Canada’s Health Care System

1. Canada’s Health Care System

2. Canada’s Health Care System: Fact and Fiction Ernie Lightman Professor of Social Policy University of Toronto Faculty of Social Work

3. Outline • Two qualifications • A brief history of medical care in Canada • The details: How medicare works • The principles • What’s good? What’s bad? • An assessment • Future prognosis

4. Two caveats • Limits to international comparisons • Different cultures, value systems, priorities • E.g. Role of government • No model is perfect

5. Generic Social Policy Questionsrelevant to this presentation • What is the role of the state and that of individual responsibility? • Universality/selectivity • Cash/In-kind • Is health care different from other goods and services we buy in the marketplace? (posed by Richard Titmuss, 1954)

6. Some comparative data

7. Canada: Decentralized Federalism • Due to court interpretations and the politics of Quebec • Constitutional division of responsibilities • Social Union Framework Agreement (SUFA), 1999

8. A Brief History of Health Insurance • 1946: Hospital care in Saskatchewan • 1957: Federal 50/50 cost-sharing • 1961: All provinces participated in hospital care • 1962: Saskatchewan doctors’ strike • 1965: Federal 50/50 sharing for health/physician care • Post-1965: All provinces participated

9. 5 Key Principles (1957) • Introduced for hospital care; later formed the basis of health care coverage • Public administration • Comprehensive • Universal • Accessible • Portable

10. Canada Health Act (1984) • Reaffirmed the 5 principles of medicare; and also • Explicitly prohibited user fees/co-payments • Earlier legislation silent on the issue

11. How does it work?(Based on 5 Principles) • Coverage • All ‘insured persons’ • Permanent residents with legal status • No ‘pre-existing condition’ or other disqualification • All ‘medically necessary’ services, in hospital or delivered by a physician (usually) • Defined by provinces: can vary • No user fees/co-payments

12. Providers • Hospitals are almost all non-profit corporations, funded by provinces • Block funding by the province • Physicians usually private entrepreneurs, paid on a fee-for-service basis • In or out: No mixed models as in Europe, etc • No extra-billing • Single payer means fast, guaranteed payments • Few/no restrictions on professional autonomy

13. Role of the State • Single payer • Program is paid for through taxes (general revenues) plus in some provinces, premiums • High degree of coverage (95% of pop) • 70% of health costs covered by medicare • Vs 45% in US • Gaps are with drugs, dental, ambulance, long-term/community care

14. Private insurance • No private insurance permitted for medicare-covered services (“medically necessary”) • The “Buffalo” option exists • Industry exists at the fringes, covering other services (drugs, semi-private coverage, etc)

15. Overall program • Highly effective on coverage • Highly effective on meeting certain needs • Weak on others (which are not covered) • Weak on cost control and cost minimization • High power to medical profession • Emphasizes traditional medical model at expense of other approaches

16. What’s good? What’s bad? • A more detailed look at the program and its impact

17. Coverage: Good • 95% of population required • Pooling of risks • Excluded 5% include new arrivals (90-day waiting period), illegals, street people who lose cards • Formerly easy to get cards • Sarah Palin travelled to Canada • Now much harder to get coverage

18. Accessibility: Mostly Good • No financial barriers to ‘insured services’ • Often high barriers to uninsured services • Has led to a very traditional, medical model • People go to a psychiatrist (an MD) in preference to a psychologist or social worker (who cannot bill medicare) • Homeopathy, naturopathy, physio, dietician, chiropractors, Chinese medicine all excluded (except when ‘controlled’ by a physician)

19. Accessibility (cont’d) • Uninsured services can be costly • One estimate 65% have private insurance for drug coverage • Number seems high (to me) today • ‘catastrophic’ coverage out of lottery funds (Ontario) • May have to enter hospital to get coverage • Inadequate LTC/Home care leads to premature institutionalization

20. Access to health insurance by income quintile

21. Accessibility (cont’d) • Go on/stay on welfare to get eyeglasses, drugs, dental • Changes in definitions of ‘insured’ services over time • Cosmetic surgeries, sex changes, circumcision (‘bris’) • Restrict coverage to save money

22. Accessibility (cont’d) • Can be questions of timely access • Somebody decides who gets served first • Criteria can be financial or bureaucratic/need • Triaging exists in every system • For non-emergency services, we do wait longer than often in the US • Emergencies/crises are handled well

23. Comprehensiveness • What is ‘medically necessary’? • All services are rationed in every system • Sometimes by the market; sometimes by administrative procedures • There are bureaucratic procedures and budget issues to approve new hardware and procedures in Canada • There are no ‘death panels’

24. Comprehensiveness (cont’d) • Private insurance companies/for-profit hospitals/doctors use market criteria (profit) while bureaucracies use other, less clear criteria (intended to measure need) • Time lags (and cost constraints) with new, ‘cutting-edge’ technologies in Canada • These will be available at a private clinic in Houston before a public hospital in Toronto

25. One example • Shona Holmes (2005), Ontario • Went to Mayo Clinic for life-threatening brain cancer • 2007, sued Ontario • 2009, appeared in Republican Party ads • Facts: Her illness was not cancer, but Rathke’s cleft cyst • Not life-threatening; mortality rate is zero • Issue: How would this have been handled in the US?

