While health care is under provincial jurisdiction in Canada, the federal government wields considerable influence over provincial health care policy. Provinces must adhere to the Canada Health Act (CHA) in order to qualify for federal health care dollars allocated through the Canada Health Transfer (CHT). The CHA clearly limits some reforms the provinces might otherwise consider implementing, while remaining unclear on the permissibility of others. Conflicting interpretations of the CHA’s program criteria as well as the discretion that federal authorities have in interpreting provincial adherence to the Act create significant political and financial risks for reform-oriented provinces. These risks bias provincial government policy towards the status quo and create incentives for the development of prohibitions that go beyond what is explicitly required by the CHA—even when some of the proposed reforms are commonly found in better performing universal health care systems around the world. This study considers the federal CHA and British Columbia’s legislation and discusses six reforms that are either: not explicitly disallowed at the provincial and federal level, such as expanding capacity through the use of private providers, remunerating hospitals based on activity and creating centralized referral pools; not explicitly disallowed at the federal level but prohibited provincially, such as implementing parallel private financing, and allowing doctors to work in both the public and private systems simultaneously (dual practice); or disallowed both federally and prohibited provincially, such as imposing cost-sharing on patients for basic health care. The recommendations outlined in this study could improve the efficiency and accessibility of health care services in British Columbia and, except for cost sharing, could be implemented without necessarily contravening the CHA.