Health care in Canada

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Canada's health care system is a publicly funded health care system, with most services provided by private entities. It is important to understand that it is not a true public system, even though the government calls it so.^{[1][citation needed]} In Canada the various levels of government pay for about 70% of Canadians' health care costs, which is about average for a developed country. Canada is unusual in that the government pays for almost 100% of hospital and physician care, but contributes very little in areas such as prescription drug costs and dental care.

[edit] History

The first organized health care in Canada were hospitals set up by Catholic religious orders in New France. Religiously run hospitals were the norm up to the early twentieth century. They were generally for the poor; wealthier citizens would be cared for in their homes by expensive doctors. In the late nineteenth century a movement began that called for the improved health care for the poor, focusing mainly on sanitation and hygiene. This period saw important advances including the provision of safe drinking water to most of the population, public baths and beaches, and municipal garbage services to remove waste from the city.

While King promised to create national health care, he instead formed Canada's Department of Health in the early 20th century. Canada would not get national health care until 1946.

The early 20th century saw the first widespread construction of government run hospitals, mainly asylums for the mentally ill and Sanatoriums for those suffering from tuberculosis. Calls for increased government involvement also became common, and the idea of a national health insurance system had considerable popularity. William Lyon Mackenzie King promised to introduce such a scheme, but while he created the Department of Health he failed to introduce a national program. During the Great Depression calls for a public health system were widespread. Doctors who had long feared such an idea reconsidered hoping a government system could provide some stability as the depression had badly affected the medical community. However, governments had little money to enact the idea. In 1935, the United Farmers of Alberta passed a bill creating a provincial insurance program, but they lost office later that year and the Social Credit Party scrapped the plan due to the financial situation in the province. The next year a health insurance bill passed in British Columbia, but its implementation was halted over objections from doctors.

[edit] The beginning of coverage

It was not until 1946 that the first Canadian province introduced near universal health coverage. Saskatchewan had long suffered a shortage of doctors, leading to the creation of municipal doctor programs in the early twentieth century in which a town would subsidize a doctor to practice there. Soon after groups of communities joined to open union hospitals under a similar model. There had thus been a long history of government involvement in Saskatchewan health care, and a significant section of it was already controlled and paid for by the government. In 1946, Tommy Douglas' Co-operative Commonwealth Federation government in Saskatchewan passed the Saskatchewan Hospitalization Act, which guaranteed free hospital care for much of the population. Douglas had hoped to provide universal health care, but the province did not have the money.

In 1949, BC created a program similar to Saskatchewan's. Alberta, however, created Medical Services (Alberta) Incorporated (MS(A)I) in 1948 to provide prepaid health services. This scheme eventually provided medical coverage to over 90% of the population.^[2]

In 1957, the federal government passed the Hospital Insurance and Diagnostic Services Act to fund 50% of the cost of such programs for any provincial government that adopted them. The HIDS Act outlined five conditions, public administration, comprehensiveness, universality, portability, and accessibility. These remain the pillars of the Canada Health Act.

By 1961, all ten provinces had agreed to start HIDS Act provinces. In Saskatchewan, the act meant that half of their current program would now be paid for by the federal government. Premier Woodrow Lloyd decided to use this freed money to extend the health coverage to also include physicians. Despite the sharp disagreement of the Saskatchewan College of Physicians and Surgeons, Lloyd introduced the law in 1962.

[edit] Medical Care Act

The Saskatchewan program proved a success and the federal government of Lester B. Pearson, pressured by the New Democratic Party (NDP) who held the balance of power, introduced the Medical Care Act in 1966 that extended the HIDS Act cost-sharing to allow each province to establish a universal health care plan. It also set up the Medicare system. In 1984, the Canada Health Act was passed, which prohibited user fees and extra billing by doctors. In 1999, the prime minister and most premiers reaffirmed in the Social Union Framework Agreement that they are committed to health care that has "comprehensiveness, universality, portability, public administration and accessibility."^[3]

[edit] Doctors Union

The national doctors association or union is called the Canadian Medical Association^[4] while there are also provincial unions as in the Ontario Medical Association.^[5]

It is also important to note that the doctors are self regulating through the College of Physicians and Surgeons.

