1

THE CANADIAN HEALTH CARE SYSTEM: OVERVIEW

• Class Discussion: • How successful has Health care been in broadening

and equalizing access to the medical care system for all Canadians?

• Has change in accessibility led to changes in the overall health of the population or in the distribution of health of the population?

• The Reform of Health Care: What's wrong with the health care system?

• What kinds of changes are needed?• What kinds of changes are being proposed and why?

2

THE CANADIAN HEALTH CARE SYSTEM: OVERVIEW

• No such thing as ‘the Canadian Health Care System’

• In fact - 10 provincial systems working in parallel - minor differences between provinces re: cost/fees; scheduled items, etc.

• It is joint operation of, and co-operation between, provinces that allows us to speak about the 'Canadian' system– System is the envy of many others– Americans particularly– Brits– Germans, other Europeans

3

Six features/characteristics of Western health care systems (Torrance, 1987)

1. Heavy emphasis on curative medicine as enshrined in private practice and acute-treatment hospitals with little attention to sources of illness, prevention, public health or rehabilitation

2. Growth of specialization at expense of primary care

3. Rigid division of labour that discourages reallocation of roles

4

Six features/characteristics of Western health care systems…

4. Creation of new sources of corporate profits + professional wealth from state-subsidized care

5. Intrusion of medical industry into range of problems previously considered outside its competence

6. Fiscal crisis

5

THE DEVELOPMENT OF THE HEALTH CARE SYSTEM IN CANADA

• Weller & Manga (1983) identify 3 policy periods.

1. Benign neglect (up to 1945)

2. Shared cost agreements (1945-76)

3. Established Program Areas Acts (1977)

4. Federal withdrawal (1990 - ?)

6

Benign Neglect

• Little government involvement.

• Health a provincial responsibility with few exceptions (native Canadians, regulation of environment and food; radiation, veterans health).

7

Benign Neglect

• Public health a government concern (water, food quality; regulation of restaurants, etc.)

• Private health a private matter

• Rise of physician dominance through late 19th and early 20th century.

8

Benign Neglect …

• 1912 Canada Medical Act

• Marked the turning point in the position of allopathic practitioners (physicians)

• Licensing of physicians others excluded: chiropractors, natural paths, apothecary, midwifery...

• Proposed and spearheaded by Dr. Thomas Roddick - physician turned politician.

9

Benign Neglect …

• 1920's Flexner report

• Advocated rise of 'scientific' biomedicine at expense of public health

• Shaped curriculum of medical schools; affiliation with universities (legitimation)

• Radically changed medical education in both Canada and US

10

• 1920's Flexner report …

• Some successes (vaccination for polio, smallpox...)

• Insurance private, typically only middle-class easterners could afford it or had it offered to them... this fed flames of discontent in the west...

• Dirty 30's - rise of labour movements, pressure for improved living conditions/standards

11

Shared Cost Arrangements

• Post WWII - prosperity and renegotiation of social contract in UK - rise of welfare state establishment of NHS

• 1947 - Saskatchewan - institutes compulsory hospital insurance scheme

• 1948 - National Health Program - comprised of 10 granting schemes for health surveys, public health care, tuberculosis, cancer, mental health, sexually transmitted diseases, crippled children... and hospital construction

• 1949 - joined by Alberta and B.C.

12

Shared Cost Arrangements …

• 1958 HOSPITAL INSURANCE + DIAGNOSTIC SERVICES ACT

• Public insurance provided for services offered in hospitals but not for nursing homes, mental institutions, sanatoria, etc.

• Costs of insurance shared - feds paid 25% per capita and 25% of total (National) cost

• Very popular, stopped barriers to access, defaulting on hospital bills, etc.

13

Shared Cost Arrangements …

• Raised physician incomes

• But - institutionalized care - made it hospital based, acute focussed

• 1962 - Saskatchewan - extends insurance to cover all physician services - doctors strike!

14

Shared Cost Arrangements …

• 1962-64 EMMETT HALL COMMISSION

• This commission on health services made two recommendations:

1. That government, in co-operation with the provinces, should introduce universal health care

2. Recommends universal health insurance criteria to be guided by 4 principles

15

• Universal health insurance criteria to be guided by 4 principles:

1. public administration2. comprehensiveness3. universal coverage4. portability5. accessibility (added in 1984)

• MEDICAL CARE ACT of 1966 • implemented between 1968-72 - set stage for

universal health care insurance

16

ESTABLISHED PROGRAMS FUNDING ACT (1977)

• Financing of health care reorganized - direct tax transfers rather than % capita reimbursement

• Funding too uncertain for provinces, too inflexible• Provinces reimbursed after payout - cash-flow

problems; unforeseen costs for provinces with rapid population change

• For Feds - arrangement too costly!• New formulas agreed to by Provinces and Feds• But - fears of erosion of underlying principles• USER FEES, EXTRA BILLING

17

TODAY?? Federal Withdrawal

• April 1990 - Bill C-69 - now law• Withdrawal of tax transfers from Feds for Health,

Welfare and Education• Size of current Ont. deficit largely due to shortfall in

transfer payments - all provinces hit hard by this• On the day the Feds announced cuts in transfer

payments, Clyde Wells (NFlD) announced closure of 200 hospital beds

• What is the future of public health insurance?

