Is Canadian Health Care a Model for the United States Gerard W. Boychuk, Ph.D. Author of National Health Insurance in

2. Is Canadian Health Care a Model for the US? the Canadian �model�? should Canadian health care be a model? could Canadian health care be a model?

3. Is Canadian Health Care a Model for the US? the Canadian �model�? should Canadian health care be a model? could Canadian health care be a model?

4. What is the Canadian model? Canada Health Act, 1984 (CHA) health care as predominantly provincial jurisdiction federal principles governing financial reimbursement for eligible health services by provincial health plans does not apply to means of provision of services (which may be provided by for-profit providers) physicians -- primarily private, for-profit practice on a fee-for-service basis hospitals -- primarily private not-for-profits (e.g. not publicly-owned) on a global-funding basis increasingly, private for-profit facilities offering surgical and diagnostic services on a fee-for-service basis arguably a single-payer system � not a single-provider system

5. What is the Canadian model? universal availability of publicly-administered health insurance (on uniform terms and conditions) for access to all medically necessary hospital and physician services

6. What is the Canadian model? universal availability of publicly-administered health insurance (on uniform terms and conditions) for access to all medically necessary hospital and physician services

7. What is the Canadian model? universal availability of publicly-administered health insurance (on uniform terms and conditions) for access to all medically necessary hospital and physician services single-public-payer (not exclusive-public payer system)

8. What is the Canadian model? universal availability of publicly-administered health insurance (on uniform terms and conditions) for access to all medically necessary hospital and physician services single-public-payer public plan may charge premiums (various provinces)

9. What is the Canadian model? universal availability of publicly-administered health insurance (on uniform terms and conditions) for access to all medically necessary hospital and physician services single-public-payer public plan may charge premiums (various provinces) on uniform terms and conditions

10. What is the Canadian model? universal availability of publicly-administered health insurance (on uniform terms and conditions) for access to all medically necessary hospital and physician services single-public-payer public plan may charge premiums (various provinces) on uniform terms and conditions mandatory community-rating -- cannot be experience-rated

11. What is the Canadian model? universal availability of publicly-administered health insurance (on uniform terms and conditions) for access to all medically necessary hospital and physician services

12. What is the Canadian model? universal availability of publicly-administered health insurance (on uniform terms and conditions) for access to all medically necessary hospital and physician services no mandate that individuals carry public insurance coverage

13. What is the Canadian model? universal availability of publicly-administered health insurance (on uniform terms and conditions) for access to all medically necessary hospital and physician services no mandate that individuals carry public insurance coverage individuals allowed to opt out of public coverage (various provinces)

14. What is the Canadian model? universal availability of publicly-administered health insurance (on uniform terms and conditions) for access to all medically necessary hospital and physician services no mandate that individuals carry public insurance coverage individuals allowed to opt out of public coverage (various provinces) cannot subsidize private coverage

15. What is the Canadian model? universal availability of publicly-administered health insurance (on uniform terms and conditions) for access to all medically necessary hospital and physician services no mandate that individuals carry public insurance coverage individuals allowed to opt out of public coverage (various provinces) cannot directly subsidize private coverage eligibility for coverage cannot be categorical or income-tested

16. What is the Canadian model? universal availability of publicly-administered health insurance (on uniform terms and conditions) for access to all medically necessary hospital and physician services

17. What is the Canadian model? universal availability of publicly-administered health insurance (on uniform terms and conditions) for access to all medically necessary hospital and physician services financial barriers at point of access must not �impede or preclude�reasonable access� to insured services places limits on allowable extent of user fees (co-payments) and extra-billing (balance billing)

18. What is the Canadian model? universal availability of publicly-administered health insurance (on uniform terms and conditions) for access to all medically necessary hospital and physician services financial barriers at point of access must not �impede or preclude�reasonable access� to insured services limited required coverage of services within province

19. What is the Canadian model? universal availability of publicly-administered health insurance (on uniform terms and conditions) for access to all medically necessary hospital and physician services financial barriers at point of access must not �impede or preclude�reasonable access� to insured services limited required coverage of services within province �narrow but deep� -- e.g. not comprehensive not covered: pharmaceuticals home care long-term care dental care

20. What is the Canadian model? regulation of private purchase of health services and private health insurance? limits on how public payment can be combined with private payment for privately-purchased health services payment from public plan must be accepted by provider as payment in full if services are to be billed directly to the public plan (or province faces federal penalties) physicians can opt-out of public plan � e.g. forfeit ability to bill public plan directly bill patients at rates above provincial fee schedule patient reimbursed from public plan up to provincial rate schedule patient allowed to carry third-party, private insurance for the difference

21. What is the Canadian model? does not preclude competition between publicly and privately funded services or competition between public and private insurance

22. What is the Canadian model? does not preclude competition between publicly and privately funded services or competition between public and private insurance does not mandate a single-payer system allows for a single-payer dominant system

23. What is the Canadian model? does not preclude competition between publicly and privately funded services or competition between public and private insurance does not mandate a single-payer system allows for a single-payer dominant system sets the terms of competition different degrees of tax-funded subsidization of public insurance versus private payment/private insurance

24. What is the Canadian model? does not preclude competition between publicly and privately funded services or competition between public and private insurance does not mandate a single-payer system allows for a single-payer dominant system sets the terms of competition different degrees of tax-funded subsidization of public insurance versus private payment/private insurance public insurance insulated from adverse selection individuals may opt out of provincial insurance premiums/coverage cannot opt out of provincial taxes!

25. Is Canadian Health Care a Model for the US? the Canadian �model�? should Canadian health care be a model? could Canadian health care be a model?

