In December 1951, after a three-week voyage crossing the Atlantic, my grandfather, Jacques Elie Shilton, reached Pier 21 in Halifax. He was forty-two at the time, and had shepherded ten family members—three generations—through the rigorous and at times perilous process of leaving Egypt for a better life. My mother, who was three, spent the voyage playing with a doll she still remembers.

Gaping at the five-foot-high snowbanks, they boarded the night train for the forty-eight-hour trip to Montreal. My grandparents had left everything behind—their jobs, their savings, their home. They brought several trunks of inappropriate clothing and the few hundred dollars they were allowed to take out of the country. A local immigrant-support organization helped them find an apartment at the outer edge of the city. At least they spoke the language, but the French of North African Jews stuck out as different, just as they did.

My grandfather measured six foot two. He was handsome, with a strong, calm presence and a baritone voice. He spoke seven languages. In Cairo he had worked for a French newspaper, and later for 20th Century Fox. He loved music and he was a talented musician. In the evenings, he played in a dance band to supplement the family income. His two young daughters had no sense of the weight he carried on his shoulders. It seemed to them that he had the strength of ten men.

In the spring of 1953, he went to visit a friend who was being cared for at the Jewish General Hospital in Montreal. But the steep hill on Côte-des-Neiges Road proved too much for him, and as he sat in the waiting room, he suffered a major heart attack. He spent nine weeks in hospital. So began my family’s experience of Canadian health care in the pre-medicare days.

After the heart attack, Jacques began having trouble with his breathing. Coughing fits and respiratory distress required frequent visits to the doctor, who had to be paid in cash. Medications were expensive. Sometimes he bought them; at other times, he preferred to save the money. He started having terrible pains in his legs. He experienced increasing difficulty walking, but since every visit to the doctor was expensive, he pushed on.

Time passed, and the pain became unbearable. The blood circulation to his legs was so restricted that his doctor told him his life was on the line. There was no effective treatment for such extensive arterial disease in those days. But then they read about Dr. Michael DeBakey, an international innovator in the emerging field of vascular surgery. DeBakey had pioneered an experimental procedure to open up blood supply in blocked arteries, a technique he hoped could help people with Jacques’s problem. He had begun performing it in Houston, Texas. It was worth a shot.

Already crippled by medical debt and his inability to earn a good living, Jacques and my grandmother, Sarah, borrowed money from family members to finance his care, a decision that would taint family relationships for generations. They went to Houston. At my grandfather’s request, and in order to save money, the nine-hour surgery was done on both legs at once. During that entire time my grandmother stayed planted on a chair in the waiting room without anyone coming to tell her whether her husband was dead or alive.

Despite the fact that Dr. DeBakey had decided to forgo his fees, Jacques and Sarah couldn’t afford to stay in Houston for the recommended six months of convalescence. They returned home nearly immediately.

But the experimental surgery wasn’t very successful. The “arteries” that had been inserted served as a pipeline for clots. Jacques was bedridden, and he suffered multiple small heart attacks. He lost fifty pounds and looked like a shadow of the man he had been.

Over the years, the impact on my grandmother was profound. She ate poorly; she had trouble sleeping. The medical bills and the strain of family relationships—ruined now by the borrowed money they couldn’t pay back—preyed on her mind. Jacques’s efforts to work from his bed, the daily injections of diuretics, the pills, and the constant visits to the doctor wore away at her and her two daughters. Eventually, Sarah’s mental health succumbed and she spent six weeks in hospital.

Sarah and Jacques then separated for a time so that they could each try to recover. My mother, who was now in her teens, stayed with Jacques, and her sister went to live with Sarah. The two girls did the best they could to work and contribute to the family income while they embarked on their university studies. And after their mother recovered and was feeling emotionally stronger, Jacques began to court her again. He would bring groceries to her apartment and they would talk about where they might move together in the spring.

But that didn’t happen. My mother found him dead at four o’clock in the morning on March 9, 1966, six days after her eighteenth birthday. He was fifty-four years old. He had stayed up more than half the night working on a French-to-English translation to earn a little cash. Sarah, who’d worked from the time they arrived in Canada as an assistant in a fancy Montreal ladies’ dress shop, was widowed at age forty-one with a pile of unpaid medical bills on the kitchen table.

My mother’s view is that the struggle to deal with financial hardship—along with health problems—destroyed her family. She was studying at McGill at the time, the same university I would attend decades later coming from all the luck and privilege anyone could ask for. She hadn’t yet earned her master’s degree or launched a successful career. She hadn’t yet met my father, a nice boy from a Fine Old Ontario Family who wanted to make the world a better place. She hadn’t yet raised a daughter who would make improving health care in Canada her life’s passion.