26. Shona Holmes and friends

27. Satisfaction: High • 86.2% of Canadians surveyed supported or strongly supported "public solutions to make our public health care stronger.” (2009, Nanos Research) • 82% of Canadians preferred their healthcare system to the one in the US (2009 Harris/Decima) • 8% preferred a US-style system

28. Other polls show the same • Gallup (2003) • 25% of Americans either "very" or "somewhat" satisfied with "the availability of affordable healthcare in the nation," versus 50% of those in the UK and 57% of Canadians. • Those "very dissatisfied" made up 44% of Americans, 25% of respondents of Britons, and 17% of Canadians

29. Less differences at the individual level • Gallup (Sept 2009) • "Overall, 80% (of Americans) are satisfied with the quality of medical care available to them, including 39% who are very satisfied. • Sixty-one percent are satisfied with the cost of their medical care, including 20% who are very satisfied"

30. Effectiveness/Prevention • Good within constraints of the traditional medical model • Don’t need to wait until seriously ill to see a doctor • But: may lead to unnecessary use/abuse?? • Traditional medical model may limit use of other approaches, including prevention (diet, exercise, etc)

31. Efficiency • Single payer is extremely important • Rapid payment; no bad debts; no insurance companies • Little bureaucracy • Canada spends 10% of GDP on health care (public and private) versus 16% in US • As noted, single payer does limit ‘freedom’

32. Equity: Good • To the extent health outcomes depend on the delivery system, Canada has high equity • But health, of course, depends on far more variables, such as income and economic class • Social indicators • Results of my recent research on health outcomes

33. Canadian Community Health Survey (2006 data)

34. Diabetes

35. Bronchitis

37. Equity (cont’d) • Do not/cannot (usually) pay extra for preferred access to insured services • No ‘two-tiers’ of access • Cannot privately insure for ‘medically necessary’ services • Chaoulli case in Quebec • Class matters • Middle class are more articulate and demanding

38. Unnecessary services • Fewer financial incentives to do unnecessary procedures • The consequence of a more tightly rationed system • Not getting access to necessary procedures is the greater concern • Occasional problems of fraudulent billings by physicians

39. Two Tiers • Doctors cannot work both in the public and the private system • No way to bypass the public system by ‘going private’ as in Britain, other places • Limits ‘freedom’, with the choice being to go abroad • Cannot buy priority

40. Cost • In general, Canada spends about the OECD average on health care, less than the US • Rapid increase in health costs in recent years, but much of this in Drugs • Less growth in spending on hospitals and doctors

41. Total health spending ($1997)

42. Major health costsCanada 1975 and 1997

43. Controlling Cost • There are few effective controls on costs in either physician services or hospitals • Governments are aware and are experimenting, with limited success • Ont: Just announced hospitals will ‘compete’ as in the UK • Didn’t work there as hospitals did more ‘high valued added’ procedures, neglecting others

44. Cost (cont’d) • With doctors, fee-for-service is the problem • Experiment with other models (salary, capitation, group practices, attempts to reduce ‘doctor shopping’, etc) • Resistance from medical profession • Seems to be lessening with generational change

45. Rationing, Wait times, Queues • There is always rationing, triaging • Based on market principles or ‘need’ • We may wait for non-emergency services • Long waits do happen • In emergency cases, triaging works well • In a market model, pay extra for excess capacity • No waiting, but at high cost

46. Cutting Edge, innovation • A free market system innovates quickly in search of profits • Bureaucratic systems move more slowly • A wealthy society will also innovate quickly • Is speed of innovation determined by resources (wealth) or the delivery system??

47. Malpractice • Less litigation in Canada • But not necessarily less malpractice • Does the direct link between payment and service encourage litigation, while the indirect link in Canada discourages it? • Or are there national, cultural issues that make Americans litigious?

48. Future Concerns • Loss of political commitment in Ottawa • Culturally appropriate care in a multicultural milieu • Excluded groups, esp First Nations, Innuit • Controlling costs • Public-private partnerships • Other delivery models than fee-for-service • Chaoulli case and other court action • Aging of the population