In the post-pandemic world, health spending in Canada continues to be marked by the paradox of simultaneous feast and famine, according to the Canadian Institute for Health Information (CIHI) release of the National Health Expenditure Trends 2023.

Total health spending in Canada for 2023 is projected at $343.8 billion, up 2.8 percent from 2022. The lingering effects of the pandemic contributed to growth in hospital expenditures of 11 percent in 2022 and 4 percent in 2023. Meanwhile, physician spending grew almost 10 percent in 2022 and nearly 7 percent in 2023. As a share of GDP, health spending’s projected share of GDP in 2023 is approximately the same as the previous year, at about 12 percent which is still above the pre-pandemic figure of 11 percent.

However, despite what seems to be robust overall growth numbers, once one factors in population growth as well as inflation, it turns out that real per capita health spending in Canada is expected to be down for the second year in a row. Indeed, for 2023, the change in real total health spending per capita is -0.5 percent which comes after a nearly 2 percent decline the previous year. However, it remains that real per capita spending is still substantially higher than it was going into the pandemic.

Figure 1 provides some historical perspective on the long ascent of real per capita health spending in Canada providing a plot not only of total spending but also provincial government and private sector health spending. The pre-pandemic period saw a slowdown in the growth rate of real per capita spending, which was more pronounced at the provincial government level.

From 2010 to 2019, the average annual growth rate for total real per capita spending was 1.2 percent, but provincial government spending grew at 1.1 percent while private spending grew at 1.6 percent. By way of comparison, during the heyday of the federal transfer escalator, the 2000 to 2010 period saw average annual growth in real per capita total health spending of 3.2 percent—3.3 percent for provincial government and 3.1 percent for private.

The pandemic, fueled by emergency federal health transfers, saw real per capita public sector health spending surge, but also a decline in private sector. Figure 2 dramatically illustrates the 2020 surges in real per capita health spending for total and provincial government health, which each clocked in at about 8 percent respectively, but this was accompanied by a nearly 8 percent drop in private spending. The next year, provincial government spending grew at a slower but still robust rate at 4.7 percent, but real per capita private health spending rebounded at 8 percent and total health spending at 4.9 percent. For the subsequent two years however, decline sets in for real per capita total health spending at -3.9 and -0.5 percent driven mainly by declining provincial government spending at -2.2 and -0.5 percent given that private spending rose at 1.8 and 2.2 percent. However, this decline in per capita spending was partly driven by the wind-up of COVID-19 supports as well as other public health spending.

It should be noted that for 2023, real per capita provincial government health spending is projected at $5,723. If after 2019 spending had continued to increase at the same average rate from 2010 to 2019, then 2023 would clock in at approximately $5,450 which means that real per capita health spending in 2023 is still projected at several hundred dollars above what the previous trends might have placed it at. Indeed, compared to 2019, real per capita provincial government health spending in Canada is 10 percent higher. Overall, despite the recent declines due to both a winding up of pandemic-specific health spending as well as robust population growth, it would appear that there has been an enrichment of per-person health spending.

However, performance varies across health spending categories. In the case of provincial government health spending, for 2023 the largest components are hospitals (36 percent), physicians (20 percent), other institutional care including LTC homes (14 percent), and provincial drug plan spending (7 percent). If one looks at a comparison of real per capita provincial government spending between 2019 and 2023 for these key categories, hospital spending is up 6 percent, other institutions is up 25 percent, physicians is up 1.3 percent, but drugs is down nearly 2 percent. As for some of the other categories, real per capita provincial government public health over the same period is up 29 percent, other professionals at 10 percent, administration is up 9 percent, and home care/community care is up 14 percent.

So, what is one to make of all this in the current context of waiting lists and health care shortages that continue to plague health systems across Canada? Despite the post-pandemic decline in emergency health spending and the resulting slowdown in real per capita health spending growth for 2022 and 2023, it remains that real per capita health spending is up substantially. But two areas still lag the others: physician spending and drugs. Drug spending by provincial drug plans is linked to physician spending: if people cannot access physicians because of shortages in family doctors, then they are also going to find it more difficult to fill their prescriptions.

