They arrived before the sun. On a snowy January morning in Walkerton, Ontario, hundreds of people began 2025 by lining up, bundled in scarves and winter coats, hoping to score the hottest ticket in town: the chance to register with a family doctor.

The crowd represented only a fraction of the more than six million Canadians who currently lack a family physician, and their presence was a stark reminder that, despite its reputation, the country’s universal health-care system has gaps big enough for millions to slip through.

For many Canadians, universal health care is a point of pride. The Canada Health Act, passed by Parliament in 1984,¹ is the legislative backbone of this system. It ensures that most residents can see a doctor or visit a hospital without worrying about the bill. Yet in the more than 40 years since its passage, the act has never been substantially updated.

Now, with the health system strained by long wait times, a critical shortage of family doctors and rising rates of mental illness and addiction, some health experts argue the time has come for a Canada Health Act 2.0.

“We need to fundamentally alter our thinking because not all Canadians have access to the medically necessary care they need,” says Gregory Marchildon, a professor emeritus at the Institute of Health Policy, Management and Evaluation at the Dalla Lana School of Public Health and one of the country’s leading voices on health policy. He wants us to rethink what it means to have “reasonable access to health services” and to redefine which health professionals can provide care.

One standard for all

The Canada Health Act was designed to ensure that no matter where in the country someone lives they receive the same standard of health care without having to pay out of pocket. This ethos is opposite to what airlines use, says Marchildon: “There’s no business class, there’s no economy class, there’s just one class.”

The legislation, only 13 pages long, sets out criteria for what services must be publicly covered. Provinces and territories then receive federal funding via the Canada Health Transfer, based on how they meet those criteria. Marchildon, who has written extensively about the introduction of Medicare in Canada, compares the act to a house: it provides the basic layout, and the furniture and appliances required, but leaves the provinces and territories free to add extras. He says the act was initially effective in making health care more accessible for those who previously couldn’t afford it.

Back then, however, the focus was on medically necessary hospital and physician care. Services from nurse practitioners, addictions specialists, physiotherapists and occupational therapists were not included under the act. Neither were First Nations’ traditional healing and treatments. Some provinces and territories have since passed legislation to cover these services, but access depends on where a person lives – and their ability to pay. Ontario, for example, saw several private nurse practitioner-led clinics pop up last year, with fees ranging from $70 a visit to more than $400 for a yearly membership.

Having moved to a new city, Marchildon himself is among those without a doctor. The last time he was sick, he simply didn’t receive care. “But we can’t just keep adding more doctors,” he says. “That doesn’t do the trick.

“Good primary health care requires the contributions of many others. Nurse practitioners, for example, can more easily provide services to people living in areas chronically underserved by traditional family physicians.”

Modern pressures

The cracks in the system show up in many ways. In addition to the difficulty of finding a family doctor, many Canadians report exceedingly long wait times or barriers to care – delays that have been intensified by backlogs from the pandemic. In 2024, at least one in four people waiting for a hip or knee replacement didn’t get surgery within the recommended six-month window. More than half of young adults with early signs of mental health issues said cost kept them from seeking care. And one in 20 Canadians took measures such as skipping doses or delaying refills because of the out-of-pocket expense of prescription medication. The house, as Marchildon described, needs renovations.

“The act was groundbreaking in its time, but the care we need now goes far beyond hospitals and doctors,” says Sara Allin, an associate professor at the Dalla Lana School of Public Health and co-editor of the journal Healthcare Papers, which devoted a recent issue to reimagining the Canada Health Act.

Allin explains that changing the act is “the only real tool the federal government has to influence and shape the way the health system is organized.”

Marchildon agrees, noting that the current definition of “reasonable access” focuses almost entirely on eliminating user fees. “If access in the Canada Health Act was defined to include timely access, then provinces and territories would strive to reduce the most unacceptably long waiting times and barriers, since none would want to lose part of their cash under the Canada Health Transfer,” or, more significantly, he adds, “the bad publicity that comes with being in breach of the Canada Health Act.” ²

What reform could look like

Revising the act could mean expanding insured services to include a broader range of health professionals – from nurse practitioners and midwives to addiction specialists – no matter where you live.

Marchildon argues that it could also mean building in greater accountability and transparency measures. In 2024, for example, the Canadian Medical Association called for a Chief Health Accountability Officer to monitor how the provinces and territories are meeting their obligations under the act – and to publicly report outcomes. “So much of our taxes go toward this transfer,” says Allin. “Updating the act could help ensure we get more out of that investment.”

Critics will raise concerns about the cost associated with adding more services to an already pricey publicly funded bill. But supporters counter that many changes could be achieved through more efficient organization, not just more spending. Nurse practitioners and physician assistants can often provide high-quality primary care less expensively than physicians, while expanded roles for pharmacists or midwives could also achieve savings and relieve some of the workload falling solely to family doctors.

The politics of change

Revising such an iconic piece of legislation, let alone one that hasn’t been significantly updated in 40-plus years, is not simple. In that time, governments have sidestepped the issue by creating parallel legislation or “letters of interpretation” that adjust definitions without changing the act.

Last January, then federal Health Minister Mark Holland released an interpretation letter (effective next spring) to add health professionals including nurse practitioners, pharmacists and midwives to the list of “insured services” providers. Marchildon says steps like this are helpful but warns that these changes can be easily reversed as politics or parties change.

“One of the protections of the Canada Health Act is that it’s of such great importance to Canadians that it is very difficult, for good reason, for the government to make major changes,” says Marchildon.

Building consensus for change among provinces, territories, political parties, various stakeholders and the public will be a daunting task.

But Allin and Marchildon argue that the moment may be right. After four decades, Canadians have a clearer sense of the system’s strengths and weaknesses. And the pandemic underscored both the value of universal health care and the urgent need for modernization. The act has ensured generations of Canadians access to care without paying out of pocket. The question now is how to protect that principle while adapting to 21st-century realities.

“Yes, there are challenges – but we’ve built something worth protecting, and we can make it better, from the bottom up with improvements to service delivery at a local level facilitated by provincial reforms, and from the top down through improvements to the Canada Health Act, initiated by the federal government,” says Marchildon.

“It’s all about strengthening the system we have and building on our success.”

This story is one of a six-part feature on big, bold Canadian ideas.