There are more stories of course, but this is a glimpse. It’s the story of my family, and also of countless others across Canada who rejoiced when we decided together as a country that it was time to create medicare, a system of hospital and medical care that is free at the point of service for all Canadians.

Health care in Canada isn’t perfect. We face very real challenges, challenges I see up close every day. But I grew up believing, as most Canadians do, that the values on which our system is built are sound. That being sick is bad enough without worrying about having to pay for your care. That the families who lived at the top of the hill in Westmount mansions were no more or less deserving of good health care than Jacques and Sarah were.

Our system will need to change to meet the needs of patients over the next fifty years. But that does not require us to institute one system for the rich and another for everyone else. Instead, Canadians can show that we have the courage to address some real and substantial issues without abandoning fairness as if it were a trend that’s gone out of fashion.

Most doctors (and nurses, and patients, and citizens) who support medicare are not blind supporters of the status quo. To the extent that our commitment to medicare might make us vulnerable to accepting mediocrity, we need to do better. But we can work for change that addresses our problems and still honours our principles.

As a family doctor working in the system, I believe this now more than ever. Medicare is a work in progress, but it’s a work worthy of our greatest efforts. It represents a promise to be the kind of country we can be proud of. This book explains what I think needs to be done to deliver on that promise.

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Many books have been written about Canadian health care, and many reports have charted the way forward to improve it. What makes this book any different? It brings together two views that don’t always converge: the perspective of the front line—individual patients and health care providers—and the perspective of system thinkers. From that vantage point, I’m proposing six “Big Ideas” for making meaningful improvements to medicare. They focus on cultivating relationship-based primary care, establishing a national drug program, reducing unnecessary and wasteful tests and procedures, reorganizing our existing resources to improve care, ensuring a basic income to promote health, and building the systems we need to actually implement change instead of just talking about it.

As a family doctor, I’ve had the privilege of working in the Canadian health care system for more than ten years. I have worked in rural northern communities, on First Nation reserves, in small emergency departments and inpatient wards, and downtown in Canada’s largest city. My current work is in a general family practice at Toronto’s Women’s College Hospital, where I teach medical students and residents the art and science of family medicine and see patients of every age and stage. Another part of my practice is taking care of pregnant women and delivering babies. While it sounds trite to say, it’s really true that my patients teach me as much about health and health care as I teach them. So throughout these chapters, I’ll introduce you to some of the patients who have had a lasting effect on me. I think the lessons of their experience are important to us all. Their names have been changed, and some details of their stories have been altered to protect their privacy. In some cases, these lessons come from colleagues who work in different parts of the health care system and offered case studies of their own memorable patients. All are real people.

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In addition to my work as a clinician, in my eighth year of practice I started a new job as a vice-president at my hospital. As a medical administrator, I help to manage the hospital budget and to decide what kinds of physicians we need in the hospital. I work on a team that faces tough decisions about how to achieve our hospital’s mission within fiscal constraints, how to partner with other organizations in our neighbourhood and beyond, and how to add value for patients in a system under pressure.

When I started this job, Women’s College Hospital had committed to redesigning the way we deliver care. Our hospital is different from most: we have no emergency department and no overnight beds. Our maximum length of stay is eighteen hours. We have a large number of general and specialty outpatient clinics; an extensive day-surgery program, including complex surgeries that used to require overnight stays; and a variety of programs for people living with chronic illness. We call ourselves the “hospital designed to keep people out of hospital” because we want to develop new ways of delivering health care to an aging population that wants to live longer, and better, outside an institutional setting. It was that mandate that attracted me to the work.

I had a series of extraordinary mentors who helped prepare me for this job. They encouraged me to take a leadership role at every stage of my career. And with their support and counsel, I did just that. Throughout my medical training, my initial clinical work, and the process of obtaining my master’s degree in public policy, I found myself speaking out about the promise of public health care and the need to revitalize our system. In small groups and at conferences, across Canada and the United States, I argued that privatizing some or all of Canadian health care would make us poorer as a society and meaner as a culture. This wasn’t solely because of my grandfather’s story, although my family’s experience remains a sharp reminder of the need for a strong public health care system. It was my work both in health care policy and as a practising doctor that shaped my belief in medicare.

Then one day in early 2014 the phone rang, and everything changed.