Of course, the Canadian health spending paradox of more spending and yet growing issues of access and timely service delivery is not a new one. It has, however, entered a more concerning phase given that physicians are the primary gatekeepers when it comes to health care access. If large proportions of provincial populations are not able to access physician services and get in line for care, how exactly are all these spending increases going to meet the health-care needs of Canadians?

For the time being, provincial health-care systems appear to be dealing with access issues by changing the access rules to some health services. Take the case of Ontario. Pharmacists in Ontario can now prescribe treatments for nineteen health services including diaper rashes, canker sores, and yeast infections. And most recently, Ontario has expanded the ability to self-refer for screening tests by lowering the age for women’s breast screening without a doctor’s referral to 40. One expects that eventually you may be able to self-refer for other routine screening tests in order to free up scarce physician time.

While such measures are a way of dealing with current physician shortages by reducing some of their gatekeeping requirements, it remains that they are short-term stop-gap measures. Eventually, once results from self-referred tests come back and short-term pharmacy treatments are exhausted, people will still need to see a doctor. Expect to see within a year or two complaints that despite a test result requiring follow-up, people cannot get in to see a physician. The next health-care accessibility crisis is already taking shape.

The saintly editors here at The Hub have agreed to my request to produce one of my two monthly articles for the site as a monthly transatlantic diary. For those readers not familiar with the format, which is more common in British journalism, the diary is a grab bag of short items, sometimes on a common theme, but often not. In my case, what they have in common is that they are either too inconsequential to merit a full article or I can’t be bothered to come up with more than a knee-jerk reaction or a flip comment. This is October.

’In Paradise, the fruits were ripe the first minute, and in Heaven it is always autumn.” I can’t speak for paradise, but Donne’s apothegm has certainly applied to Oxford’s heavenly autumn this year. The sun has stayed its sentence on the year long enough to keep October bright and warm and the wet river mist away. The leaves are only lately turning brown and gold, as though the brick terraces of North Oxford have donned a tweed coat in reluctant concession to the season. 

One advantage to spending the fall in England is the smell of burning leaves. I don’t know when or why we stopped backyard burns in Canada, but whatever smug gains it has secured cannot compensate for the loss of the most evocative smells of fall. Burning leaves are to October what pine needles are to December. It’s a smell that runs through human history. Bonfires have been beacons, warnings, and celebrations since man mastered fire, and their banishment is one more way we have cut ourselves off from the past, one more thing we no longer share with our ancestors. 

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As idyllic as Oxford has been this fall, it hasn’t been insulated from worldly cares. The outside world intruded this month in the form of ragged mobs parading through the city cheering Hamas’ “resistance.” I heard the rabble from my desk in the library at All Souls, a soaring neoclassical oasis in the heart of Oxford that is usually so quiet the briefest chair-squeak or scrupulously suppressed cough echoes through the sepulchral hush like the opening cannonade at Austerlitz. On this day, the muffled rhythm of protest chants penetrated the thick walls, and I ventured out into Radcliffe Square in time to hear the chants of “From Oxford to Gaza, long live the intifada.” The parade, which was organised by an outfit called the Socialist Worker Student Society, was dominated by young progressives. I sincerely hope none of them know that the main weapon of the last intifada was 140 suicide bombings targeting Israeli civilians and that calling for intifada in Oxford is a call to kill Jews here too. I say I hope, but…honestly, these days.

