Fraser Institute
Policymakers in Ottawa and Edmonton maintain broken health-care system
From the Fraser Institute
What’s preventing these reforms? In a word, Ottawa.
To say Albertans, and indeed all Canadians, are getting poor value for their health-care dollars is a gross understatement. In reality, Canada remains among the highest spenders on health care in the developed world, in exchange for one of the least accessible universal health-care systems. And while Canadians are increasingly open to meaningful reform, policymakers largely cling to their stale approach of more money, platitudes and little actual change.
In 2021 (the latest year of available data), among high-income universal health-care countries, Canada spent the highest share of its economy on health care (after adjusting for age differences between countries). For that world-class level of spending, Canada ranked 28th in the availability of physicians, 23rd in hospital beds, 25th in MRI scanners and 26th in CT scanners. And we ranked dead last on wait times for specialist care and non-emergency surgeries.
This abysmal performance has been consistent since at least the early 2000s with Canada regularly posting top-ranked spending alongside bottom-ranked performance in access to health-care.
On a provincial basis, Albertans are no better off. Alberta’s health-care system ranks as one of the most expensive in Canada on a per-person basis (after adjusting for population age and sex) while wait times in Alberta were 21 per cent longer than the national average in 2023.
And what are governments doing about our failing health-care system? Not much it seems, other than yet another multi-billion-dollar federal spending commitment (from the Trudeau government) and some bureaucratic shuffling (by the Smith government) paired with grandiose statements of how this will finally solve the health-care crisis.
But people aren’t buying it anymore. Canadians increasingly understand that more money for an already expensive and failing system is not the answer, and are increasingly open to reforms based on higher-performing universal health-care countries where the public system relies more on private firms and entrepreneurs to deliver publicly-funded services. Indeed, according to one recent poll, more than six in 10 Canadians agree that Canada should emulate other countries that allow private management of public hospitals, and more than half of those polled would like increased access to care provided by entrepreneurs.
What’s preventing these reforms?
In a word, Ottawa. The large and expanding federal cash transfers so often applauded by premiers actually prevent provinces from innovating and experimenting with more successful health-care policies. Why? Because to receive federal transfers, provinces must abide by the terms and conditions of the Canada Health Act (CHA), which prescribes often vaguely defined federal preferences for health policy and explicitly disallows certain reforms such as cost-sharing (where patients pay fees for some services, with protections for low-income people).
That threat of financial penalty discourages the provinces from following the examples of countries that provide more timely universal access to quality care such as Germany, Switzerland, Australia and the Netherlands. These countries follow the same blueprint, which includes patient cost-sharing for physician and hospital services (again, with protections for vulnerable populations including low-income individuals), private competition in the delivery of universally accessible services with money following patients to hospitals and surgical clinics, and allowing private purchases of care. Yet if Alberta adopted this blueprint, which has served patients in these other countries so well, it would risk losing billions in health-care transfers from Ottawa.
Finally, provinces have seemingly forgot the lesson from Saskatchewan’s surgical initiative, which ran between 2010 and 2014. That initiative, which included contracting out publicly financed surgeries to private clinics, reduced wait lists in Saskatchewan from among the highest in the country to among the shortest. And when the initiative ended, wait times began to grow again.
The simple reality of health care in every province including Alberta is that the government system is failing despite a world-class price tag. The solutions to this problem are known and increasingly desired by Canadians. Ottawa just needs to get out of the way and allow the provinces to genuinely reform the way we finance and deliver universal health care.
Author:
Economy
Number of newcomers to Canada set to drop significantly
From the Fraser Institute
Late last year, Statistics Canada reported that Canada’s population reached 41.5 million in October, up 177,000 from July 2024. Over the preceding 12 months, the population rose at a 2.3 per cent pace, indicating some deceleration from previous quarters. International migration accounts for virtually 100 per cent of the population gain. This includes a mix of permanent immigrants and large numbers of “non-permanent residents” (NPRs) most of whom are here on time-limited work or student visas.
The recent easing of population growth mainly reflects a slowdown in non-permanent immigration, after a period of increases with little apparent oversight or control by government officials. The dramatic jump in NPRs played a key role in pushing Canada’s population growth rate to near record levels in 2023 and the first half of 2024.
Amid this demographic surge, a public and political backlash developed, due to concerns that Canada’s skyrocketing population has aggravated the housing affordability and supply crisis and put significant pressure on government services and infrastructure. In addition, the softening labour market has been unable to create enough jobs to employ the torrent of newcomers, leading to a steadily higher unemployment rate over the last year.
In response, the Trudeau government belatedly announced a revised “immigration plan” intended to scale back inflows. Permanent immigration is being trimmed from 500,000 a year to less than 400,000. At the same time, the number of work and study visas will be substantially reduced. Ottawa also pledges to speed the departure of temporary immigrants whose visas have expired or will soon.
Remarkably, NPRs now comprise 7.3 per cent of the country’s population, a far higher share than in the past. The government has promised to bring this down to 5 per cent by 2027, which equates to arranging for some two million NPRs to depart when their visas expire. There are doubts that our creaking immigration and border protection machinery can deliver on these commitments. Many NPRs with expired visas may seek to stay. That said, the total number of newcomers landing in Canada is set to drop significantly.
According to the government, this will cause the country’s total population to shrink in 2025-2026, something that has rarely happened before.
