHC) called for increased provincial and federal funding for Medicare and an end to provincial funding cuts as solutions to unacceptable wait times.^[153]

In December 2002, the Romanow Report recommended that "provincial and territorial governments should take immediate action to manage wait lists more effectively by implementing centralized approaches, setting standardized criteria, and providing clear information to patients on how long they can expect to wait."^[5] In response to the report, in September 2004, the federal government came to an agreement with the provinces and territories add an additional C$41 billion over a ten-year period, to the Canada Health Transfer (CHT) to improve wait times for access to essential services, a challenge that most other OECD countries shared at that time. By 2006, the federal government had invested C$5.5 billion to decrease wait times.^[154]

In April 2007, Prime Minister Stephen Harper announced that all ten provinces and three territories would establish wait-time guarantees by 2010. Canadians will be guaranteed timely access to healthcare in at least one of the following priority areas, prioritized by each province: cancer care, hip and knee replacement, cardiac care, diagnostic imaging, cataract surgeries or primary care.^[155]

In 2015, Choosing Wisely Canada promoted evidence-based medicine in 2015.^[156] Organizations like this focus on facilitating doctor-patient communication to decrease unnecessary care in Canada, and to decrease wait times.^[157]

In 2014, wait times for knee replacements were much longer in Nova Scotia,^[158] compared to Denmark, Germany, the Netherlands and Switzerland.

A 2016 study by the Commonwealth Fund, based in the US, found that Canada's wait time for all categories of services ranked either at the bottom or second to the bottom of the 11 surveyed countries (Australia, Canada, France, Germany, Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States). Canada's wait time on emergency services was the longest of the 11 nations, with 29% of Canadians reporting that they waited for more than four hours the last time they went to an emergency department. Canada also had the longest wait time for specialist appointments, with 56% of all Canadians waiting for more than four weeks. Canada ranked last in all other wait time categories, including same- or next-day appointments, same-day answers from doctors, and elective surgeries, except for access to after-hour care, where Sweden ranks lower. The 2016 study also noted that despite government investment, Canada's wait-time improvements were negligible when compared to the 2010 survey.^[159]

Gender gap in healthcare

Disparities between men and women's access to healthcare in Canada have led to criticism, especially regarding healthcare privatization. While most healthcare expenses remain covered by Medicare, certain medical services previously paid for publicly have been shifted to individuals and employer-based supplemental insurance. While this shift has affected both genders, women have been more affected. Compared to men, women are generally less financially stable, and individual payments are a greater burden.^[160] Furthermore, many women work part-time or in fields that do not offer supplemental insurance, such as homemaking. As such, women are less likely to have private insurance to cover the costs of drugs and healthcare services.^[161]

The shift from public to private financing has also meant additional labor for women due to families relying on them as caregivers. Less public financing has shifted care to women, leaving "them with more support to provide at home."^[162]

Women's additional healthcare requirements, such as pregnancy, further exacerbate the gender gap. Despite comprising approximately half of Canada's population, women receive the majority of Canadian healthcare.^[160]

Men and women also experience different wait times for diagnostic tests; longer wait times have been associated with a higher risk of health complications. One Canadian study reports, "mean wait times are significantly lower for men than for women pertaining to overall diagnostic tests: for MRI, 70.3 days for women compared to 29.1 days for men."^[163]

Socioeconomic gap in healthcare

It has been previously documented that one's socioeconomic status significantly impacts their health.^[164][165] Another recent study re-assessed this relationship and found similar results that demonstrated that people with higher levels of education or income experience longer life expectancies and health-adjusted life expectancies.^[166] The study discovered a distinct stepwise gradient in Canada, with life expectancy and health-adjusted life expectancy incrementally increasing as social position improves.^[166] They also found that this socioeconomic gap in healthcare had gotten wider in the previous 15 years.^[166]

