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HLTH 4011 Portfolio. Click any image to view it full size.

Title: Who Pays, Who Decides? Federal vs. provincial health care in Canada, and three challenges I see as a student RT. Cherry Fan, HLTH 4011, Artifact 1.

We often talk about “Canadian health care” as if it were one system. This infographic breaks down who pays for health care and who runs it, then looks at three challenges I have noticed as a student respiratory therapist.

Two levels of government, two jobs. Responsibility is shared, but day-to-day health care is provincial. Federal: sets national rules through the Canada Health Act; funds provinces through the Canada Health Transfer; directly serves a few groups, such as First Nations on reserve, the military and refugee claimants. Provinces and territories: run insurance plans (BC: MSP); decide what is medically necessary; deliver care through health authorities.

Under Canada’s constitution, health care is mainly a provincial responsibility (Marchildon, 2012). Ottawa sets national rules through the Canada Health Act, funds the provinces through the Canada Health Transfer, and directly serves a few groups (Health Canada, 2025a). The provinces and territories run their own insurance plans, decide what is “medically necessary,” and deliver care (Health Canada Today, 2025).

Follow the money. 78% of public health spending is paid by provinces and territories and 22% by the federal government. To get the full transfer, provinces must meet five criteria (public administration, universality, comprehensiveness, portability, accessibility) and two conditions (information, recognition). Not required by the Canada Health Act: outpatient drugs like inhalers, dental, vision, home care and long-term care.

Ottawa pays only about 22% of public health spending, but that money comes with conditions (Canadian Medical Association, n.d.; Public Health Agency of Canada, 2020). The catch is that the Act only protects hospital and physician services. Outpatient drugs, like the inhalers my patients with COPD and asthma rely on, are left to each province, so coverage varies across the country (Statistics Canada, 2022).

Issue 1: Pharmacare paperwork. Being covered by MSP does not mean you are covered by PharmaCare. The national Pharmacare Act (2024) covers contraceptives and diabetes drugs only. In BC, everything else needs a separate Fair PharmaCare registration plus a CRA income check. Policy: unverified income means a $10,000 default deductible. Some insurers stop paying until you are registered. An anecdotal story in four steps: tax information not confirmed; partly deregistered; insurer stopped paying; prescriptions disrupted.

Being enrolled in MSP does not mean you are enrolled in Fair PharmaCare. You have to register separately and consent to a CRA income check (Government of British Columbia, 2026), and some private insurers stop paying for drugs until you do (Pacific Blue Cross, 2025). On paper, unverified income should only raise the deductible. In this anecdotal story, it led to partial deregistration and disrupted prescriptions instead. Busy middle-income families who fall behind on paperwork are the ones most likely to slip through. Medicare’s founders rejected opt-in enrolment for exactly this reason (Marchildon, 2012).

Issue 2: One country, many health systems. Is quality of care really equal across BC, let alone Canada? 1 federal act sets the minimum; 13 provincial and territorial plans; 7 BC health authorities; 2 or more ways to call a pulmonary function test normal. Z-score or plus or minus 20% of predicted? The same patient can be normal in one lab and abnormal in another.

Each province and territory decides what is covered beyond the basics, and within BC, care is split across seven health authorities (Government of British Columbia, 2021). In my own field, the ERS/ATS standard recommends z-scores for interpreting pulmonary function tests (Stanojevic et al., 2022), yet labs in BC still differ, and practice varies even more across Canada. I believe health care should work like a truly national program, with shared standards and not just shared funding rules.

Issue 3: Caught between two bureaucracies. Indigenous Peoples are served by federal and provincial systems at once. Federal: some community health and benefits, funded year to year. Gaps and disputes: who pays? Care waits while governments decide. Provincial: hospital and physician care for all residents. Jordan's Principle: a First Nations child died in 2005 while two governments argued. Indian hospitals: segregated care, 1945 to the 1980s. 34 hours: Brian Sinclair died untreated in a Winnipeg ER.

