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National Health Policy

National Health Policy. Ervin B. Podgorsak McGill University Montreal, Quebec, Canada. North America Canada USA Mexico Canada Federal parliamentary monarchy Federation of 10 provinces 3 territories USA Federal presidential republic Federation of 50 states. North America

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National Health Policy

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  1. National Health Policy Ervin B. Podgorsak McGill University Montreal, Quebec, Canada

  2. North America • Canada • USA • Mexico • Canada • Federal parliamentary monarchy • Federationof • 10 provinces • 3 territories • USA • Federal presidential republic • Federationof • 50 states

  3. North America • Canada • USA • Mexico • Tenets of Constitution • USA • Life • Liberty • Pursuit of happiness • Canada • Peace • Order • Good government

  4. North America (2003) U.S.CanadaU.S./Canada Population (million)288329 : 1 GNP (billion $ US) 10 450 728 14.4 : 1 (1 : 0.07) GNP per capita ($ US) 34 320 27 130 1.3 : 1 (1 : 0.77) SOURCE: HDR 2003

  5. UNITED STATESvs.CANADA • Similar political systems • Similar economic and social systems • One another’s best trading partner • Differences between the two countries: • - World view • - Foreign policy • - Gun control • - Organization and financing of health care

  6. Canada versus the United States Canadians see themselves as part of the world. Americans see themselves as part of the United States.

  7. Health Care • The most important characteristics • of a health care system are: • Quality • Cost • Access

  8. MODELS FOR HEALTH CARE FINANCING • Nationalized public single-payer not-for-profit • Privatized multi-payer for-profit • Combination of public and private

  9. Health Care in North America: (2003) Shares of total health expenditures • Public (%) Private (%) • Canada71 29 • United States44 56 • OECD average72 28 • SOURCE: OECD

  10. THE GREAT AMERICANHEALTH CARE DEBATE • Americans are aware that their health care • system is expensive, overly bureaucratic, • inequitable, and socially unjust. • Americans agree in principle that all residents • of the U.S. should have access to high quality • health care regardless of their ability to pay; • however, there is not enough political will • to reform the system.

  11. THE GREAT AMERICANHEALTH CARE DEBATE • Despite numerous attempts by various presidents during the past 2 decades to reform the U.S. health care system, the reform of the system is as elusive as ever. • Despite having by far the most expensive health care system in the world, in ranking on health care indicators the U.S. achieves only a mediocre place among the 30 OECD countries.

  12. THE GREAT CANADIAN HEALTH CARE DEBATE • Canadians are both proud of, and unhappy • with, their health care system. • During the 1980s and 1990s the debate • concentrated on perceived excessive costs. • During the past 5 years the debate shifted to • a much more ominous symptom: • the problems with access to diagnostic • and therapeutic services.

  13. THE GREAT CANADIAN HEALTH CARE DEBATE • Canadians generally agree that their health • care system needs reform. • There is no agreement on how to solve • the current problems. • Proposed solutions range from pumping • much more public money into the system • to an outright privatization.

  14. Health Care in North America (2004) • • Main issue in Canada: • How to best ensure the universal and timely access to the public health care system in an era of severe fiscal restraint by governments. • • Main issue in the United States: • How to use government intervention to make the current health care system universally accessible and more cost- effective.

  15. Health Care in North America • During 1970s and 1980s Americans have paid considerable attention to the structure and history of the Canadian health care system with its: • • universal coverage • • lower cost • • high standards • • public administration • • clinical autonomy of physicians • During 1990s health care reforms in the United States failed and, concurrently, the Canadian health care system run into serious financial trouble.

  16. HEALTH CARE in CANADA in 2004 The main concern of the Canadian Governments is the “high” cost of health care. The main concern of the Canadian public is access to health care.

  17. CANADIAN HEALTH CARE SYSTEM • The Canadian health care is financed publicly and has three primary players: • Provincial governments: Under the Canadian Constitution health care is the jurisdiction of provincial governments who manage, deliver and plan health care services. • Federal government: Sets and enforces national health care standards through the Canada Health Act and assists the provinces in health care system financing through the transfer of tax revenue to the provinces. • Private physicians: paid on a fee-for-service basis by provincial governments to deliver publicly-funded health services. The fees are negotiated between the provincial goverments and physician associations.