The reasoning behind the socioeconomic gap is complex and multifaceted.^[167] Certain relationships between socioeconomic status and health outcomes can be relatively easily explained through direct exposures.^[167] For example, lead or pollutant exposure tends to be more common in rural neighbourhoods, which can result in lower cognitive functions, stunted growth and exacerbated asthma.^[168][169]  Higher income levels allow for the purchase of higher-quality resources, including food products, produce and shelter, as well as faster access to services.^[170] Higher education is often thought to lead to greater health literacy, resulting in the adoption of healthier lifestyles.^[171]

Longer, more complex pathways can also be used to explain potential relationships between socioeconomic status and health outcomes. Duration of poverty has been related to increased chronic stress levels.^[172] Recent studies have described how these stress levels can result in the biological "wear-and-tear" for these individuals constantly exposed to social and environmental stressors.^[173] Increased stress and lower SES has been correlated with increased blood pressure, worser cholesterol profiles and increased risk for other cardiovascular diseases.^[174]

Inequality in the LGBT community

Canadians in the LGBT community, especially those in poverty, receive inadequate levels of treatment. A research study by Lori Ross and Margaret Gibson notes that of all demographics, LGBT members need mental health services the most due to systemic discrimination. According to the study, LGBT members often need to turn to mental health services that are mainly private and not covered by publicly-funded healthcare. Low-income LGBT members might be unable to afford these private programs; subsequently, their mental health issues may remain unaddressed or even worsen.^[175]

Researcher Emily Colpitts states that LGBT members in Nova Scotia experience ambiguous or alienating language in their health policies. According to Colpitts, the "heteronormative and gender-binary language and structure of medical intake forms have the consequence of alienating LGBT populations." Colpitts adds that in the previous study of queer and transgender women in Nova Scotia, patients experienced significant discomfort in their meetings with healthcare providers and feared that because of the language of health policy, they would not be able to receive adequate healthcare based on their sexual identities.^[176]

According to researcher Judith MacDonnell, LGBT members, especially childbearing lesbians, have trouble navigating through health policy. MacDonnell states that LGBT women encounter challenges at every point of the childbearing process in Canada and have to rely on personal and professional means to receive information that they can understand, such as in reproductive health clinics and postpartum or parenting support.^[177]

The healthcare needs of the LGBT community are affected by a number of social, behavioural, and structural factors.^[178] Various bodies of literature have identified the health disparities associated with the LGBT community, and how these individuals receive disproportionate healthcare services. For example, mental health disorders such as depression and anxiety, eating disorders, obesity, and cardiovascular diseases are all of higher prevalence and a major concern amongst LGBT persons.^[178] These health issues are not sufficiently addressed either, as healthcare professionals (such as physicians) may be unaware of these individuals' sexual orientation. In 2008, Analysis of Canadian Community Health Service data showed that: LGB persons were more likely to seek out mental health services than heterosexuals;^[179] lesbians have lower reported rates of using family physicians.^[179] bisexuals report higher levels of unmet healthcare needs compared to heterosexuals(2); and LGB persons perceive they have less equitable access to healthcare services compared to heterosexual persons.^[180]

Another barrier that exists with regard to the healthcare disparities experienced by LGBT persons is the stigma that continues to persist in society. Moreover, LGBT populations may fear that their health needs are not considered in primary health since healthcare has been historically been constituted through a cisnormative and heteronormative framework.^[181] As a result, LGBT populations are less likely to access primary healthcare services due to the fear of discrimination.^[181] In addition, recent data shows that healthcare professionals lack adequate knowledge and cultural competence when it comes to addressing health issues predominantly affecting the LGBT community.^[182] Cultural competence is an important consideration in assessing the quality of care received by the LGBT community, as a lack of cultural competency in healthcare professionals and systems leads to a reduced life expectancy, a lower quality of life, and an increased risk of acute and chronic illness amongst LGBT persons.^[181] Research has also highlighted that higher rates of chronic illness seen in LGBT persons is associated with discrimination, minority stress, avoidance of healthcare providers, and irregular access to healthcare services.^[183]

Another important consideration in addressing the quality of care received by the LGBT community is patient-physician communication.^[184] Many health risks LGBT persons face come as a result of avoidance and/or dissatisfaction of healthcare services; this is in part due to assumptions made by the patient's healthcare providers, such as assuming the sexuality of the patient and predicting their sexual behaviours.^[184] In these scenarios, it can be very difficult for LGBT persons to feel comfortable in a clinical setting because they may experience a decline in self-confidence and trust in their healthcare providers.

