Letter to provinces and territories on the importance of upholding the Canada Health Act - 2025

To all Provincial and Territorial Ministers of Health

Dear Ministers:

Evolutions in health care delivery have the potential to improve how care is provided to meet the health care needs of people in Canada. It is clear from discussions to date that all governments support advances that help to ensure Canadians can get the care they need, when they need it.

In 2023, the Prime Minister and Premiers agreed on shared health priorities to deliver real results to Canadians, supported by additional federal health investments of close to $200 billion over 10 years. I am pleased that we have worked together to sign bilateral agreements with all jurisdictions. The Working Together to Improve Health Care for Canadians Plan emphasizes the importance of upholding the Canada Health Act (CHA) to protect Canada's publicly funded health care system.

A key aspect in upholding these principles is to ensure that patients do not face charges for medically necessary care when a service would otherwise be covered if provided by a physician. When innovations are introduced into our health care system, it is important to ensure that they benefit all Canadians equally. Unfortunately, over the past few years we have seen that this is not the case in all circumstances and is resulting in patients being charged for medically necessary care.

Physician-Equivalent Services and the Core Basket of Services

There has been an expansion in scopes of practice for many regulated health care professionals (e.g. nurse practitioners, pharmacists, midwives) to better utilize the full extent of their competencies, knowledge and skills to increase access to needed care. This now permits these professionals to deliver some of the same services that would normally be insured if provided by a physician. In no area has this been more evident than in team-based primary care where nurse practitioners, in particular, are being integrated more fully into the primary care system, greatly increasing access for Canadians while helping to relieve pressure.

Nurse practitioners are now able to practise autonomously—diagnosing, treating, prescribing and referring patients—mirroring many of the tasks of a primary care physician, and in some cases, becoming the sole primary care provider for many Canadians, particularly in rural and remote communities. These developments support the CHA's objective of reasonable access to medically necessary care.

However, increasingly, there are reports of the growth of patient charges arising from health care professionals offering medically necessary services to Canadians on a private pay basis. If left unchecked, more and more Canadians could be required to pay to access care services that would otherwise be insured if delivered by a physician.

CHA Services Policy

I want to acknowledge the work of the provinces and territories in increasing patients' access to care through expanding the scope of practice of health care professionals, such as pharmacists and nurse practitioners. I also want to ensure access to these services remains based on medical need, and not a patient's ability or willingness to pay.

As such, when the CHA Services Policy is implemented, patient charges for medically necessary services, whether provided by a physician or other health care professional providing physician-equivalent services, will be considered extra-billing and user charges under the CHA.

The purpose of this policy is not to expand the core basket of services insured under the CHA. It is, instead, to maintain the basket by ensuring patients are not charged for services that would otherwise be provided without charges if delivered by a physician. As such, this policy does not include regulated health providers who had an overlapping scope of practice with physicians prior to the enactment of the CHA in 1984, and whose services were not considered insured at that time. The core basket of insured services remains the same regardless of who is providing the provincially or territorially regulated services.

Implementation

In order to give provincial and territorial governments sufficient time to review the administration of their health care plans and make any necessary adjustments, the CHA Services Policy will come into effect on April 1, 2026.

The federal government will work with provinces and territories on developing measures to collect the information required to implement this policy in an open and transparent manner. To collect the information required to respect the reporting obligations under the CHA's Extra-Billing and User Charges Information Regulations, the provinces and territories will be required to report patient charges under this new policy for the first time in December 2028.

I would like to underline that the federal goal of the CHA is not to levy penalties, but to ensure access to medically necessary care. Therefore, any deductions made under the policy will be eligible for reimbursement under the CHA Reimbursement Policy, once patient charges and the circumstances that led to them are eliminated.

I would also like to take the opportunity to commend all provinces and territories for the significant work undertaken to date to integrate virtual care services, delivered by physicians, into their health insurance plans. I encourage all jurisdictions to continue down this path. I look forward to the opportunity to further discussing the integration of virtual care at our upcoming Health Ministers' Meeting.

I am also aware that, in some cases, private surgical clinics are offering patients opportunities to jump the queue for surgical procedures that are not an emergency (e.g. cataract surgery, knee or hip replacements, hernia repair) by accessing care outside their home province or territory for a fee. I am concerned that this practice could undermine the fundamental principle of Medicare, where access to care should be based on health need rather than the ability or willingness to pay. That is why I have directed departmental officials to continue working with you to closely monitor this issue.

Our publicly funded health care system is dynamic, and can benefit from innovation while remaining true to the fundamental principle of Medicare. By embracing positive evolution while ensuring access based on need, I am confident we can keep delivering improvements in the health care system that will benefit all Canadians.

Please accept my best wishes.

Yours sincerely,

 

The Honourable Mark Holland, P.C., M.P.