Canadian healthcare system

1. 1
THE CANADIAN HEALTH CARE
SYSTEM: OVERVIEW
• Class Discussion:
• How successful has Health care been in broadening
and equalizing access to the medical care system for
all Canadians?
• Has change in accessibility led to changes in the
overall health of the population or in the distribution
of health of the population?
• The Reform of Health Care: What's wrong with the
health care system?
• What kinds of changes are needed?
• What kinds of changes are being proposed and why?

2. 2
THE CANADIAN HEALTH CARE
SYSTEM: OVERVIEW
• No such thing as ‘the Canadian Health Care System’
• In fact - 10 provincial systems working in parallel -
minor differences between provinces re: cost/fees;
scheduled items, etc.
• It is joint operation of, and co-operation between,
provinces that allows us to speak about the 'Canadian'
system
– System is the envy of many others
– Americans particularly
– Brits
– Germans, other Europeans

3. 3
Six features/characteristics of Western health
care systems (Torrance, 1987)
1. Heavy emphasis on curative medicine as enshrined
in private practice and acute-treatment hospitals
with little attention to sources of illness, prevention,
public health or rehabilitation
2. Growth of specialization at expense of primary care
3. Rigid division of labour that discourages
reallocation of roles

4. 4
Six features/characteristics of Western health
care systems…
4. Creation of new sources of corporate profits +
professional wealth from state-subsidized care
5. Intrusion of medical industry into range of
problems previously considered outside its
competence
6. Fiscal crisis

5. 5
THE DEVELOPMENT OF THE HEALTH
CARE SYSTEM IN CANADA
• Weller & Manga (1983) identify 3 policy periods.
1. Benign neglect (up to 1945)
2. Shared cost agreements (1945-76)
3. Established Program Areas Acts (1977)
4. Federal withdrawal (1990 - ?)

6. 6
Benign Neglect
• Little government involvement.
• Health a provincial responsibility with few exceptions
(native Canadians, regulation of environment and
food; radiation, veterans health).

7. 7
Benign Neglect
• Public health a government concern (water, food
quality; regulation of restaurants, etc.)
• Private health a private matter
• Rise of physician dominance through late 19th and
early 20th century.

8. 8
Benign Neglect …
• 1912 Canada Medical Act
• Marked the turning point in the position of allopathic
practitioners (physicians)
• Licensing of physicians others excluded:
chiropractors, natural paths, apothecary, midwifery...
• Proposed and spearheaded by Dr. Thomas Roddick -
physician turned politician.

9. 9
Benign Neglect …
• 1920's Flexner report
• Advocated rise of 'scientific' biomedicine at expense
of public health
• Shaped curriculum of medical schools; affiliation
with universities (legitimation)
• Radically changed medical education in both Canada
and US

10. 10
• 1920's Flexner report …
• Some successes (vaccination for polio, smallpox...)
• Insurance private, typically only middle-class
easterners could afford it or had it offered to them...
this fed flames of discontent in the west...
• Dirty 30's - rise of labour movements, pressure for
improved living conditions/standards

11. 11
Shared Cost Arrangements
• Post WWII - prosperity and renegotiation of social
contract in UK - rise of welfare state establishment of
NHS
• 1947 - Saskatchewan - institutes compulsory hospital
insurance scheme
• 1948 - National Health Program - comprised of 10
granting schemes for health surveys, public health
care, tuberculosis, cancer, mental health, sexually
transmitted diseases, crippled children... and hospital
construction
• 1949 - joined by Alberta and B.C.

12. 12
Shared Cost Arrangements …
• 1958 HOSPITAL INSURANCE + DIAGNOSTIC
SERVICES ACT
• Public insurance provided for services offered in hospitals but
not for nursing homes, mental institutions, sanatoria, etc.
• Costs of insurance shared - feds paid 25% per capita and 25%
of total (National) cost
• Very popular, stopped barriers to access, defaulting on hospital
bills, etc.

13. 13
Shared Cost Arrangements …
• Raised physician incomes
• But - institutionalized care - made it hospital
based, acute focussed
• 1962 - Saskatchewan - extends insurance to
cover all physician services - doctors strike!

14. 14
Shared Cost Arrangements …
• 1962-64 EMMETT HALL COMMISSION
• This commission on health services made two
recommendations:
1. That government, in co-operation with the
provinces, should introduce universal health care
2. Recommends universal health insurance criteria to
be guided by 4 principles

15. 15
• Universal health insurance criteria to be guided by
4 principles:
1. public administration
2. comprehensiveness
3. universal coverage
4. portability
5. accessibility (added in 1984)
• MEDICAL CARE ACT of 1966
• implemented between 1968-72 - set stage for
universal health care insurance

16. 16
ESTABLISHED PROGRAMS FUNDING
ACT (1977)
• Financing of health care reorganized - direct tax
transfers rather than % capita reimbursement
• Funding too uncertain for provinces, too inflexible
• Provinces reimbursed after payout - cash-flow
problems; unforeseen costs for provinces with rapid
population change
• For Feds - arrangement too costly!
• New formulas agreed to by Provinces and Feds
• But - fears of erosion of underlying principles
• USER FEES, EXTRA BILLING

17. 17
TODAY?? Federal Withdrawal
• April 1990 - Bill C-69 - now law
• Withdrawal of tax transfers from Feds for Health,
Welfare and Education
• Size of current Ont. deficit largely due to shortfall in
transfer payments - all provinces hit hard by this
• On the day the Feds announced cuts in transfer
payments, Clyde Wells (NFlD) announced closure of
200 hospital beds
• What is the future of public health insurance?