18

THE CANADIAN HEALTH ACT

• The Canada Health Act (CHA) is Canada's federal health insurance legislation.

• The provinces of Canada are constitutionally responsible for the administration and delivery of health care services.

• They decide where their hospitals will be located, how many physicians they will need, and how much money they will spend on their health care systems.

• The CHA establishes the criteria and conditions related to insured health care services

19

THE CANADIAN HEALTH ACT …

• The national standards—that the provinces and territories must meet in order to receive the full federal cash transfer contribution under the transfer mechanism, that is, the Canada Health and Social Transfer (CHST).

• The aim of the national health insurance program is to ensure that all residents of Canada have reasonable access to medically necessary insured services without direct charges.

20

THE CANADIAN HEALTH ACT …

Requirements of the Act

• The CHA contains nine requirements that the provinces and territories must meet in order to qualify for the full federal cash contributions:

• Five program criteria that apply only to insured health care services;

• Two conditions that apply to insured health care services and extended health care services; and

• Two extra-billing and user charges provisions that apply only to insured health care services.

21

CHA - THE CRITERIA

1. Public Administration

2. Comprehensiveness

3. Universality

4. Portability

5. Accessibility

22

Public Administration

• This criterion applies to the health insurance plans of the provinces and territories (not to hospitals or the services hospitals provide).

• The health care insurance plans are to be administered and operated on a non-profit basis by a public authority, responsible to the provincial/territorial governments and subject to audits of their accounts and financial transactions.

23

Comprehensiveness

• The health insurance plans of the provinces and territories must insure all insured health services (hospital, physician, surgical-dental) and, where permitted, services rendered by other health care practitioners.

24

Universality

• One hundred percent of the insured residents of a province or territory must be entitled to the insured health services provided by the plans on uniform terms and conditions.

• Provinces and territories generally require that residents register with the plans to establish entitlement.

25

Portability• Residents moving from one province or territory to

another must continue to be covered for insured health care services by the "home" province during any minimum waiting period, not to exceed three months, imposed by the new province of residence.

• After the waiting period, the new province or territory of residence assumes health care coverage.

• Residents temporarily absent from their home provinces or territories, or from the country, must also continue to be covered for insured health care services.

26

Accessibility

• The Canada Health Act of 1984 added accessibility to make five principles

• The health insurance plans of the provinces and territories must provide: reasonable access to insured health care services on uniform terms and conditions, unprecluded or unimpeded, either directly or indirectly, by:– charges (user charges or extra-billing)

– others (age, health status, SES.

27

Accessibility …

• Reasonable access in terms of physical availability of medically necessary services has been interpreted under the Canada Health Act using the "where and as available" rule.

• Thus, residents of a province or territory are entitled to have access to insured health care services at the setting "where" the services are provided and "as" the services are available in that setting;

• Reasonable compensation to physicians and dentists for all the insured health care services they provide, and payment to hospitals to cover the cost of insured health care services.

28

CHA – THE CONDITIONS

1. Information — the provincial and territorial governments are to provide information to the Minister of Health as may be reasonably required, in relation to insured health care services and extended health care services, for the purposes of the Canada Health Act.

2. Recognition — the provincial and territorial governments are to appropriately recognize the federal contributions toward both insured and extended health care services.

29

CHA - Extra-billing and User Charges

• The cost of the new plan were to be shared 50/50 by the federal and provincial governments

• They were also to be shared in a way that would serve to redistribute income between the proorer and richer provinces

30

CHA - Extra-billing and User Charges …

1. Extra-billing — this occurs if a physician or a dentist directly charges an insured person for an insured service that is in addition to the amount that would normally be paid for by the provincial or territorial health insurance plan.

• For example, if a physician were to charge patients five dollars for an office visit that is insured by a health insurance plan, the five-dollar charge would be extra-billing.

31

CHA - Extra-billing and User Charges …

2. User charges — these are direct charges to patients, other than extra-billing, for insured services of a province or territory's health insurance plan that are not payable, directly or indirectly, by the health insurance plan.

• .For example, if patients were charged a fee before being provided treatment at a hospital emergency department, the fee would be considered a user charge.