The underlying message in terms of providing equitable care, and access to care, for patients in the LGBT community is that healthcare providers and systems must be aware of the appropriate methods through which to administer care. The specific needs of LGBT persons must be appreciated in order to enhance the quality of care and provide it in a non-judgemental, gender-neutral manner.^[184]

Inequality in care for refugees

Refugees in Canada experience numerous barriers to healthcare, such as gaps in knowledge regarding healthcare needs, which may not be always considered by public health initiatives and policies.^[185][186] Immigrants and refugees are among the groups most at risk for negative health effects resulting from persistent health disparities; differences in race, socioeconomic status, income, citizenship status, and other social factors further exacerbate healthcare inequalities. Compared to immigrants, refugees often require additional healthcare due to previous conditions in their countries of origin.^[187]

The 2012 Protecting Canada's Immigration System Act formed a tiered system that classified refugees and separated care based on these classifications.^[188][189] Differing levels of care were provided to refugees based on each refugee's home country and other factors.^[189] The act also reduced healthcare coverage for refugees provided by the Interim Federal Health Program (IFHP).^[190] The changes in refugee healthcare programs created in a rise in emergency room (ER) visits due to a lack of provisions of healthcare to refugees. This created concerns among Canadian citizens that the overall cost of healthcare will rise due. According to one study, the cuts to IFHP also made funding uncertain for programs that helped pay for ER costs.^[191]

In July 2014, Canada's Federal Court ruled that denying health services to asylum seekers was "cruel and unusual treatment" and therefore unconstitutional.^{[188][192][193][189][194]}

One study suggested open dialogue among policymakers, clinicians, and researchers and working with settlement programs to effectively respond to challenges encountered by the healthcare system regarding refugees.^[195] The study notes that supporting primary care and focusing on social accountability training in medical schools will help ensure the sustainability of the healthcare system's response to refugees.^[195]

Inequality in care for immigrants

Inadequate access to primary care and treatment interventions has been and continues to be a prevalent issue amongst minority populations in Canada. As a result, many immigrants are faced with constant barriers with regard to receiving high-quality care. The patient experience is revered as one of the most significant aspects of healthcare, however its relation to immigrant status is not well defined.^[196] The "healthy immigrant effect" is a term that recognizes how immigrants on average enter Canada with better health than those born in the country. However, over time, this health advantage experienced by immigrants may begin to decline.^[197] Multiple factors contribute to this health decline, including: racialization and discrimination, stress of immigration, barriers accessing healthcare practitioners and others.^[197]

The most prevalent barriers faced by immigrants with regard to accessing primary care services are related to geography and geographic distribution, language, and culture.^[198] Moreover, the distribution of physicians has a direct impact on the utilization of primary care services by immigrants. Immigrants tend to settle in suburbs, and long term immigrants tend to migrate toward suburban areas. These areas offer the most affordable housing options for immigrants, however this creates a "spatial mismatch"^[198] between patients and physicians since physicians and medical services are primarily concentrated in urban areas.^[198]

Language is another strong barrier faced by immigrant populations due to the poor distribution of same-language physicians. Immigrants often face challenges in terms of understanding English medical terms.^[198] These linguistic differences are yet another contributing factor to the discordance and miscommunication between immigrants and English-speaking physicians.

Since healthcare services in Canada are paid in-part by the federal and provincial governments and by health insurance systems, economic and financial barriers are generally not considered to be a severe issue dealt with by the immigrant community. However, local availability (i.e., spatial accessibility^[198]) of physicians and individual patient preferences such as ethnicity and language spoken by physicians are both impactful factors contributing to the precipitous decrease in primary healthcare access by immigrants.

