Box 1.

: The legal basis for Canada's healthcare system

• The Constitution Act (1982) assigns responsibility for most health care to the provinces (the national government retains responsibility for aboriginal populations covered by treaties, the armed forces, and members of parliament)
• The Canada Health Act (1984) consolidates and defines the principles of the publicly funded healthcare system, known as Medicare. The five principles are comprehensiveness, universality, portability, public administration, and accessibility
• The Canada Health Act requires that all hospital and physician services be (virtually) 100% publicly financed without user charges. Third party insurance for these services is prohibited. Physicians can “opt out” of their provincially operated Medicare plans, with no state financing of care. There are nuances in how individual provinces regulate this provision, but uptake is very small
• The Canada Health Act is silent on other services, resulting in a patchwork of coverage arrangements that varies considerably from province to province
• The federal government has long shared tax revenues and negotiated cost sharing agreements with the provinces. It used its fiscal levers to engineer the key legislation that created a national Medicare system in the 1950s (Hospital Insurance and Diagnostic Services Act 1957) and 1960s (Medicare Act 1966). Its ability to enforce provisions and penalties under the Canada Health Act is contingent on its power to withhold fiscal transfers to offending jurisdictions