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Fraser Institute

Time to finally change the Canada Health Act for the sake of patients

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From the Fraser Institute

By Nadeem Esmail

Back in 1984, the Canada Health Act (CHA) received royal assent and has since reached near iconic status. At the same time, under its purview, the Canadian health-care system has become one of the least accessible—and most expensive—universal health-care systems in the developed world.

Clearly, policymakers should reform the CHA to reflect a more contemporary understanding of how to structure a truly world-class universal health-care system.

Consider for a moment the remarkably poor state of access to health care in Canada today. According to international comparisons of universal health-care systems, we endure some of the lowest access to physicians, medical technologies and hospital beds in the developed world. Wait times for health care in Canada also routinely rank among the longest in the developed world.

None of this is new. Canada’s poor ranking in the availability of services reaches back at least two decades. And wait times for health care have nearly tripled since the early 1990s. Back then, in 1993, Canadians could expect to wait 9.3 weeks for medical treatment after GP referral compared to 30 weeks in 2024.

This is all happening despite Canadians paying for one of the world’s most expensive universal-access health-care systems. And this brings us back to the CHA, which contains the federal government’s requirements for provincial policymaking. To receive their full federal cash transfers for health care from Ottawa, provinces must abide by CHA rules and regulations. And therein lies the rub.

We can find the solutions to our health-care woes in other countries such as Germany, Switzerland, the Netherlands and Australia, which all provide more timely access to quality care. Every one of these countries requires patient cost-sharing for physician and hospital services, and private competition in the delivery of universally accessible services with money following patients to hospitals and surgical clinics. And all these countries allow private purchases of health care, as this reduces the burden on the publicly-funded system and creates a valuable pressure valve for it.

Unfortunately for Canadians, the CHA expressly disallows requiring patients to share the cost of treatment while the CHA’s often vaguely defined terms and conditions have been used by federal governments to discourage a larger role for the private sector in the delivery of health-care services. At the same time, every new federal commitment to fix health care means increased provincial reliance on Ottawa. In 2024-25, federal cash transfers for health care are expected to total $52 billion, which means there’s $52 billion on the line for perceived non-compliance with the CHA. In short, this is why the provinces beholden to a policy approach that’s clearly failing Canadians.

So, what to do?

For starters, Ottawa should learn from its own welfare reforms in the 1990s, which reduced federal transfers and allowed provinces more flexibility with policymaking. The resulting period of provincial policy innovation reduced welfare dependency and government spending on social assistance (i.e. savings for taxpayers). When Ottawa stepped back and allowed the provinces to vary policy to their unique circumstances, Canadians got improved outcomes for fewer dollars.

We need that same approach for health care today, and it begins with the federal government reforming the CHA to expressly allow provinces the ability to explore alternate policy approaches, while maintaining the foundational principles of universality.

Next, the federal government should either hold cash transfers for health care constant (in nominal terms), reduce them or eliminate them entirely with a concordant reduction in federal taxes. By reducing (or eliminating) the pool of cash tied to the strings of the CHA, provinces would have greater freedom to pursue reform policies they consider to be in the best interests of their residents without federal intervention.

After 40 years, it’s high time to remove ambiguity and minimize uncertainty—and the potential for politically motivated interpretations—of the CHA. If federal policymakers want Canadians to finally have access to world-class health care, they should allow the provinces to choose their own set of universal health-care policies. The first step is to fix the 40-year-old legislation that has held the provinces back.

Nadeem Esmail

Senior Fellow, Fraser Institute

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Environment

Canada’s river water quality strong overall although some localized issues persist

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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.”

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.

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Community

Charitable giving on the decline in Canada

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From the Fraser Institute

By Jake Fuss and Grady Munro

There would have been 1.5 million more Canadians who donated to charity in 2023—and $755.5 million more in donations—had Canadians given to the same extent they did 10 years prior

According to recent polling, approximately one in five Canadians have skipped paying a bill over the past year so they can buy groceries. As families are increasingly hard-pressed to make ends meet, this undoubtedly means more and more people must seek out food banks, shelters and other charitable organizations to meet their basic necessities.

And each year, Canadians across the country donate their time and money to charities to help those in need—particularly around the holiday season. Yet at a time when the relatively high cost of living means these organizations need more resources, new data published by the Fraser Institute shows that the level of charitable giving in Canada is actually falling.

Specifically, over the last 10 years (2013 to 2023, the latest year of available data) the share of tax-filers who reported donating to charity fell from 21.9 per cent to 16.8 per cent. And while fewer Canadians are donating to charity, they’re also donating a smaller share of their income—during the same 10-year period, the share of aggregate income donated to charity fell from 0.55 per cent to 0.52 per cent.

To put this decline into perspective, consider this: there would have been 1.5 million more Canadians who donated to charity in 2023—and $755.5 million more in donations—had Canadians given to the same extent they did 10 years prior. Simply put, this long-standing decline in charitable giving in Canada ultimately limits the resources available for charities to help those in need.

On the bright side, despite the worrying long-term trends, the share of aggregate income donated to charity recently increased from 0.50 per cent in 2022 to 0.52 per cent in 2023. While this may seem like a marginal improvement, 0.02 per cent of aggregate income for all Canadians in 2023 was $255.7 million.

The provinces also reflect the national trends. From 2013 to 2023, every province saw a decline in the share of tax-filers donating to charity. These declines ranged from 15.4 per cent in Quebec to 31.4 per cent in Prince Edward Island.

Similarly, almost every province recorded a drop in the share of aggregate income donated to charity, with the largest being the 24.7 per cent decline seen in P.E.I. The only province to buck this trend was Alberta, which saw a 3.9 per cent increase in the share of aggregate income donated over the decade.

Just as Canada as a whole saw a recent improvement in the share of aggregate income donated, so too did many of the provinces. Indeed, seven provinces (except Manitoba, Nova Scotia and Newfoundland and Labrador) saw an increase in the share of aggregate income donated to charity from 2022 to 2023, with the largest increases occurring in Saskatchewan (7.9 per cent) and Alberta (6.7 per cent).

Canadians also volunteer their time to help those in need, yet the latest data show that volunteerism is also on the wane. According to Statistics Canada, the share of Canadians who volunteered (both formally and informally) fell by 8 per cent from 2018 to 2023. And the total numbers of hours volunteered (again, both formal and informal) fell by 18 per cent over that same period.

With many Canadians struggling to make ends meet, food banks, shelters and other charitable organizations play a critical role in providing basic necessities to those in need. Yet charitable giving—which provides resources for these charities—has long been on the decline. Hopefully, we’ll see this trend turn around swiftly.

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