THE CANADIAN HEALTH CARE SYSTEM: OVERVIEW

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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?

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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

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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
• 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
• Intrusion of medical industry into range of
  problems previously considered outside its
  competence
• 6. Fiscal crisis

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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)
• Established Program Areas Acts (1977)
• 4. Federal withdrawal (1990 - ?)

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Benign Neglect

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

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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.

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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.

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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

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• 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

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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.

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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.

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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!

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Shared Cost Arrangements

• 1962-64 EMMETT HALL COMMISSION
• This commission on health services made two
  recommendations
• 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

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• Universal health insurance criteria to be guided
  by 4 principles
• 1. public administration
• 2. comprehensiveness
• 3. universal coverage
• 4. portability
• accessibility (added in 1984)
• MEDICAL CARE ACT of 1966
• implemented between 1968-72 - set stage for
  universal health care insurance

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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

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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?

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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

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THE CANADIAN HEALTH ACT

• The national standardsthat 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.

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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.

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CHA - THE CRITERIA

• Public Administration
• Comprehensiveness
• Universality
• 4. Portability
• 5. Accessibility

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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

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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.

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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.