From the Fraser Institute

By Nadeem Esmail, Mackenzie Moir and Lauren Asaad

In October, Alberta’s provincial government announced forthcoming legislative changes that will allow patients to pay out-of-pocket for any diagnostic test they want, and without a physician referral. The policy, according to the Smith government, is designed to help improve the availability of preventative care and increase testing capacity by attracting additional private sector investment in diagnostic technology and facilities.

Unsurprisingly, the policy has attracted Ottawa’s attention, with discussions now taking place around the details of the proposed changes and whether this proposal is deemed to be in line with the Canada Health Act (CHA) and the federal government’s interpretations. A determination that it is not, will have both political consequences by being labeled “non-compliant” and financial consequences for the province through reductions to its Canada Health Transfer (CHT) in coming years.

This raises an interesting question: While the ultimate decision rests with Ottawa, does the Smith government’s new policy comply with the literal text of the CHA and the revised rules released in written federal interpretations?

According to the CHA, when a patient pays out of pocket for a medically necessary and insured physician or hospital (including diagnostic procedures) service, the federal health minister shall reduce the CHT on a dollar-for-dollar basis matching the amount charged to patients. In 2018, Ottawa introduced the Diagnostic Services Policy (DSP), which clarified that the insured status of a diagnostic service does not change when it’s offered inside a private clinic as opposed to a hospital. As a result, any levying of patient charges for medically necessary diagnostic tests are considered a violation of the CHA.

Ottawa has been no slouch in wielding this new policy, deducting some $76.5 million from transfers to seven provinces in 2023 and another $72.4 million in 2024. Deductions for Alberta, based on Health Canada’s estimates of patient charges, totaled some $34 million over those two years.

Alberta has been paid back some of those dollars under the new Reimbursement Program introduced in 2018, which created a pathway for provinces to be paid back some or all of the transfers previously withheld on a dollar-for-dollar basis by Ottawa for CHA infractions. The Reimbursement Program requires provinces to resolve the circumstances which led to patient charges for medically necessary services, including filing a Reimbursement Action Plan for doing so developed in concert with Health Canada. In total, Alberta was reimbursed $20.5 million after Health Canada determined the provincial government had “successfully” implemented elements of its approved plan.

Perhaps in response to the risk of further deductions, or taking a lesson from the Reimbursement Action Plan accepted by Health Canada, the province has gone out of its way to make clear that these new privately funded scans will be self-referred, that any patient paying for tests privately will be reimbursed if that test reveals a serious or life-threatening condition, and that physician referred tests will continue to be provided within the public system and be given priority in both public and private facilities.

Indeed, the provincial government has stated they do not expect to lose additional federal health care transfers under this new policy, based on their success in arguing back previous deductions.

This is where language matters: Health Canada in their latest CHA annual report specifically states the “medical necessity” of any diagnostic test is “determined when a patient receives a referral or requisition from a medical practitioner.” According to the logic of Ottawa’s own stated policy, an unreferred test should, in theory, be no longer considered one that is medically necessary or needs to be insured and thus could be paid for privately.

It would appear then that allowing private purchase of services not referred by physicians does pass the written standard for CHA compliance, including compliance with the latest federal interpretation for diagnostic services.

But of course, there is no actual certainty here. The federal government of the day maintains sole and final authority for interpretation of the CHA and is free to revise and adjust interpretations at any time it sees fit in response to provincial health policy innovations. So while the letter of the CHA appears to have been met, there is still a very real possibility that Alberta will be found to have violated the Act and its interpretations regardless.

In the end, no one really knows with any certainty if a policy change will be deemed by Ottawa to run afoul of the CHA. On the one hand, the provincial government seems to have set the rules around private purchase deliberately and narrowly to avoid a clear violation of federal requirements as they are currently written. On the other hand, Health Canada’s attention has been aroused and they are now “engaging” with officials from Alberta to “better understand” the new policy, leaving open the possibility that the rules of the game may change once again. And even then, a decision that the policy is permissible today is not permanent and can be reversed by the federal government tomorrow if its interpretive whims shift again.

The sad reality of the provincial-federal health-care relationship in Canada is that it has no fixed rules. Indeed, it may be pointless to ask whether a policy will be CHA compliant before Ottawa decides whether or not it is. But it can be said, at least for now, that the Smith government’s new privately paid diagnostic testing policy appears to have met the currently written standard for CHA compliance.