Immigrants in Canada face multiple barriers to accessing mental health services.^[199] As with primary care access, the language barrier between healthcare providers and immigrants remains one of the greatest challenges in delivering mental health care and often leads to underuse.^[200] Many subpopulations of immigrants, including but not limited to: African women,^[201] Latin American men,^[202] Iranian immigrants^[203] and South Asian immigrants^[204] have been shown in studies to underuse mental health services due to the limited amount of services offered outside of the English language, which hinders their access to mental health care. One study discussed how immigrants avoided, or did not benefit from, mental health counselling services as there lacks an adequate amount of professional interpretation services.^[205]

Another study conducted in Montreal examined the reasons behind why immigrants were reluctant to access mental health services. They found a multitude of reasons as to why immigrants were hesitant to seek help, including the fact that their perception of Western doctors' over willingness to utilize pharmaceutical medications, while they believed in the curative powers of non-pharmaceutical interventions, such as God and traditional folk medicine.^[206]

Inequality in care for Indigenous peoples

Many immigrants report experiencing social isolation in Canada while also lacking social support from friends or family, which significantly impacts their mental health and also impacts their access to mental health services.^[207] Other racialized immigrants, specifically seniors, may be reluctant to access mental health services due to the stigmatization that surrounds these issues.^[200] Another significant barrier reported was the difficulty immigrants faced in finding mental health providers that were appropriately trained in cultural sensitivity.^[208]

It is well documented in the literature that Indigenous peoples in Canada lack equitable access to healthcare services for a variety of reasons.^[209] One major reason for this inequitable access is due to Indigenous locations of residence. Statistics Canada reported that the majority of Métis live in urban centres, while almost half of First Nations people live on reserves.^[210] In rural northern communities, they struggle to attract and retain healthcare professionals, leaving a great shortage in services that results in far lesser access to care.^[211] In the Inuit Nunangat, it was found that just 23% of Inuit people had a medical doctor they regularly visited.^[212] Additionally, due to the lack of healthcare access in northern communities, many are forced into lengthy transportation to southern Ontario to receive necessary care. One study examined an Inuit community in Rigolet, Canada, and looked at the direct and indirect costs of these long-distance healthcare visits, including missed paid employment, mental well-being costs, transportation costs and others. Altogether, this community experiences healthcare costs greater than other Canadian non-Indigenous and urban areas.^[213]

Another prominent reason for inequitable access to care is the persistence of racism that remains in Canada.^[214] In 2012, The Health Council of Canada conducted a series of meetings across the country with a variety of healthcare workers, researchers and Aboriginal people. Through their conversations, they discovered that a large part of the problem comes from the healthcare system. They found that many Indigenous people simply do not trust mainstream health service due to stereotyping, racism and that they feel intimidated. One participant described their experiences as "being treated with contempt, judged, ignored, stereotyped, racialized, and minimized." Finally the Health Council of Canada went on to describe that this lack of equitable access comes as an extension of systemic racism in Canada.^[214]

A 2015 study examined 80 Indigenous women who experienced neurological conditions.^[215] Participants described their lack of access to health services to stem from the racism and sexism experienced in the system. In the same study, the researchers interviewed multiple key informants, including various types of health practitioners. They described how important it is for the health system to implement culturally safe care. They also discussed how many stereotyping problems occur in medical school and that Canada requires further Indigenous-centred training. They recommend higher education and awareness training amongst medical schools and healthcare institutions to address the growing healthcare disparities between Indigenous and non-Indigenous peoples in Canada.^[215]

Inequality in care for people living with intellectual disabilities

Healthcare needs and comorbidities are often underdiagnosed in those living with intellectual disabilities.^[216] A study conducted in Quebec, Canada investigated healthcare utilization and access amongst people with intellectual disabilities in comparison to the general population.^[217] Of the study sample, approximately 30 percent reported not having had a comprehensive medical examination in the past year, which is what is currently advised in the 2018 Canadian consensus guidelines for practitioners providing primary care for those with intellectual disabilities.^[217][218]