  18. Health Care in Canada (2004) • •Difficulties with financing • • Decline in public support • • Shortages of staff and equipment • • Low morale among health care workers • • Increased tension between federal government and provinces • • Restricted access to specialists • • Waiting times for diagnostic procedures • • Waiting times for non-emergency surgery and cancer therapy

  19. Health Care System in Canada • IN PRINCIPLE: • The single payer, publicly-administered health care system: • • provides universal access to health care for all citizens • • is less expensive and more efficient than the private health care system • - because of its lower administrative costs • - because governments can set global budgets for hospitals and negotiate fees with physicians

  20. Health Care in North America • • Canada • - Health care is publicly administered. • - All residents enjoy universal access to hospital care and physicians’ services without any cost-sharing requirements. • • United States • - Health care financing is based on profit-driven private insurance plans and health maintenance organizations (HMOs). • - Publicly financed are Medicare and Medicaid, covering 40% of the population for hospital insurance and 25% of population • for medical coverage. • - An estimated 44 million Americans are not insured.

  21. Milestones: Health Care in the United States • 1935 Social Security Act (does not include health insurance) • 1939, 1943, Attempts to introduce a national health insurance • late 1940s plan were defeated by the Congress • Early 1960s President Kennedy’s attempts were unsuccessful • 1964 Medicare and Medicaid programs pass

  22. Milestones: Health Care in the United States • 1973 Health Maintenance Organization (HMO) Act • encourages development of prepaid group plans to restrain providers and centralize health care delivery. • 1982 to control Medicare costs the government introduces a fee schedule based on Diagnostic Related Groups (DRGs) and beneficiaries were encouraged to use Preferred Provider Organizations. • 1992 President Bush proposed a tax credit and health insurance voucher program. • 1993 President Clinton’s Health Security Plan which would ensure health coverage for all Americans and control costs through managed competition is defeated.

  23. Milestones:Health Care in Canada • 1957 Hospital Insurance and Diagnostic Services Act • universal hospital insurance plan • • administered by provinces • • financed jointly by the provinces and the federal government on a 50:50 basis

  24. Milestones:Health Care in Canada • 1966 Medical Care Insurance Act • universal health care plan providing coverage of: • hospital care, diagnostic services, and physicians’ fees • • Administered by provinces. • • Financed by provinces and the federal government on a 50:50 basis. • • Patients have free choice of hospitals and physicians. • • Hospitals are paid through the imposition of annual global budgets. • • Physicians are reimbursed for their services according to negotiated fee schedules.

  25. Milestones:Health Care in Canada • 1977 Established Programs Financing Act • • Replaced cost sharing with block grants that were tied to the GNP growth and transferred federal tax points to the provinces to raise additional revenues. • •Federal government abandons the 50:50 cost sharing formula and its share of total health care expenditures declines from 50% in 1977 to 15% in 2002: • 1977 (50%); 1980 (45%); 1990 (37%); 1997 (23%); • 2002 (15%)

  26. Milestones:Health Care in Canada • 1984 Canada Health Act • • amalgamated hospital and medical insurance into one statute • • banned extra-billing by physicians • • banned user fees for insured health services • • proscribed five health act principles: • - universal coverage • - equal access to health care • - comprehensive benefits • - portability across provinces • - public administration

  27. CANADA HEALTH ACT (CHA) • The CHA sets the Canadian national health care standards and ensures that all Canadian residents have access to necessary health services regardless of their ability to pay. • Provincial insurance plans must meet CHA standards to qualify for full federal health contributions.

  28. CANADA HEALTH ACT (CHA) • CHA stipulates the following five criteria: (1) Public administration (2) Comprehensiveness (3) Universality (4) Portability (5) Accessibility

  29. “It is no longer acceptable morally, ethically, or economically for so many of our people to be uninsured or seriously under-insured”. JAMA 1991 15 years later, not much has changed.

  30. Human Development Index (HDI) • • Serves as an alternative measure of social development, supplementing GNP • • Accounts for three distinct indicators: • - longevity and health care • - adult literacy rate and education • - GNP per capita (real and PPP adjusted)

  31. Human Development Index (HDI) • Indicators • - Life expectancy at birth (health care) • - Education: • literacy of adults (2/3) • attendance at 3 levels of schooling (1/3) • - Income • • Goals • - Life expectancy : 85 years • - Education accessible for all • - Reasonable income for all

  32. Human Development Index (HDI) Ranking of 175 countries • 1995 1997 1999 2001 2003 • Canada1 1 2 3 8 • USA2 3 5 6 7

  33. Human Development Index (HDI): 2003 • 1. Norway 6. Belgium • 2. Iceland 7. United States • 3. Sweden 8. Canada • 4. Australia 9. Japan • 5. Netherlands 10. Switzerland