Nadeem Esmail

Director, Health Policy, Fraser Institute

Mackenzie Moir

Senior Policy Analyst, Fraser Institute

Lauren Asaad

Policy Analyst, Fraser Institute

From the Fraser Institute

By Annika Segelhorst and Elmira Aliakbari

Canada’s rivers are vital to our environment and economy. Clean freshwater is essential to support recreation, agriculture and industry, an to sustain suitable habitat for wildlife. Conversely, degraded freshwater can make it harder to maintain safe drinking water and can harm aquatic life. So, how healthy are Canada’s rivers today?

To answer that question, Environment Canada uses an index of water quality to assess freshwater quality at monitoring stations across the country. In total, scores are available for 165 monitoring stations, jointly maintained by Environment Canada and provincial authorities, from 17 in Newfoundland and Labrador, to 8 in Saskatchewan and 20 in British Columbia.

This index works like a report card for rivers, converting water test results into scores from 0 to 100. Scientists sample river water three or more times per year at fixed locations, testing indicators such as oxygen levels, nutrients and chemical levels. These measurements are then compared against national and provincial guidelines that determine the ability of a waterway to support aquatic life.

Scores are calculated based on three factors: how many guidelines are exceeded, how often they are exceeded, and by how much they are exceeded. A score of 95-100 is “excellent,” 80-94 is “good,” 65-79 is “fair,” 45-64 is “marginal” and a score below 45 is “poor.” The most recent scores are based on data from 2021 to 2023.

Among 165 river monitoring sites across the country, the average score was 76.7. Sites along four major rivers earned a perfect score: the Northeast Magaree River (Nova Scotia), the Restigouche River (New Brunswick), the South Saskatchewan River (Saskatchewan) and the Bow River (Alberta). The Bayonne River, a tributary of the St. Lawrence River near Berthierville, Quebec, scored the lowest (33.0).

Overall, between 2021 and 2023, 83.0 per cent of monitoring sites across the country recorded fair to excellent water quality. This is a strong positive signal that most of Canada’s rivers are in generally healthy environmental condition.

A total of 13.3 per cent of stations were deemed to be marginal, that is, they received a score of 45-64 on the index. Only 3.6 per cent of monitoring sites fell into the poor category, meaning that severe degradation was limited to only a few sites (6 of 165).

Monitoring sites along waterways with relatively less development in the river’s headwaters and those with lower population density tended to earn higher scores than sites with developed land uses. However, among the 11 river monitoring sites that rated “excellent,” 8 were situated in areas facing a combination of pressures from nearby human activities that can influence water quality. This indicates the resilience of Canada’s river ecosystems, even in areas facing a combination of multiple stressors from urban runoff, agriculture, and industrial activities where waterways would otherwise be expected to be the most polluted.

Poor or marginal water quality was relatively more common in monitoring sites located along the St. Lawrence River and its major tributaries and near the Great Lakes compared to other regions. Among all sites in the marginal or poor category, 50 per cent were in this area. The Great Lakes-St. Lawrence region is one of the most population-dense and extensively developed parts of Canada, supporting a mix of urban, agricultural, and industrial land uses. These pressures can introduce harmful chemical contaminants and alter nutrient balances in waterways, impairing ecosystem health.

In general, monitoring sites categorized as marginal or poor tended to be located near intensive agriculture and industrial activities. However, it’s important to reiterate that only 28 stations representing 17.0 per cent of all monitoring stations were deemed to be marginal or poor.

Provincial results vary, as shown in the figure below. Water quality scores in Newfoundland and Labrador, Prince Edward Island, New Brunswick, Saskatchewan and Alberta were, on average, 80 points or higher during the period from 2021 to 2023, indicating that water quality rarely departed from natural or desirable levels.

Rivers sites in Nova Scotia, Ontario, Manitoba and B.C. each had average scores between 74 and 78 points, suggesting occasional departures from natural or desirable levels.

Finally, Quebec’s average river water quality score was 64.5 during the 2021 to 2023 period. This score indicates that water quality departed from ideal conditions more frequently in Quebec than in other provinces, especially compared to provinces like Alberta, Saskatchewan and P.E.I. where no sites rated below “fair.”

CanvasJS.com

Overall, these results highlight Canada’s success in maintaining a generally high quality of water in our rivers. Most waterways are in good shape, though some regions—especially near the Great Lakes and along the St. Lawrence River Valley—continue to face pressures from the combined effects of population growth and intensive land use.