Compared to the general population, women with intellectual disabilities aged 18–69 years were found to undergo cervical cancer screening less often. Results demonstrated them to be 1.5 times less likely to undergo a Pap test in the past three years compared to similar aged women without disabilities.^[217] For breast cancer screening, women living with severe or profound intellectual disabilities or Down syndrome were found to be screened significantly less than those in the general population.^[217]

People with Down syndrome also reported the lowest usage of physiotherapy services compared to other measured population groups, which is a concern given that Down syndrome is associated with a variety of musculoskeletal problems that may be improved with physiotherapy.^[217][219]

Inequality in care for Canadian women

With regard to disparities in healthcare associated with gender and sex, there are significant inequities among women related to socioeconomic status, geographical location, and ethnicity.^[220] It has been hypothesized that women experience a higher rate of health-related issues because of their reduced access to the material and social conditions of life that foster good health, as well as a heightened level of stress associated with their gender and marital roles.^[221] Moreover, extensive research evidence has shown that women with low income and who work full-time outside of the house have poorer health status in comparison to their male counterparts.^[222] The added responsibilities women hold as primary caregivers in households not only creates additional stress, but also indirectly increases the difficulty of the scheduling and meeting of medical appointments; these implications explain women's poorer self-rated health status in comparison to men, as well as their report of their unmet healthcare needs.^[222] These findings demonstrate the implications gender has on the receival of care, but more specifically, women's ability, or the lack thereof, to address their own healthcare needs. Further investigating ways in which women face disparities in Canada's healthcare system is crucial to ensuring optimal health outcomes.

Americans visiting Canada to receive healthcare

Some U.S. citizens travel to Canada for healthcare-related mainly to access lower costs.

Many U.S. citizens purchase prescription drugs from Canada, either over the Internet or by travelling there to buy them in person, because prescription drug prices in Canada are substantially lower than prescription drug prices in the United States; this cross-border purchasing has been estimated at $1 billion annually.^[234] Some states like Florida have signed bills to import prescription drugs from Canada but are awaiting federal approval.^{[235][236][237]}

Because marijuana is legal in Canada but illegal in some of the U.S., many U.S. citizens with cancer, AIDS, multiple sclerosis, and glaucoma have travelled to Canada for medical treatment. One of those is Steve Kubby, the Libertarian Party's 1998 candidate for governor of California, who has adrenal cancer.^[238] Recent legalization of marijuana in some states of the U.S. has reduced this type of travelling.

Healthcare spending compared to other countries

In 2018, The OECD average represented 8.8% of GDP or CAN$5,175 per person with 27% private and 73% public. Canada's health spending represented 10.7% of GDP or $6,448 per person with 30% private and 70% public. The U.S. spending represented 16.9% of GDP or $13,722 per person with 51% private and 49% public.^[29]: 11

In 2019, Canada's per-capita spending on health expenditures ranked 11th among health-care systems in the OECD.^[13]

In comparison, in 2006, Canada spent approximately 10.0% of GDP on healthcare in 2006. The average of OECD countries at that time was 8.9%.^[244]

Elective surgery

In its 2016 international health survey, the Commonwealth Fund found that 18 percent of patients in Canada had waited four months or longer for elective surgery in the previous two years, compared to 3 percent of patients in the United States, 6 percent in Switzerland, 4 percent in the Netherlands, and 0 percent in Germany.^[245]

Life expectancy at birth

Based on OECD 2018 data, in terms of life expectancy at birth by gender, women in France is 85.9, Switzerland's 85.7, Canada's 84.1, the Netherlands's 83.4, Germany's 83.3, and the U.S.' 81.2 years.^[246][247] The Commonwealth Fund report ranked Canada at slightly above average in life expectancy and the U.S. at the bottom of the list with a life expectancy of 78.6 years.^[243] Of the eleven countries, the U.S. spends the most of healthcare.^[243]