18. 18
THE CANADIAN HEALTH ACT
• The Canada Health Act (CHA) is Canada's federal
health insurance legislation.
• The provinces of Canada are constitutionally
responsible for the administration and delivery of
health care services.
• They decide where their hospitals will be located,
how many physicians they will need, and how much
money they will spend on their health care systems.
• The CHA establishes the criteria and conditions
related to insured health care services

19. 19
THE CANADIAN HEALTH ACT …
• The national standards—that the provinces and
territories must meet in order to receive the full
federal cash transfer contribution under the
transfer mechanism, that is, the Canada Health
and Social Transfer (CHST).
• The aim of the national health insurance program is to
ensure that all residents of Canada have reasonable
access to medically necessary insured services
without direct charges.

20. 20
THE CANADIAN HEALTH ACT …
Requirements of the Act
• The CHA contains nine requirements that the
provinces and territories must meet in order to qualify
for the full federal cash contributions:
• Five program criteria that apply only to insured
health care services;
• Two conditions that apply to insured health care
services and extended health care services; and
• Two extra-billing and user charges provisions that
apply only to insured health care services.

21. 21
CHA - THE CRITERIA
1. Public Administration
2. Comprehensiveness
3. Universality
4. Portability
5. Accessibility

22. 22
Public Administration
• This criterion applies to the health insurance plans of
the provinces and territories (not to hospitals or the
services hospitals provide).
• The health care insurance plans are to be
administered and operated on a non-profit basis by a
public authority, responsible to the
provincial/territorial governments and subject to
audits of their accounts and financial transactions.

23. 23
Comprehensiveness
• The health insurance plans of the provinces
and territories must insure all insured
health services (hospital, physician,
surgical-dental) and, where permitted,
services rendered by other health care
practitioners.

24. 24
Universality
• One hundred percent of the insured residents
of a province or territory must be entitled to
the insured health services provided by the
plans on uniform terms and conditions.
• Provinces and territories generally require
that residents register with the plans to
establish entitlement.

25. 25
Portability
• Residents moving from one province or territory to
another must continue to be covered for insured
health care services by the "home" province during
any minimum waiting period, not to exceed three
months, imposed by the new province of residence.
• After the waiting period, the new province or
territory of residence assumes health care
coverage.
• Residents temporarily absent from their home
provinces or territories, or from the country, must also
continue to be covered for insured health care
services.

26. 26
Accessibility
• The Canada Health Act of 1984 added accessibility to
make five principles
• The health insurance plans of the provinces and
territories must provide: reasonable access to
insured health care services on uniform terms and
conditions, unprecluded or unimpeded, either
directly or indirectly, by:
– charges (user charges or extra-billing)
– others (age, health status, SES.

27. 27
Accessibility …
• Reasonable access in terms of physical availability of
medically necessary services has been interpreted
under the Canada Health Act using the "where and as
available" rule.
• Thus, residents of a province or territory are entitled
to have access to insured health care services at the
setting "where" the services are provided and "as" the
services are available in that setting;
• Reasonable compensation to physicians and dentists
for all the insured health care services they provide,
and payment to hospitals to cover the cost of insured
health care services.

28. 28
CHA – THE CONDITIONS
1. Information — the provincial and territorial
governments are to provide information to the
Minister of Health as may be reasonably required, in
relation to insured health care services and extended
health care services, for the purposes of the Canada
Health Act.
2. Recognition — the provincial and territorial
governments are to appropriately recognize the
federal contributions toward both insured and
extended health care services.

29. 29
CHA - Extra-billing and User Charges
• The cost of the new plan were to be shared 50/50 by
the federal and provincial governments
• They were also to be shared in a way that would
serve to redistribute income between the proorer and
richer provinces

30. 30
CHA - Extra-billing and User Charges …
1. Extra-billing — this occurs if a physician or a
dentist directly charges an insured person for an
insured service that is in addition to the amount that
would normally be paid for by the provincial or
territorial health insurance plan.
• For example, if a physician were to charge patients
five dollars for an office visit that is insured by a
health insurance plan, the five-dollar charge would be
extra-billing.

31. 31
CHA - Extra-billing and User Charges …
2. User charges — these are direct charges to
patients, other than extra-billing, for insured services
of a province or territory's health insurance plan that
are not payable, directly or indirectly, by the health
insurance plan.
• .For example, if patients were charged a fee before
being provided treatment at a hospital emergency
department, the fee would be considered a user
charge.