Even if Ottawa falls short of hitting its revised immigration goals, a period of much lower population growth lies ahead. However, this will pose its own economic challenges. A fast-expanding population has been the dominant factor keeping Canada’s economy afloat over the last few years, as productivity—the other source of long-term economic growth—has stagnated and business investment has remained sluggish. It’s also important to recognize that per-person GDP—a broad measure of living standards—has been declining as economic growth has lagged behind Canada’s rapid population growth. Now, as the government curbs permanent immigrant numbers and sharply reduces the pool of NPRs, this impetus to economic growth will suddenly diminish.
However, Canada will continue to have high levels of immigration compared to peer jurisdictions. The lowered targets for permanent immigration—395,000 in 2025, followed by 380,000 and 365,000 in the following two years—are still above pre-pandemic benchmarks. This underscores the continued importance of immigration to Canada’s economic and political future.
Instead of obsessing about near-term targets, policymakers should think about how to ensure that immigration can advance Canada’s prosperity and provide benefits to both the existing population and those who come here.
Jock Finlayson
Senior Fellow, Fraser Institute
Business
Trump, taunts and trade—Canada’s response is a decade out of date
From the Fraser Institute
Canadian federal politicians are floundering in their responses to Donald Trump’s tariff and annexation threats. Unfortunately, they’re stuck in a 2016 mindset, still thinking Trump is a temporary aberration who should be disdained and ignored by the global community. But a lot has changed. Anyone wanting to understand Trump’s current priorities should spend less time looking at trade statistics and more time understanding the details of the lawfare campaigns against him. Canadian officials who had to look up who Kash Patel is, or who don’t know why Nathan Wade’s girlfriend finds herself in legal jeopardy, will find the next four years bewildering.
Three years ago, Trump was on the ropes. His first term had been derailed by phony accusations of Russian collusion and a Ukrainian quid pro quo. After 2020, the Biden Justice Department and numerous Democrat prosecutors devised implausible legal theories to launch multiple criminal cases against him and people who worked in his administration. In summer 2022, the FBI raided Mar-a-Lago and leaked to the press rumours of stolen nuclear codes and theft of government secrets. After Trump announced his candidacy in 2022, he was hit by wave after wave of indictments and civil suits strategically filed in deep blue districts. His legal bills soared while his lawyers past and present battled well-funded disbarment campaigns aimed at making it impossible for him to obtain counsel. He was assessed hundreds of millions of dollars in civil penalties and faced life in prison if convicted.
This would have broken many men. But when he was mug-shotted in Georgia on Aug. 24, 2023, his scowl signalled he was not giving in. In the 11 months from that day to his fist pump in Butler, Pennsylvania, Trump managed to defeat and discredit the lawfare attacks, assemble and lead a highly effective campaign team, knock Joe Biden off the Democratic ticket, run a series of near daily (and sometimes twice daily) rallies, win over top business leaders in Silicon Valley, open up a commanding lead in the polls and not only survive an assassination attempt but turn it into an image of triumph. On election day, he won the popular vote and carried the White House and both Houses of Congress.
It’s Trump’s world now, and Canadians should understand two things about it. First, he feels no loyalty to domestic and multilateral institutions that have governed the world for the past half century. Most of them opposed him last time and many were actively weaponized against him. In his mind, and in the thinking of his supporters, he didn’t just defeat the Democrats, he defeated the Republican establishment, most of Washington including the intelligence agencies, the entire corporate media, the courts, woke corporations, the United Nations and its derivatives, universities and academic authorities, and any foreign governments in league with the World Economic Forum. And it isn’t paranoia; they all had some role in trying to bring him down. Gaining credibility with the new Trump team will require showing how you have also fought against at least some of these groups.
Second, Trump has earned the right to govern in his own style, including saying whatever he wants. He’s a negotiator who likes trash-talking, so get used to it and learn to decode his messages.
When Trump first threatened tariffs, he linked it to two demands: stop the fentanyl going into the United States from Canada and meet our NATO spending targets. We should have done both long ago. In response, Trudeau should have launched an immediate national action plan on military readiness, border security and crackdowns on fentanyl labs. His failure to do so invited escalation. Which, luckily, only consisted of taunts about annexation. Rather than getting whiny and defensive, the best response (in addition to dealing with the border and defence issues) would have been to troll back by saying that Canada would fight any attempt to bring our people under the jurisdiction of the corrupt U.S. Department of Justice, and we will never form a union with a country that refuses to require every state to mandate photo I.D. to vote and has so many election problems as a result.
As to Trump’s complaints about the U.S. trade deficit with Canada, this is a made-in-Washington problem. The U.S. currently imports $4 trillion in goods and services from the rest of the world but only sells $3 trillion back in exports. Trump looks at that and says we’re ripping them off. But that trillion-dollar difference shows up in the U.S. National Income and Product Accounts as the capital account balance. The rest of the world buys that much in U.S. financial instruments each year, including treasury bills that keep Washington functioning. The U.S. savings rate is not high enough to cover the federal government deficit and all the other domestic borrowing needs. So the Americans look to other countries to cover the difference. Canada’s persistent trade surplus with the U.S. ($108 billion in 2023) partly funds that need. Money that goes to buying financial instruments can’t be spent on goods and services.
So the other response to the annexation taunts should be to remind Trump that all the tariffs in the world won’t shrink the trade deficit as long as Congress needs to borrow so much money each year. Eliminate the budget deficit and the trade deficit will disappear, too. And then there will be less money in D.C. to fund lawfare and corruption. Win-win.
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