Federal Health Minister Mark Holland leaves after a news conference in Vancouver, on July 23.DARRYL DYCK/The Canadian Press
Federal Health Minister Mark Holland is promising to issue in “short order” a letter clarifying that Canadians shouldn’t have to pay out of pocket for medically necessary primary care provided by health professionals other than physicians, including nurse practitioners.
However, he declined to provide a timeline for the letter, which his office has been promising for months, saying he didn’t want to risk reinterpreting parts of the Canada Health Act, “in a way that’s injurious to federal, provincial and territorial relations.”
Mr. Holland made the remarks on the same day the Canadian Medical Association released a draft policy on balancing public and private for-profit medical care. Among the CMA’s 22 recommendations is a call for governments to “enforce the Canada Health Act prohibition against user fees by clamping down on jurisdictions that allow the charging of membership fees, user fees or bundled payments.”
The Canada Health Act, adopted in 1984, applies only to medically necessary services provided in hospitals or by physicians. In the intervening years, most provinces have expanded the scopes of practice of other health professionals – including nurse practitioners and pharmacists – who are not covered by the act.
Nurse practitioners, or NPs, are nurses with advanced training who are allowed to provide many of the same services as family doctors, including diagnosing illnesses, writing prescriptions and making referrals to specialists.
That has left NPs to operate in a grey area where, unlike physicians, they are sometimes allowed to charge patients directly for care that would otherwise be covered by public health insurance.
As the shortage of family doctors has worsened – an estimated 6.5 million Canadians don’t have one – some private clinics and virtual-care companies are charging subscription or user fees to access primary care through NPs, although data on the practice is scarce.
Asked about the CMA recommendations, Mr. Holland called it “absolutely sacrosanct” that “our public system remains public, and that Canadians are not in a circumstance where they can’t afford care.”
“It’s a simple matter of justice,” he added, speaking Tuesday at a news conference announcing $426-million in federal funding for personal support workers and drugs for rare diseases in British Columbia.
As Katherine Fierlbeck, a professor of politics and health policy at Dalhousie University, pointed out, provincial governments could pass legislation any time prohibiting NPs from charging patients.
“The provinces don’t have to wait for Ottawa to do this,” she said. “But, of course, provinces won’t because it’s expensive. A lot of these services now are being covered in the private sphere. If provinces imposed upon themselves the requirement that they have to cover all of these other services provided by non-physicians, then it is going to cost them a lot more.”
In April, Ontario Health Minister Sylvia Jones sent a letter urging her federal counterpart to clarify the Canada Health Act so non-physician providers would be treated the same way no matter where they practised.
Her spokeswoman, Hannah Jensen, reiterated that position Tuesday. “We are calling on the Federal government to close a loophole that certain health care providers and their clinics are taking advantage of and develop a national solution to ensure Ontarians, and Canadians, can access the publicly funded primary care they deserve,” Ms. Jensen said by e-mail.
Laura Housden, president of the Nurse Practitioner Association of Canada, said her organization strongly supports the public health system. However, she is concerned that some patients who can’t find a family doctor and currently pay to see NPs out-of-pocket or through workplace insurance could lose access to primary care if fees are banned before all provinces put in place robust public funding programs for NPs.
“If we start putting these safeguards in place against private user fees right now without publicly funded services,” she said, “is this going to result in a reduction in access for Canadians, which we do not want to see?”
Danyaal Raza, a family physician at St. Michael’s Hospital, part of Unity Health Toronto, and a past president of Canadian Doctors for Medicare, said that while he appreciates Mr. Holland’s support of medicare, he is frustrated that Ottawa hasn’t already acted to ban user fees.
“We need to see an interpretation letter with real teeth,” Dr. Raza said. “I frankly don’t know why it’s taking so long.”