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A SINGLE PAYER, UNIVERSAL HEALTH SYSTEM

A SINGLE PAYER, UNIVERSAL HEALTH SYSTEM. The Canadian Model in light of new U.S. Proposals Gregory P. Marchildon Pierre-Gerlier Forest Woodrow Wilson International Center for Scholars Washington, DC, September 23, 2003. THE CANADIAN MODEL. Does one exist?

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A SINGLE PAYER, UNIVERSAL HEALTH SYSTEM

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  1. A SINGLE PAYER, UNIVERSAL HEALTH SYSTEM The Canadian Model in light of new U.S. Proposals Gregory P. Marchildon Pierre-Gerlier Forest Woodrow Wilson International Center for Scholars Washington, DC, September 23, 2003

  2. THE CANADIAN MODEL • Does one exist? • If so, can we describe its unique and/or essential components? • How much of Canadian health care actually within the model? • How did we end up with this particular model?

  3. EXISTENCE OF MODEL? • Goes beyond having unique system of public health care (after all, every OECD country does!) • Having aspects that are of sufficient interest to others • Canada recognized by others as having a model worth examining and (in some cases) emulating

  4. MODEL: COMPARISON OF OUTCOMES AND SERVICE • Generally good health outcomes • Public and Population Health • Nature of Health Services • Services provided • Training of providers • Expectations of patients

  5. FOUR ESSENTIAL COMPONENTS OF MODEL • Hospital care • Primary physician care • Provincial-federal tax-financed system • Provincial control and administration, private and mixed delivery, and federal principles

  6. HOSPITAL CARE • Hospitalization introduced in SK in 1947 • HIDSA (1957) and national implementation (1958-61) • Universal access without user fee • Public and NFP delivery unaffected • Hospital Construction = more beds

  7. PRIMARY PHYSICIAN CARE • 1962: Saskatoon Compromise • Guarantee of provincial autonomy • Basket of services and remuneration: medical associations and provincial governments • MCA of 1966 and implementation on national basis (1968-72) • Universal access with limited (but eventually no) user fees • Private FFS delivery within provincial plans and federal principles

  8. F/P TAX FINANCED SYSTEM • Versus social insurance and co-pays • Tax revenues (GRF) of both orders of government • Complex history of F/P funding arrangements: a) shared-cost; b) EPF cash/tax; c) CHST block • Progressive financing depends on tax sources and incidence

  9. FEDERAL PRINCIPLES AND FRAMEWORK FOR SYSTEM • Nature of HIDSA and bilateral agreements • Broad principles of MCA • Severing of funding from policy objectives (EPF) • The Canada Health Act (CHA), 1984 • Long-term decline in federal funding • Sept. 2000 Agreement and Feb. 2003 Accord

  10. PROVINCIAL CONTROL AND ADMINISTRATION • Constitutional authority and responsibility primarily provincial • Developed provincially since 1945 • Innovation and variation across provinces • Provincial Studies, Reports, and Current Initiatives

  11. PUBLIC, PRIVATE AND MIXED DELIVERY • Predominantly non-governmental • Historic evolution of hospitals • Physician “Entrepreneurs” • Emergence of RHAs • Big business (PFP & NFP) largely absent from acute & primary care

  12. CHARACTERISTICS OF CANADIAN MODEL • Narrow but deep coverage (complete coverage for 42% of all health services • Parallel private tier prohibited or discouraged (private insurance for CHA-covered services) • But enormous variation in funding, administration and delivery of non-insured services including prescription drugs, vision care, dental care, etc.

  13. WHAT HEALTH SPENDING INCLUDED IN MODEL • Traditional hospital services and primary care services: 42.4% • Provincial plans provide non-CHA services beyond this: 25.2% • Private health services: 27.4% • Add in another 5% for direct federal services

  14. CURRENT CHALLENGES TO CANADIAN MODEL • Universal versus targeted access (cost) • Single-payer administrative system (competition) • Prohibition on user fees for CHA services (incentive effects) • Legislated single-tier • Declining tolerance for variation within Canada and with US: quality, access, and equity

  15. GENERAL CHALLENGES TO CANADIAN HEALTH CARE • Timely access (waiting lists) • Quality services and evidence-based practice • Movement away from hospital care • Nature and quality of primary care • Drug therapies: appropriateness and cost • Providers: number, morale, etc. • Patient involvement v. citizen engagement?

  16. CHALLENGES re: CANADIAN AND U.S. MODELS • Governance • Finance • Coverage/ethics • Outcomes

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