Indigenous Services Canada funds some community health services and benefits year to year, while the provinces provide hospital and physician care (Government of Canada, 2025). Jordan’s Principle exists because a First Nations child died in hospital while Ottawa and Manitoba argued over who would pay for his care (First Nations Child & Family Caring Society, n.d.). This sits on a history of segregated “Indian hospitals” and indifference in care (Alberta Health Services, 2021; Canada’s History, 2020). In BC, the First Nations Health Authority is a hopeful step, but it works alongside the provincial system, not instead of it (First Nations Health Authority, n.d.).

Questions I want to explore next: who is responsible when someone falls through a gap? Automatic enrolment: should everyone on MSP be enrolled in PharmaCare automatically? National standards: what would shared protocols across provinces look like? Closing the gaps: how can Indigenous-led models like the FNHA end disputes over who pays?

Ottawa sets the rules and pays about a fifth of the bill, and the provinces run the system. All three issues come back to one question: who is responsible when someone falls through a gap? These are the questions I would like to explore in my later artifacts.

References

Alberta Health Services. (2021). Indigenous wellness core – Indian hospitals [Video]. YouTube. https://www.youtube.com/watch?v=5o9ubDDmF98

Canada’s History. (2020). Structures of indifference: An Indigenous life and death in a Canadian city [Video]. YouTube. https://www.youtube.com/watch?v=mLEiKbk7N6Q

Canadian Institute for Health Information. (2025, November 27). NHEX trends – Infographics. https://www.cihi.ca/en/national-health-expenditure-trends/nhex-trends-infographics

Canadian Medical Association. (n.d.). Understanding public and private health care. https://www.cma.ca/our-focus/public-and-private-health-care/understanding-public-and-private-health-care

First Nations Child & Family Caring Society. (n.d.). Jordan’s Principle. https://fncaringsociety.com/jordans-principle

First Nations Health Authority. (n.d.). About us [Fact sheet]. https://www.fnha.ca

Government of British Columbia. (2021). Health authorities. https://www2.gov.bc.ca/gov/content/health/about-bc-s-health-care-system/partners/health-authorities

Government of British Columbia. (2026, October 8). Fair PharmaCare plan. https://www2.gov.bc.ca/gov/content/health/health-drug-coverage/pharmacare-for-bc-residents/who-we-cover/fair-pharmacare-plan

Government of Canada. (2025, August 6). About Indigenous health care. Indigenous Services Canada. https://www.sac-isc.gc.ca/eng/1626810177053/1626810219482

Health Canada. (2025a, June 25). Canada’s health care system. https://www.canada.ca/en/health-canada/services/canada-health-care-system.html

Health Canada. (2025b, March 6). Government of Canada signs pharmacare agreement with British Columbia to improve universal access to free medications [News release]. https://www.canada.ca/en/health-canada/news/2025/03/government-of-canada-signs-pharmacare-agreement-with-british-columbia-to-improve-universal-access-to-free-medications.html

Health Canada Today. (2025). Canada Health Act a detailed explanation [Video]. YouTube. https://www.youtube.com/watch?v=TQUrgtjRw40

Marchildon, G. P. (2012). Canadian Medicare: Why history matters. In G. P. Marchildon (Ed.), Making Medicare: New perspectives on the history of Medicare in Canada (pp. 3–18). University of Toronto Press.

Pacific Blue Cross. (2025, December 9). Pacific Blue Cross drug coverage explained. https://pac.bluecross.ca/advicecentre/story/pacific-blue-cross-drug-coverage-explained/

Public Health Agency of Canada. (2020, February 24). Infographic: Canada Health Act. https://www.canada.ca/en/public-health/services/publications/science-research-data/canada-health-act-infographic.html

Stanojevic, S., Kaminsky, D. A., Miller, M. R., Thompson, B., Aliverti, A., Barjaktarevic, I., Cooper, B. G., Culver, B., Derom, E., Hall, G. L., Hallstrand, T. S., Leuppi, J. D., MacIntyre, N., McCormack, M., Rosenfeld, M., & Swenson, E. R. (2022). ERS/ATS technical standard on interpretive strategies for routine lung function tests. European Respiratory Journal, 60(1), Article 2101499. https://doi.org/10.1183/13993003.01499-2021

Statistics Canada. (2022, November 2). Study: Inequities in pharmaceutical access and use. The Daily. https://www150.statcan.gc.ca/n1/daily-quotidien/221102/dq221102a-eng.htm

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