Why is health care different in every Canadian province?

To answer this question, we need to dig into Canadian history and travel all the way back to the creation of the Constitution Act of 1867.

We’re talking the very DNA of Canadian democracy and the moment when the Act united three of five British North American colonies into a federal state, and outlined the distribution of powers between a central Parliament and provincial legislatures.

Section 91 of the Act gave the federal government the power to oversee affairs of national importance and “to make laws for the peace, order and good government of Canada,” while section 92 gave provinces jurisdiction over “all matters of merely local or private nature in the province,” which included property, taxation and hospitals.

Fast forward 100 years to the Canada Health Act (1984), which gives the federal government responsibility for setting and administering national principles for our health care system. In exchange, the federal government shares in the cost of administering health care through the Canada Health Transfer.

These two laws govern how health care works in Canada. The Canada Health Act provides overarching national standards for our health care system, but the constitution guarantees provincial and territorial governments’ freedom to make decisions based on their own regional needs and resources.

What parts of health care are the same across Canada?

The Canada Health Act outlines several standards that provincial and territorial health plans must meet to receive federal government funding. These include:

• Public administration: Health plans must be administered and operated on a nonprofit basis by a public authority responsible to the provincial government. For example, Health Insurance BC administers medical coverage on behalf of the provincial government in British Columbia.
• Comprehensiveness: Medically necessary services provided by hospitals and doctors must be covered.
• Universality: Health plans must cover all Canadian citizens and permanent residents. The Canada Health Act defines insured persons as residents of a province or territory "lawfully entitled to be or to remain in Canada who makes their home and is ordinarily present in the province, but does not include a tourist, a transient or a visitor to the province." Tourists typically have coverage under travel insurance, and some health care for refugees are covered under the Interim Federal Health Program.
• Portability: Residents must be able to access health care when they travel within Canada. Limited coverage is also required for travel outside the country, typically limited to emergency hospital and doctor services. 
• Accessibility: Residents must have reasonable access to medically necessary services. (What constitutes “reasonable access” is up to provinces and territories to decide.) Access must be based on medical need and not the ability to pay.

Medically necessary services are not defined in the Canada Health Act. To sort out what’s necessary and what’s not covered under public health care, provinces and territories get help from provincial/territorial medical associations.

This means what’s covered by a public health plan can be very different across the country. Take in-vitro fertilization (IVF), a treatment for infertility, as an example:

• Ontario, Quebec and British Columbia (starting in 2025) fully cover one cycle of IVF.
• Manitoba, New Brunswick, Nova Scotia, Prince Edward Island and Newfoundland and Labrador all cover partial costs associated with IVF through tax credits, grants or reimbursements. 
• Alberta, Saskatchewan and the territories offer no coverage for IVF.

One way to look at this: The flexibility to define what is “medically necessary” in each province and territory allows political leaders to allocate resources where they’re most needed — which might not be the same across the board in a country as large and diverse as Canada. The criticism of this system is that it means access to certain publicly insured health services is not equitable across Canada.