Life expectancy at 65

Based on Statistics Canada data from 2017 to 2019, women in Canada have a life expectancy at 65 of 22.2 years or 87.5 years and men at 65 have a life expectancy of 19.5 years or 84.5 years.^[32]

Under-five mortality rates

From 1971 to 2020, the under-five mortality rate per 1000 live births rate for Canada dropped gradually from 20.9 deaths per 1000 live births to 4.98 deaths per 1000.^[248]

In comparison, in the U.S. during the same period, the rate decreased slowly from 22.49 to 6.98 deaths per 1000.^[249]

Maternal mortality rate per 100,000 live births

In 2018, the maternal mortality rate per 100,000 live births in Canada was 8.3 deaths.^[250] Since 2008, the rate has been between "4.5 and 8.7 deaths per 100,000 live births".^[250]

Physicians per 1000 people

According to the Commonwealth report, 11 wealthy countries have a higher number of physicians per 1000 people, than Canada.^[243] Norway has 4.8, Canada has 2.7 and the U.S. has 2.6 physicians per 1000 people.^[243]

Healthcare spending by country

In 2018, Canada's health expenditures per person was $6,448, which was close to the amount spent by Australia—C$6,488, France—$6,436, and the Netherlands—$6,855.^[29] In comparison, the U.S. spent US$10,739—C$13, 637—per person in 2018.^[251]

A 2009 report commissioned by the Association of the British Pharmaceutical Industry (ABPI) ranked 13 developed countries based on sales volumes for conditions such as acute MI, antipsychotics, dementia, hepatitis C, multiple sclerosis, osteoporosis, RDS, rheumatoid arthritis, statins, wet AMD, and cancer hormones.^[252]

Country	Life expectancy. 2015.[253]	Under-five mortality rate per 1000 live births. 2016.[254]	Maternal mortality rate per 100,000 live births. 2015.[255]	Physicians per 1000 people. 2013.[95][256]	Nurses per 1000 people. 2013.[96][257]	Per capita expenditure on health (USD - PPP). 2016.[13]	Healthcare costs as a percent of GDP. 2016.[13][258]	% of government revenue spent on health. 2014.[259]	% of health costs paid by government. 2016.[260][261]
Australia	82.8	3.7	5.5	3.4	11.5	4,708	9.6	17.3	67.8
Canada	82.2	4.9	7.3	2.6	9.5	4,753	10.1	18.8	70.3
France	82.4	3.9	7.8	3.3	9.4	4,600	11.0	15.7	78.8
Germany	81.0	3.8	9.0	4.0	13.0	5,551	11.3	19.7	84.6
Japan	83.7	2.7	6.4	3.3	11.5	4,519	10.9	20.3	84.1
Singapore	82.9	2.7	5.3	3.2	7.2	4,280	5.4	14.2	80.1
Sweden	82.4	2.9	4.4	4.1	11.2	5,488	11.0	19.0	83.9
UK	81.2	4.3	9.2	2.8	8.2	4,192	9.7	16.5	79.2
US	79.3	6.5	26.4	2.6	11.1	9,892	17.2	21.3	49.1

In 2000, the World Health Organization using a methodology that was since changed because of the inaccuracy of its results, gave Canada's health system a very low standing in its list of countries by total health expenditure (PPP) per capita,compared to France, for example.^[262] It was revealed that the "primary reason for Canada's low standing" resulted from the "high educational level" of Canada's population not on its health system.^[263]

Cambie's failed constitutional challenge

On September 10, 2020, Justice John J. Steeves of the Supreme Court of British Columbia (BCSC) dismissed Canadian Charter of Rights and Freedoms violation claims in the high-profile, multi-year trial, Cambie Surgeries Corporation v. British Columbia, launched in 2016 by Vancouver, British Columbia-based Cambie Surgeries Corporation.^{[268][270][271][272]}