26. Is Canadian Health Care a Model for the US? the Canadian �model�? should Canadian health care be a model? could Canadian health care be a model?

27. Should Canadian Healthcare be a Model for the US? performance objective criteria optimizing among competing goals quality (e.g. physician perceptions) access (e.g. unmet health care needs) effectiveness (e.g. survival rates, avoidable events) cost and cost control (over time)

28. Total Health Expenditures, % of GDP, Canada, 1992-2008

29. Should Canadian Healthcare be a Model for the US? performance objective criteria optimizing among competing goals quality (e.g. physician perceptions) access (e.g. unmet health care needs) effectiveness (e.g. survival rates, avoidable events) cost and cost control (over time)

30. Should Canadian Healthcare be a Model for the US? performance objective criteria subjective (public) perceptions quality and general satisfaction caveats insurance status �sicker adults� indirect evidence of public perceptions fundamental reform of the Canadian health funding system is not on the political agenda

31. Should Canadian Healthcare be a Model for the US? performance objective criteria subjective (public) perceptions

32. Should Canadian Healthcare be a Model for the US? performance objective criteria subjective (public) perceptions similar problems

33. Should Canadian Healthcare be a Model for the US? performance objective criteria subjective (public) perceptions similar problems esp. fee for service vs. capitation cost-shifting

34. Should Canadian Healthcare be a Model for the US? performance normative implications of different models

35. Is Canadian Health Care a Model for the US? the Canadian �model�? should Canadian health care be a model? could Canadian health care be a model?

36. Is Canadian Health Care a Model for the US? the Canadian �model�? should Canadian health care be a model? could Canadian health care be a model?

37. �Now�tell me something interesting, David.� Hillary Rodham Clinton to David Himmelstein, 1993

38. Is Canadian Health Care a Model for the US? the Canadian �model�? should Canadian health care be a model? could Canadian health care be a model? feasibility of reforms that would move the US system closer toward the �Canadian model� in the long-term

39. Political Feasibility of the Canadian Model inception of health care in Canada occurred in political culture and institutional context no more favourable to public insurance than US displaced existing private benefits which paved the way for public benefits

40. Political Feasibility of the Canadian Model inception of health care in Canada occurred in political culture and institutional context no more favourable to public insurance than US displaced existing private benefits positive feedback -- created its own self-sustaining dynamic

41. Political Feasibility of the Canadian Model inception of health care in Canada occurred in political culture and institutional context no more favorable to public insurance than US displaced existing private benefits positive feedback -- created its own self-sustaining dynamic public predisposition toward/against public insurance is not immutable

42. Political Feasibility of the Canadian Model inception of health care in Canada occurred in political culture and institutional context no more favorable to public insurance than US displaced existing private benefits positive feedback -- created its own self-sustaining dynamic public predisposition toward/against public insurance is not immutable impressive resilience of the public insurance element of the Canadian system

43. Public Expenditures as Proportion of Total Health Expenditures, Canada, 1996-2008

44. Political Feasibility of the Canadian Model inception of health care in Canada occurred in political culture and institutional context no more favorable to public insurance than US displaced existing private benefits positive feedback -- created its own self-sustaining dynamic public predisposition toward/against public insurance is not immutable impressive resilience of the public insurance element of the Canadian system

45. Political Feasibility of the Canadian Model inception of health care in Canada occurred in political culture and institutional context no more favourable to public insurance than US displaced existing private benefits positive feedback -- created its own self-sustaining dynamic length of time for system implementation

46. Political Feasibility of the Canadian Model inception of health care in Canada occurred in political culture and institutional context no more favourable to public insurance than US displaced existing private benefits positive feedback -- created its own self-sustaining dynamic length of time for system implementation comprehensive universal public health insurance proposed in 1942 national hospital insurance � 1958 national physician care insurance � 1968-1971 CHA � 1984 (effective 1987) system remains incomplete by standards of 1945 blueprint

47. Political Feasibility of the Canadian Model inception of health care in Canada occurred in political culture and institutional context no more favourable to public insurance than US displaced existing private benefits positive feedback -- created its own self-sustaining dynamic length of time for system implementation

49. Health Care and Hockey proposing universal public health insurance in US is tantamount to ��selling the US a product that is about as American as hockey.� (Birch, 1993) National Hockey League new NHL franchises since 1993 US +6 Canada -2 US (2008) 24/30 NHL franchises Stanley Cup winning franchises 1978-1992 Canadian 9/15 US 6/15 1993-2008 Canadian 0/14 US 14/14

52. Political Feasibility of the Canadian Model politics of health care in the US gaining perspective on resistance reform period 1945-1965

54. Is Canadian Health Care a Model for the US? the Canadian �model�? should Canadian health care be a model? health care performance in Canada and the US could Canadian health care be a model? feasibility of the �Canadian model�

55. Is Canadian Health Care a Model for the US? the Canadian �model�? should Canadian health care be a model? health care performance in Canada and the US could Canadian health care be a model? feasibility of the �Canadian model�

56. What is the Canadian model? regulation of private purchase/provision of health services and private health insurance? private purchase of health services by individuals allowed (various provinces) physicians allowed to opt out of public plan and provide services privately except Ontario since 2004 private third-party insurance for health services allowed even for services that are otherwise publicly-insured (various provinces)

58. Political Feasibility of the Canadian Model inception of health care in Canada occurred in political culture and institutional context no more favourable to public insurance than US displaced existing private benefits positive feedback -- created its own self-sustaining dynamic length of time for system implementation driven by powerful dynamics related to the politics of territorial integration