A Sustainable Health System: What can be learnt from Canada?

1. A Sustainable Health System: What can be learnt from Canada? Alan Shiell Professor and AHFMR Senior Health Scholar Markin Institute University of Calgary Institute of Public Policy Research Symposium Great Expectations: Towards a Sustainable Health System April 10 2006

2. Will George Zeliotis’s painful hip be the end of Medicare?

4. IS MEDICARE SUSTAINABLE? Canada’s publicly funded health care system, as it is currently organized and operated, is not fiscally sustainable given current funding levels (Kirby, 2002) Medicare … is as sustainable as Canadians want it to be (Romanow, 2002)

6. TODAY • What do we mean by sustainability? • What is the basis for claims that the system is or is not sustainable? • Sustainability is a choice that we can make. The greatest threat to the Medicare system is political reluctance to face up to that choice

7. ON SUSTAINABILITY What is to be sustained? • The elements of Medicare • The essence of Medicare What is meant by sustainability? • Affordability - Economic • Acceptability - Political

8. THE POLITICAL ECONOMY OF SUSTAINABILITY The debate over health care … is less a pure macroeconomic issue than an exercise in the political economy of sharing (Rheinhardt et al., 2004) It is about differing views on the correctness of who pays, how much and for what benefit

9. THE CANADIAN HEALTH CARE SYSTEM • Not one, but 13 provincial single-payer systems • Federal – Provincial cost sharing governed by the Canada Health Act The Five Pillars of Medicare • Comprehensiveness ( all “medically necessary” services) • Universality • Public administration • Portability • Accessibility

10. THE CANADIAN HEALTH CARE SYSTEM Funding: • Predominantly income tax • Some social insurance (Alberta, BC, Ontario) • Private insurance • Direct out of pocket payments CHA effectively prohibits extra billing and user fees Provincial laws effectively ban parallel private health care

11. THE CASE AGAINST ECONOMIC SUSTAINABILITY TOTAL HEALTH SPENDING (per capita) CIHI, 2006

13. THE CASE FOR ECONOMIC SUSTAINABILITY TOTAL HEALTH SPENDING: % GDP (CIHI, 2006)

14. THE CASE FOR ECONOMIC SUSTAINABILITY TOTAL HEALTH SPENDING: % GDP (CIHI, 2006)

15. A SLIGHT COMPLICATION … RISING SHARE OF GDP SOURCE: CIHI Health Expenditure Trends, 2006

17. WHERE WE’RE AT • Medicare is economically sustainable • Is it politically acceptable? • Political wolves knocking at the door (Evans) • The challenge from within

18. CHANGING HEALTH TECHNOLOGY AND CREEPING PRIVATISATION SOURCE: CIHI Health Expenditure Trends, 2006

19. PROBLEMS ACCESSING SERVICES Source: Commonwealth Fund, International Health Policy Survey, 2001

20. ACCESS PROBLEMS DUE TO COST1,2 (1) Among adults with a health problem (2) Source: Commonwealth Fund, International Health Policy Survey, 2001

21. Did not get a recommended test or treatment due to its cost – by income Source: Commonwealth Fund, International Health Policy Survey, 2001

22. THE REAL CHALLENGE: CHASING AN INCONSISTENT TRIAD • Comprehensive coverage • Universal and equal access free at point of care • High quality (timely, responsive, effective) care • Constrained by our willingness to pay SOURCE: Weale, BMJ 1998

23. THE CHALLENGE WITHIN • Changing health technology is leading to ‘creeping privatisation’, which is undermining comprehensiveness • Problems with access are experienced more by lower SES, which is contrary to universality • Political failure to address these will undermine support for Medicare and its long term political sustainability

25. Respondents who believe their health care system should be completely rebuilt SOURCE: Commonwealth Fund, International Health Policy Survey 2001

26. Equity and Physician Visits: Probability of Consultation Source: van Doorslaer et al, CMAJ, 2006

27. FUNDING SOURCE AND WHO RANKING

28. SATISFACTION WITH HEALTH CARE SYSTEM