Gerard. W. Boychuk

1. History, Institutions, and Health Insurance:The Development of Public Health Insurance in the United States & Canada Gerard. W. Boychuk Presented to the McMaster/Guelph Public Policy and Administration Program, February 2004

2. National Stereotypes – Canada and the United States • “Canada...is a more...statist, collectivity-oriented... society than the United States.” S.M. Lipset, Continental Divide • “The differences between the two countries are particularly striking with respect to the role of government in medical care.” S.M. Lipset, Continental Divide

3. Overview • differences in public policy regarding health insurance in the US and Canada • theories of public policy – generating hypotheses • theories of public policy – empirical results • alternative explanations • conclusion

4. Overview • differences in public policy regarding health insurance in the US and Canada • theories of public policy – generating hypotheses • theories of public policy – empirical results • alternative explanations • conclusion

5. Differences – Public Policy & Health Insurance in the US & Canada • Public health insurance in Canada covers ½ of all health-related expenditures • covers hospital and physician care but not prescription drugs or long-term care (among other things) • Universal public health insurance (Medicare) in the US • for those over 65 (deductibles, premiums and co-payments) • expenditures on health services for those over 65 covers about ½ of all health-related expenditures in the US

6. Differences – Public Policy & Health Insurance in the US & Canada • Third-party provision of insurance for publicly-insured services is effectively prohibited in Canada. • Public expenditures on health insurance in American states are comparable to (and in some cases, higher than) public expenditures in Canadian provinces. • Medicare and Medicaid

8. Differences – Public Policy & Health Insurance in the US & Canada • US health insurance -- coverage and public regulation • state regulation of private insurance • guaranteed issue legislation • pre-existing condition legislation • community-rating legislation • guaranteed renewal legislation • mandatory loss ratio • varies widely by state

10. Differences – Public Policy & Health Insurance in the US & Canada • Provision of Health Services • both systems based primarily on private, for-profit physician practice • both systems rely primarily on not-for profit (or government-owned) hospitals • varies by state • emergency care/non-compensated care

12. Differences – Public Policy & Health Insurance in the US & Canada • public health insurance is universal in Canada and categorical in the US • public health insurance in Canada is compulsory • private provision of insurance for publicly-insured health services is prohibited in Canada but not in the US • main differences are in funding (single-public-payer in Canada, and multiple-payer in the US) not in modes of delivery

13. Overview • differences in public policy regarding health insurance in the US and Canada • theories of public policy – generating hypotheses • theories of public policy – empirical results • alternative explanations • conclusion

31. Overview • differences in public policy regarding health insurance in the US and Canada • theories of public policy – generating hypotheses • theories of public policy – empirical results • alternative explanations • conclusion

47. “I don’t see anything socialistic about that [compulsory health insurance.] It’s absolutely necessary, and I’m going to fight for it until I die.”

48. “I don’t see anything socialistic about that [compulsory health insurance.] It’s absolutely necessary, and I’m going to fight for it until I die.” Harry S. Truman, 1959

49. “I don’t see anything socialistic about that [compulsory health insurance.] It’s absolutely necessary, and I’m going to fight for it until I die.” Harry S. Truman, 1959 • “You know, Mr. Frost doesn’t like hospital insurance either.” Prime Minister Louis St. Laurent 1957