The unfinished project of Medicare

Canadians can be proud of Medicare, but what we have to apply ourselves to now is that we have not yet grappled seriously with the second phase. 

Tommy Douglas, S.O.S. Medicare Conference, November 1979

Tommy Douglas, voted “Greatest Canadian” in a 2004 CBC contest, is perhaps best remembered as the father of Canadian medicare. His legacy goes beyond the public insurance system for physician and hospital care still protected by the Canada Health Act today. His vision for what he called “Phase Two” of medicare also remains a lasting legacy that still moves Canadians to imagine better health care for all. 

In his landmark address to the 1979 S.O.S Medicare conference, Douglas described what he called “Phase One” of medicare: winning the legal and financial framework for universal public health insurance. The people-powered victories that led to the Canada Health Act were historic achievements, but they were never the final destination. 

For Douglas, “Phase Two” was the real goal. 

“Phase Two” meant expanding the basket of health services that Canadians could access based on need rather than ability to pay. It meant publicly covering prescription drugs, dental care, home support, seniors’ care, and building a public infrastructure of community health clinics that could provide primary care. It also meant recognizing that the health system cannot succeed without sustained public investment in the social determinants of health. 

Each of these “Phase Two” components remain unfinished today. Many Canadians now understood something that Douglas named. There is a difference between a public system to treat illness and a public system that keeps people healthy in the first place. 

As explored in the previous installment in this series, much of the energy of the last forty years has been spent fighting to preserve the gains of Phase One.

In our Summer Series, Part One examined the popular movement that won the Canada Health Act. Part Two explored how that victory has remained under constant pressure from private interests, forcing advocates to defend the foundation of medicare rather than build upon it. This installment returns to Douglas' unfinished vision and asks what Phase Two could look like today.

Do we already have public health care? 

While Canadian health care is broadly described as a universal public system, the reality is more limited. Our health care system uses a mix of public and private financing as well as a mix of public and private delivery. 

Compared to our OECD peer countries like Australia, the Netherlands, France, the United Kingdom, and Germany, Canada publicly finances a smaller share of health care overall because many essential services remain outside universal coverage. 

Canada actually relies more heavily on private payment than many of the countries that are known as having “mixed” health systems. 

Many countries with stronger health outcomes publicly cover a broader basket of services than Canada does. Public coverage of primary care supports, prescription medications, dental services, and home care not only improves access but can reduce costs by preventing more expensive hospitalizations and emergency care later on.

Tommy Douglas understood that the success of medicare depended on reorganizing our health system around prevention, continuity of care, and keeping people healthy. 

In his address at the S.O.S Medicare conference, Douglas warned that “the phase number two would be the much more difficult one, and that was to alter our delivery system to reduce cost and put an emphasis on preventative medicine.”

Building public primary care infrastructure

A core building block in Douglas’ vision for “Part Two” of medicare was to be the building out of a public system of community health clinics where primary care could be delivered in a public setting. This is still a much-needed solution that can go a long way to addressing our primary care crisis. 

Today, most family physicians operate as independent small businesses that bill provincial insurance plans. While many provide excellent care, the system itself was never designed to support team-based care, integrated community services, or equitable access across neighbourhoods. 

Family physician and health policy researcher Dr. Rita McCracken argues that Canada should think about primary care the way we think about public education. 

We do not expect every teacher to open a private school, lease a building, hire staff, purchase equipment, and operate as an independent business before they can teach. We build public schools, provide infrastructure, assemble multidisciplinary teams, and allow educators to focus on educating students. 

Primary care could be organized in much the same way. 

Instead of relying on thousands of small independent medical businesses, governments could invest in publicly owned community health centres where physicians, nurse practitioners, nurses, pharmacists, social workers, mental health professionals, physiotherapists, and other providers work together as salaried teams. Patients would be attached to these community clinics rather than to individual business owners, making access more stable while improving coordination and continuity of care.

Public primary care infrastructure would also make it easier to integrate prevention, chronic disease management, mental health services, and social supports under one roof. Rather than treating illness as isolated medical events, the system could address the broader factors that shape health throughout people's lives.

This vision is remarkably consistent with what Tommy Douglas imagined nearly half a century ago.

The task ahead

More than forty years after Douglas delivered his S.O.S. Medicare address, Canada is still defending the achievements of “Phase One”. Those battles remain necessary. But if protecting medicare becomes our only objective, the project Douglas began will remain incomplete. 

The best way to protect “Phase One” is to to make it work. To do this, we need to finish the work Tommy Douglas began: “We must work to get Medicare as it was intended to be, a program that would provide, in Canada, a society in which we would have freedom from fear and freedom from want.”

Learn more about the evolution of Canadian medicare in part one and part two of our Summer Series. Written by Audrey Guay.