  34. HEALTH CARE COSTS as percentage of GDP USA CANADA % GNP

  35. Health Care Expenditures (2002) • Per capita ($ US) Percentage of GNP • United States 4887 13.9 • Germany 2808 10.7 • Canada 2792 9.7 • Japan 2009 8.0 • United Kingdom 1992 7.6 • OECD average 2117 8.4 • Source: OECD 2004

  36. Health Care Expenditures as percentage of GNP • 1960 1975 1990 1993 1998 2001 • Canada 5.4 7.2 9.2 9.9 9.1 9.7 • United States5.2 8.4 12.6 13.3 13.0 13.9 • Japan 3.0 5.6 6.1 6.6 7.1 8.0 • U.K. 3.9 5.5 6.0 6.9 6.9 7.6 • Germany 4.8 8.1 8.7 10.0 10.6 10.7 • source: OECD 2004

  37. Health Care Indicators • Accessibility • Per capita spending on health care • Percentage of GNP spent for health care • Life expectancy • Infant mortality rate • Maternal mortality rate • Waiting lists for diagnostic and therapeutic procedures • Access to high technology equipment

  38. Life expectancy at birth (years) • Japan 81.3 • Sweden 79.7 • Canada 79.2 • United Kingdom 77.4 • United States 76.9 • China 71 • India 64 • Range: 34 to 81.3SOURCE: HDR (2003)

  39. Life expectancy at birth (years) • Cigarettes % of • per adult population • per year daily smokers • Japan 81.3 2950 31 • Sweden 79.7 1085 19 • Canada 79.2 1820 18 • United Kingdom 77.4 1553 27 • United States 76.9 2092 19 • China 71 1780 • India 64 112 • Range: 34 to 81.3SOURCE:HDR (2003)

  40. United States Canada

  41. Infant mortality (per 1000 live births) • •Japan 3.1 • • Sweden 3.4 • • Canada 5.3 • • United Kingdom 5.6 • • United States 6.9 • Range: 3.1 to 182SOURCE: OECD (2003)

  42. Maternal mortality (per 100 000 live births) • • Sweden 5 • • Canada 6 • United Kingdom 7 • • United States 8 • (whites: 6, hispanics: 10, African Americans: 25) • Japan 8 • Range: 5 to 1800 SOURCE: HDR 2003

  43. United States vs. Canada • HDI indicators U.S. Canada OECD • Life expectancy 78.6 79.4 74.3 • (years) • Infant mortality 6.9 5.3 6.6 • (per 1000 live births) • Maternal mortality 8 6 • (per 100 000 live births) • Population over 65 years 12.4 12.7 13.9

  44. Health Care in North America (2002):Physicians and Nurses • United StatesCanada • Physicians • number 690 000 60 900 • number per 1000 population 2.7 2.1 • population per physician 370 476 • Nurses • number 2 300 000 231 500 • number per 100 000 population 8.1 9.9 • population per nurse 123 101

  45. Physicians per 1000 population • • U.K. 1.6 (1 per 610) • • Canada 2.1 (1 per 476) • Japan 2.0 (1 per 508) • • United States 2.7 (1 per 370) • • Italy 5.7 (1 per 176) • Range: 1 - 5.9 (world average: 1.2)SOURCE: WHO and OECD

  46. Medical Schools • Accredited by the Liaison Committee on Medical Education (LCME) • United States : 125 • Canada : 16

  47. Health Care in Canada:Physicians (2002) • Total number : 60 900 • Family physicians : 31 500 • Specialists : 29 400 • Estimated needs: • 2500 per year to compensate • for retirement (2100) and emigration (400 per year) • Actual increase: • 1750 per year (Canadian graduates and immigrants) • Source: Southam Medical Database

  48. Health Care in Canada:Cost containment during 1990s • Policy of restricting supply: • • Reduction in number of students enrolled in Canada’s medical and nursing schools. • •Tight restrictions on the purchase of high technology medical equipment through a centralized approval process. • • Closing or merger of hospitals resulting in decrease in number of hospital beds.

  49. Health Care in Canada:Results of Cost Containment • • Education • - First year medical students (16 medical schools) • 1983 (1887) 1998 (1581) • - Nursing school students • 1993 (12 621) 1997 (5063) • • High technology equipment • Of the 30 OECD countries, Canada is in the bottom third. • • Hospitals • 1991 (1128 hospitals - 175 000 acute care beds) • 1998 (877 hospitals - 122 000 acute care beds)

  50. United States (2300) United States: 8.1 Canada: 2.5 OECD average: 6.5 Canada (80) Number of MRI units per million population

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