[edit] Government involvement

The various levels of government pay for about 70% of Canadians' health care, although this number has decreased somewhat in recent years. The British North America Act did not give either the federal or provincial governments responsibility for health care, as it was then a minor concern. The Act did give the provinces responsibility for regulating hospitals, and the provinces claimed that their general responsibility for local and private matters encompassed health care. The federal government felt that the health of the population fell under the Peace, Order, and Good Government part of its responsibilities. This led to several decades of debate over jurisdiction that were not resolved until the 1930s. Eventually the JCPC decided that the administration and delivery of health care was a provincial concern, but that the federal government also had the responsibility of protecting the health and well-being of the population.

By far the largest government health program is Medicare, which is actually ten provincial programs, such as OHIP in Ontario, that are required to meet the general guidelines laid out in the federal Canada Health Act. Almost all government health spending goes through Medicare, but there are several smaller programs. The federal government directly administers health to groups such as the military, and inmates of federal prisons. They also provide some care to the Royal Canadian Mounted Police and veterans, but these groups mostly use the public system. Prior to 1966, Veterans Affairs Canada had a large health care network, but this was merged into the general system with the creation of Medicare. The largest group the federal government is directly responsible for is First Nations. Native peoples are a federal responsibility and the federal government guarantees complete coverage of their health needs. For the most part First Nations people use the normal hospitals and the federal government then fully compensates the provincial government for the expense. The federal government also covers any user fees the province charges. The federal government maintains a network of clinics and health centres on Native Reserves. At the provincial level, there are also several much smaller health programs alongside Medicare. The largest of these is the health care costs paid by the worker's compensation system.

Despite being a provincial responsibility, the large health costs have long been partially funded by the federal government. The cost sharing agreement created by the HIDS Act and extended by the Medical Care Act was discontinued in 1977 and replaced by Established Programs Financing. This gave a bloc transfer to the provinces, giving them more flexibility but also reducing federal influence on the health system. In 1996, when faced with a large budget shortfall, the Liberal federal government merged the health transfers with the transfers for other social programs into the Canada Health and Social Transfer, and overall funding levels were cut. This placed considerable pressure on the provinces, and combined with population aging and the generally high rate of inflation in health costs, has caused problems with the system.

[edit] Private sector

In Canada the private sector has always been the frontline in healthcare. Canadian doctors operate as revenue/profit businesses and are the primary gatekeepers to the whole healthcare system. The doctors also have few controls placed on them by the primary payer for services, the government, and they are therefore in a position to easily recommend more visits and are guaranteed payment by the government.

About 30% of Canadians' health care is paid for through the private sector. This mostly goes towards services not covered or only partially covered by Medicare such as prescription drugs, dentistry and optometry. Many Canadians have private health insurance, often through their employers, that cover these expenses. There are also large private entities that can buy priority access to medical services in Canada, such as WCB in BC.

Contrary to popular belief, selling private health insurance that could cover hip replacements and MRI scans is legal in several provinces, but because they are available without charge in the public system, so far there has been no market for private insurance for what the Canada Health Act defines as "medically necessary services."

In June 2005, the Supreme Court of Canada ruled in Chaoulli v. Quebec (Attorney General) that Quebec's prohibition against private health insurance for medically necessary services laws was unconstitutional, potentially opening the door to much more private sector participation in the health system. Justices Beverley McLachlin, Jack Major, Michel Bastarache and Marie Deschamps found for the majority. "Access to a waiting list is not access to health care," wrote Chief Justice Beverly McLachlin.

The Quebec and federal governments asked the high court to suspend its ruling for 18 months. Less than two months after its initial ruling, the court agreed to suspend its decision for 12 months, retroactive to June 9, 2005. This means that, for the interim, there would be no change to the status quo. As a result of delays in receiving tests and surgeries, it is alleged patients have suffered and even died in some cases, although no rigorously collected data are available to substantiate or refute this claim.^[6]

The Canadian system is for the most part publicly funded, yet most of the services are provided by private enterprises, private corporations. Most all doctors do not receive an annual salary, but receive a fee per visit or service.

A CBC report [6](August 21, 2006) on the health care system reports the following:^[7]

"Dr. Albert Schumacher, former president of the Canadian Medical Association estimates that 75 per cent of health-care services are delivered privately, but funded publicly. "Frontline practitioners whether they're GPs or specialists by and large are not salaried. They're small hardware stores. Same thing with labs and radiology clinics …The situation we are seeing now are more services around not being funded publicly but people having to pay for them, or their insurance companies. We have sort of a passive privatization."

According to Dr. Albert Schumacher' remarks, they (GP's) are "small hardware stores' is a major reason why there is a shortage of doctors in Canada; simple economics dictates that doctors within the system benefit from a shortage of supply of doctors.

