Canada Health Transfer deductions for provincial/territorial non-compliance are down
Health Canada produces an annual report each fiscal year on the extent to which provincial and territorial health care insurance plans have satisfied the criteria and the conditions for payment under the Canada Health Act. The Canada Health Act 2023-2024 Annual Report was tabled in Parliament on June 13.
Health Canada’s Jennifer Goodyer and Lee Whitman joined the Canadian Health Coalition’s Anne Lagacé Dowson for a conversation about the annual report on June 25. The webinar is now available for viewing here:
Jennifer Goodyer is the executive director of the Canada Health Act division at Health Canada. She noted that while provinces and territories are responsible for administering health care and managing health care budgets, the Canada Health Act (CHA) “is really a prime example of the federal government using its spending power to set national standards in an area that is provincial and territorial jurisdiction.”
“The CHA technically is voluntary,” said Goodyer. “The provinces and territories participate at their own discretion, but they need to meet the criteria and conditions [set out in the CHA] if they want to qualify for their full Canada Health Transfer payment.”
Goodyer said that provincial and territorial legislation and regulations not only mirror the requirements of the Canada Health Act, they also often exceed the requirements.
The Act does not give Health Canada any direct powers to investigate or audit. Goodyer further clarified that Health Canada “must consult directly with provinces and territories and rely heavily on their cooperation to address potential issues when they do arise.”
“It’s when we don’t come to those resolutions that we then move to encourage compliance with the Act through deductions and reimbursements to the Canada Health Transfer payments of a province or territory,” said Goodyer.
“The goal of the Act is not to levy deductions but it’s really to ensure that patients are not paying for insured health care services because they’ve already paid for those services through their tax dollars,” explained Goodyer.
Goodyer noted Health Canada works with the provinces and territories to determine the annual reciprocal billing rates across the country each year, which allows about $1 billion worth of billing of services back and forth between the provinces, so that residents have services when they’re outside of their home province.
Deductions for non-compliance
Lee Whitman is the assistant director of compliance and interpretation at Health Canada. He noted that for the reporting year, 2023-2024, the Canada Health Transfer to provinces and territories totaled $49 billion while deductions totalled $79 million. The majority of those deductions, $72 million, were related to the diagnostic services policy, which came into effect in 2020.
Whitman remarked that deductions are going down, calling it a “good news story” because provinces and territories are compiling with policies. He also pointed to “significant reimbursements to the provinces and territories during the 2023-2024 period.” A total of $90 million was reimbursed in March 2024.
Whitman provided more recent statistics as well. “This year, our deductions were $62 million and reimbursements were $51 million. Reimbursements seem a little bit lower but that’s because in the previous year, there were multiple years to refund related to the diagnostic policy,” explained Whitman.
Whitman said the reimbursement policy, announced in 2018, involves provinces or territories being eligible for reimbursement for deductions, “if they take action to eliminate patient charges within a couple of years and they eliminate the circumstances that led to the charges.”
“A contemporary example of that would be abortion in New Brunswick. The government in New Brunswick eliminated the regulation that prohibited coverage of abortions, except in hospitals. We have been deducting New Brunswick for a number of years but with the circumstance that led to the deduction eliminated and the patient charges stopped, we were able to issue a full reimbursement” said Whitman.
Whitman stated other provinces have received full reimbursements as well including Manitoba and Nova Scotia for diagnostic services.
Whitman noted a myth that public administration criterion forbids private involvement in insured services.
“This has never been true under the Canada Health Act and there are lots of elements of the public health care system that are delivered privately. Physicians are independent contractors. Hospitals can be run by private foundations. Support services can be outsourced…. Delivery can be privately owned or privately run so long as patients are not charged for those services,” explained Whitman.
Whitman noted the Canada Health Act is intentionally broad because the jurisdiction for health care rests with provinces and territories. “What we can do is provide a framework for provinces and territories to receive their full Canada Health Transfer payments by meeting the broad conditions under the Act and so it is not nearly so prescriptive as to drill down to specific ailments or conditions.”
Interpretation letters
Health Canada also does policy foresight work to determine emerging issues that could have implications for Canada’s universal health care system. Federal ministers of health have issued clarifications to provinces and territories, what’s known as interpretation letters, over the years related to compliance with the Canada Health Act.
