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Rapid Recap: Federal Health Minister Releases Long-Awaited Canada Health Act Interpretation Letter

January 13, 2025January 14th, 2025

January 10, 2025 – The Federal Minister of Health has released the long-awaited Canada Health Act Interpretation Letter. The fourth Interpretation Letter since the creation of the Canada Health Act (CHA) in 1984, this letter clarifies the federal government’s interpretation of the CHA. In some cases, it also addresses changes in health care since the Act was adopted.

In this instance, the letter is focused largely on the expanding scope of practice for Nurse Practitioners, Midwives, and Pharmacists, all of whom have seen their scopes grow to encompass more services that were traditionally the sole purview of physicians. The letter also states that services delivered by these providers must be publicly insured, and out-of-pocket payments must be prohibited if the same services would have been publicly insured when delivered by a physician.

The letter also touches on virtual care, but only in a very directional way and with no substantive changes to policy.

The provinces have until April 2026 to implement this policy.

What’s in the Letter?

  • Three of the four Interpretation Letters to date, including this one, have addressed changes to the health care system since the enactment of the CHA. In this instance, the change is that there “has been an expansion in scopes of practice for many regulated health care professionals”, and that this “now permits these professionals to deliver some of the same services that would normally be insured if provided by a physician”.

  • The letter frames these changes as a positive and does not endeavour to roll back any expanding scopes of practice. Instead, the letter seeks to “ensure that patients do not face charges for medically necessary care when a service would otherwise be covered if provided by a physician”.

  • The letter is broad and could, in theory, apply to any number of professional services which are provided by non-physicians (e.g. mental health services), but the letter narrows this scope by stating that “this policy does not include regulated health providers who had an overlapping scope of practice with physicians prior to the enactment of the CHA in 1984”. In other words, the focus is on what’s changed since 1984, not all instances where scopes of practice overlap.

  • The core intent of the letter is to ensure that all provinces are publicly funding Nurse Practitioner (NP) care and to curtail the practice of NPs opening their own private pay clinics or otherwise charging patients out-of-pocket.

  • The letter also includes numerous secondary references to pharmacists and midwives. While less of a perceived issue, the letter also seeks to ensure that, where scopes of practice are expanding for these providers, patients are not paying out-of-pocket (e.g. pharmacist diagnosis of minor ailments) for medically-necessary services.

  • The specific policy changes required to implement this directive will vary from one province to another. Each province will need to determine where scopes have changed in the past 40 years and will need to publicly insure this expanded scope where it overlaps with medically-necessary services delivered by physicians. This may be highly complex but, again, the ultimate focus here is on NPs, midwives, and pharmacists—and NPs are highly likely to get the majority of attention.

  • If provinces are found to be allowing private payment for these services (e.g. if a private-pay NP clinic continues to operate in a province), then the federal government may claw back part of their Canada Health Transfer payment starting in 2028. This is the same mechanism that the federal government has in the past used to enforce other prohibitions under the Canada Health Act (e.g. in relation to private clinics and diagnostic services)

Virtual Care Excluded

Crucially, virtual care was largely excluded from the scope of the Interpretation letter. This is notable because, in early 2023 when the federal government first announced their intention to release this letter, virtual care (along with NP billing) was identified as a key issue, and media coverage since then has largely focused on the potential implications of this letter to virtual care.

The letter, however, encourages the provinces to continue to publicly insure virtual care, noting that the Federal Minister intends to discuss this with his provincial and territorial counterparts. The letter does not change any virtual care-specific policy. It is highly likely that a range of groups will be critical of the letter for this omission.

It is possible that another Interpretation Letter will be issued in the coming months covering virtual care, but the odds of this are quite low. Such a letter would be issued after Justin Trudeau’s successor is in place and would depend on this individual seeing this as a top priority issue and having the time to develop this letter.

The letter also alludes to the issue of individuals crossing provincial borders to pay for faster access to care (e.g. flying from Ontario to Alberta to pay for surgery that one could have received, publicly insured, in Ontario). The letter flags this as an area of concern, but only notes that the federal government will “closely monitor this issue”.

What Happens Next?

Each province will need to determine how to implement this policy direction – the specifics for each province will depend on how scopes of practice have changed since 1984 and what is currently publicly insured.

The provinces have a two-year window to implement any necessary policy reforms. The federal government has provided a deadline of April 1, 2026 at which time the new policy will come into effect. Provinces that do not comply with this policy could have some portion of their Canada Health Transfer clawed back beginning in December 2028.

The key change that we expect over the next two years is that provinces will increase and expand public funding of Nurse Practitioners, and that private-pay NPs will either close or shift to a public-funding model. Inversely, this change may make it more difficult for provinces to further expand scopes of practice where they have not yet done so, as any scope of practice change may also require a commensurate funding increase.

It is possible that a new Prime Minister or new government would overturn this Interpretation Letter, but we do not see that as likely and we expect provinces to implement these changes with minimal push-back (except for, potentially, some provinces arguing with the federal government about increased funding for this).

Further Reading

  • Read the statement from the Minister of Health on the Canada Health Act.

  • Read the full letter to provinces and territories.