[edit] Colleges of Physicians and Surgeons - Self Regulation of Doctors

Each province has set up a College of Physicians and Surgeons, which is a self-regulating body for the provinces medical profession.

Accordingly, the College of Physicians and Surgeons of Ontario (CPSO) is the self-regulating body for that province's medical profession. The College regulates the practice of medicine to protect and serve the public interest. It issues certificates of registration to doctors to allow them to practise medicine, monitors and maintains standards of practice through peer assessment and remediation, investigates complaints against doctors on behalf of the public, and disciplines doctors who may have committed an act of professional misconduct or incompetence.^[8]

Some reviews of these agencies, specifically by the Toronto Star has revealed that many complaints are passed over.^[9] In 2001, following a Toronto Star series that revealed 99 per cent of complaints against Ontario physicians are either dismissed or handled in secret, the former minister of health Tory, Tony Clement promised to amend the Regulated Health Professions Act and make the College more open and publicly accountable. The College investigates, on average, 2,000 complaints from the public annually, and in 2004, only 29 complaints — 1.45 per cent — of the cases investigated were resolved in the public eye. The College resolved 1,100 without referral to the complaints committee. Of the other 900, all but 29 were dismissed or dealt with in private.^[10]

Other concerns by some physicians is that the College discourages alternative, complimentary health care treatments.^[11]

The College of Physicians and Surgeons, a self regulating body, it cannot do the following:^[12]

1. The College cannot compel a doctor to change his or her opinion or report. Corrections to a medical record may be made by the physician to ensure accuracy of the information and must be done according to the College’s policy on Medical Records.

2. The College cannot compel a doctor to apologize.

3. The College does not have the authority to award financial compensation.

In addition, information gathered by the College cannot be used in Court in accordance with Section 36(3) of the Regulated Health Professions Act, "no report or decision of a proceeding is admissible in a civil proceeding".

[edit] Criticisms

[edit] Wait Times

Canada's hospitals are often of high quality, but critics allege the wait times to get into those hospitals can span weeks or months, including for simple procedures. According to the Fraser Institute, treatment time from initial referral by a GP through consultation with a specialist to final treatment, across all specialties and all procedures (emergency, non-urgent, and elective), averaged 17.7 weeks in 2005.^[13][14] However, the Fraser Institute's report is greatly at odds with the 2007 (and earlier) reports of the Canadian Institute for Health Information, a government-sponsored watchdog agency.^[15] Although there are long waits for some non-emergency procedures (notably hip- and knee-replacement surgery, plastic surgeries, and eye surgery) and long waits for specific other procedures in specific provinces, most waits appear to be normal with respect to other health care systems (see table, below).

[edit] Medical Professional Shortage

There is widely believed to be a shortage of doctors in Canada.^[16] Canada's 2.1 doctors per thousand population was well below the OECD average of 3.0, although its 9.9 nurses per thousand was slightly above the OECD average of 8.3.^[17] Suggested solutions include increasing the number of training spaces for doctors in Canada, as well as streamlining the licensing process for foreign doctors already in the country.^[18]

Doctors in Canada make an average of $202,000 a year (2006, before expenses). Alberta has the highest average salary of around $230,000.00 while Quebec has the lowest average annual salary $165,000.00, creating interprovincial competition for doctors and contributing to local shortages.^[19]

[edit] Canadian health care in comparison

The comparison of Canada's Health Care system is often made to its neighbor the U.S.A. which spends the most in the world per capita, and is ranked 37th in the world, by the World Health Organization; when in fact many sources rate the Health Care Systems in France, and in Italy as the top two in the world.^[20]Canada's Health System was ranked 30th, using certain specific criteria. It should be noted however, that the WHO Health Care Ranking has been criticized for its choice of ranking criteria and statistical methods, and the WHO is currently revising its methodology and is withholding new rankings until the problems are addressed.^[21]

Canada spends no more than the G7 average on health care as a fraction of GDP; however, most health statistics in Canada are at or above the G7 average^[22]. In some health statistics, Canada has slightly better numbers than the United States, although there are certainly differences by each individual province and state. Direct comparisons of health statistics across nations is complex, and conclusions should be arrived at cautiously, and only after more in-depth research is performed.

[edit] References

[edit] External links

• CBC Digital Archives - The Birth of Medicare
• Data from the Canadian Institute for Health Information
  • National Health Expenditure Database
  • Exploring the 70/30 Split: How Canada's Health Care System Is Financed
  • National Physician Database
• A short documentary showcasing the system's long wait times