Even considering the pitiful education these students have received, youthful ignorance or general stupidity can be no excuse. The now-routine refrain “from the river to the sea, Palestine will be free,” is, in this context, a call for antisemitic genocide. I don’t care what you think you are saying, if you repeat those words immediately after a Hamas massacre, you can’t complain if people take it to mean what it means in Hamas’ Charter, which is the end of the state of Israel: “Hamas rejects any alternative to the full and complete liberation of Palestine, from the river to the sea.” Similarly, if “resistance” sounds suspiciously like a euphemism for the slaughter of civilians, it’s because that’s what Hamas means by it. Again, I don’t care what you think you’re saying, right now for “resistance” can reasonably be understood to mean what Hamas means by it: “Hamas rejects any attempt to undermine the resistance and its arms.” If you mean something else, then I suggest choosing words that aren’t lifted verbatim from the playbook of a listed terrorist organisation that hunts down and kills Jews in their homes. For now, “resistance” means what we saw on October 7^th, as several prominent organisers have been good enough to make clear. 

How did so many of the best-educated young people in the West come to believe the world’s only Jewish state is illegitimate? It is clear that social media, and especially TikTok’s algorithms, are shaping the worldview of our youngest and future citizens. Effectively, this means the Chinese Communist Party is taking control of public opinion. Why we haven’t shut down this weapon of cold war manipulation is a mystery. It doesn’t help that our schools have reduced the teaching of history to Lenin’s crude dictum, “Who? Whom?” producing a generation that conflates relative power with absolute morality. The elevation of victimhood to the highest good makes it inconceivable to many students that the side of might could be in the right, or that weakness can corrupt every bit as much as power. Why we surrendered control over education policy to university education faculties—the least intellectual and most ideological part of our education system—is baffling. Why even putatively conservative governments are doing nothing to push back is inexplicable.  

* * *

Towards the end of the month, I popped down to London for dinner at the House of Lords. When I worked in the PMO, two of the prints in my Langevin office were replicas of the monumental Daniel Maclise paintings that grace the two long walls of the Royal Chamber, one of Wellington meeting Blücher after the Battle of Waterloo and the other of the death of Nelson at Trafalgar. It was a rare treat to see them in person. The room, however, looked like a builder’s site with great rolls of blue carpet stacked haphazardly in preparation for His Majesty’s first opening of Parliament as King next month. This follows the prorogation of Parliament this month, before which several bills received royal assent for the first time since 1951 with the words “Le Roy le vault.” After buying my first Charles III stamp and receiving my first Charles III coin as change this month, this really drove home the fact of the royal succession. Now, barring unthinkable calamity, it will be “Le Roy” for at least the next 75 years. How comforting it is to know the next two heads of state so far in advance; few peoples in history have been able to look so far into the future with such assurance. 

Dinner itself was lively and both expectedly and unexpectedly amusing. Our host’s quick wit and charm were expected, but the unexpected came when the conversation turned to the state of Britain’s global influence. I was bemused to hear that the delusion that attends sententious Canadian discussions of “our role in the world” extends to the British variation on the theme. According to one guest—a blustery cove with the stentorian confidence of an Englishman accustomed to life on an ex-pat pay packet in one of the lesser former colonies—the imminent eclipse of the gerontocratic American empire is the opening Britain has been waiting for to reclaim the title of Top Nation. Of course, Britain has greater enduring relevance than we do—it helps that they have a mostly-functioning military—but on that dubious foundation this chap would construct a neo-imperialist vision of such burlesque hubris that I half expected him to propose that we sail that night from Greenwich, armed with our bread knives and a barrel of Lords’ vintage port, to reconquer Mesopotamia. The performance reminded me of Frederick Lee, the last Secretary of State for the Colonies, who must have continued to file his reports, sharpen his pencils, and flirt with the tea lady, carrying on as his predecessors had done for two centuries, naggingly aware that there were no more colonies out there beyond his office door, waiting for someone to turn out the lights (as the government finally did on that office in 1966, though news of it has apparently yet to reach my whilom dinner companion). 

I don’t know if it’s reassuring or not to learn that the stubborn unreality with which our government and their panel-show courtiers face the world is not an exclusively Canadian problem. Leaders on both sides of the Atlantic seem to be taking their cue from the late General Sir Anthony Cecil Hogmanay Melchett: “If nothing else works, a total pig-headed unwillingness to look facts in the face will see us through.” I suppose it “worked” in the killing fields of France. Eventually.