“These letters help ensure the Act keeps pace with the modern realities of health care delivery, but they cannot expand the original scope of the Act. That would require an amendment to the Act,” said Goodyer.
Goodyer explained that previous interpretation letters outlined that insured services should be covered regardless of where they’re being provided in a hospital or in a clinic.
The most recent interpretation letter was in relation to expanded scopes of practice for regulated health professionals like nurse practitioners and midwives as a way to increase access to care.
“These expanded scopes of practice should not result in patients being charged when they’re receiving insured services from these regulated health care professionals,” said Goodyer referring to a new policy set to take effect next year.
“We’re working with the provinces and territories on the implementation of the policy now, but as of April 1, 2026, if a patient does access an insured service from a regulated health care professional like a nurse practitioner, it will be considered extra billing and user charges under the Canada Health Act.”
“We don’t want to see an erosion of the basket of care just because technology is moving forward in leaps and bounds,” said Goodyer.
Upselling of cataract surgeries
When asked about upselling for cataract surgeries, Whitman said, “it is fair to say that patients are being upsold… They’re being offered lens B over lens A because it does wondrous things. We would be very concerned if a patient was required to buy a lens that was better than the preferred one as a condition of receiving treatment, that is just a non-starter under the Canada Health Act and if we had a letter from a patient, we would certainly take action on that.”
Goodyer noted that the Ontario Health Coalition wrote to them about upselling and are reviewing the package of documents sent to them, including invoices. She said, “ethical gray areas” are concerning where they may not be able to do anything about it in relation to the Canada Health Act, but suggested contacting the College of Physicians if it involves ethical behavior.
Is Alberta allowed to charge people for vaccines?
An audience member raised concerns about the Alberta government charging people for COVID-19 vaccines.
“Vaccines aren’t an insured service under provincial health care plans in general. They are a public health measure that provinces and territories take,” responded Whitman. He encouraged anyone who feels they are being unfairly charged for vaccines to address it with the Alberta Health Ministry and their College of Physicians.
Friends of Medicare in Alberta is opposed to Alberta’s vaccination strategy.
“If the government was serious about tackling vaccine waste, they would get serious about public health, public education and promoting the benefits of a variety of vaccines,” said Chris Gallaway, executive director of Friends of Medicare. “Instead, last year the government slashed province-wide immunization campaign spending in half, compared to spending the previous year. Is it any surprise fewer Albertans then went and got vaccinated?”
“Putting ring-fences around Quebec doctors”
In response to the approximately 880 Québec doctors opting out of the public health care system, Goodyer said it is an unique situation and that only 12 doctors from across the country have opted out.
She said Québec does have tools to limit the opting out of physicians, if the government deems it is harming access to health care for patients.
“Quebec legislation does allow them to put ring-fences around those doctors to draw them back into the public system,” said Goodyer.
Whitman said he is optimistic with the adoption of Bill 83. The bill will force Québec doctors to work in the public system for five years or face penalties.
Annual report is only one tool
Goodyer noted the annual report is only one of Health Canada’s reporting mechanisms.
“We have a legislative requirement for provinces and territories to report to us each year on the amount of extra billing and user charges that occur. Every December, they have to submit those reports to our deputy minister of health,” said Goodyer.
“If for some reason, we are aware of patient charges in a province and we receive the report and it says zero, the minister has an obligation under the Canada Health Act to estimate what we think the scale of patient charges are in that province. We have to use the best available information to determine what we think that that dollar amount looks like and then the minister has an obligation to consult with the province, so they could provide us with their own information should they see fit and if they don’t, that’s the amount that we deduct from their plan or from their Canada Health Transfer.”
Filing complaints
To file a complaint about a physician or facility, Health Canada suggests contacting the provincial or territorial Ministry of Health. Phone numbers and websites are located on the inside back cover of the current Canada Health Act Annual Report.
If the complaint is about physician conduct, the province or territory’s College of Physicians and Surgeons, which is the organization that governs physician licensing and conduct should also be contacted. Links to each provincial and territorial medical regulatory authority can be found on the College of Physicians and Surgeons of Canada website.
The Canada Health Act Division of Health Canada can also be contacted with complaints, after contacting the relevant province or territory. Telephone: 1-800-465-7735 or email: medicare.spb.chad-dlcs.dgps.assurance.maladie@hc-sc.gc.ca. Visit Health Canada’s Frequently Asked Questions page for more information on the Canada Health Act.
