Health care in Canada

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Health care in Canada is funded and delivered through a publicly-funded health care system, with most services provided by private entities.^[1]

Health care spending in Canada is projected to reach $160 billion, or 10.6% of GDP, in 2007. This is slightly above the average for OECD countries. In Canada, the various levels of government pay for about 71% of Canadians' health care costs, which is slightly below the OECD average. Under the terms of the Canada Health Act, the publicly funded insurance plans are required to pay for medically necessary care, but only if it is delivered in hospitals or by physicians. There is considerable variation across the provinces/territories as to the extent to which such costs as outpatient prescription drugs, physical therapy, long-term care, home care, dental care and even ambulance services are covered.^[2]

Considerable attention has been focused on two issues: wait times and health human resources. There is also a debate about the appropriate 'public-private mix' for both financing and delivering services.

Canada's healthcare spending is expected to reach $171.9 billion, or $5,170 per person, in 2008. Health expenditures are expected to be 10.7% of the gross domestic product. Hospitals account for the largest segment in spending at $48.1 billion, however, this amount is declining. According to the OECD, spending was second amongst other countries, behind the United States and ahead of Norway, Switzerland and Luxembourg^[3].

Canada has a federally sponsored, publicly funded Medicare system, with most services provided by the private sector. Each province may opt out, though none currently do. Canada's system is known as a single payer system, where basic services are provided by private doctors (since 2002 they have been allowed to incorporate), with the entire fee paid for by the government at the same rate. Most family doctors receive a fee per visit. These rates are negotiated between the provincial governments and the province's medical associations, usually on an annual basis. A physician cannot charge a fee for a service that is higher than the negotiated rate — even to patients who are not covered by the publicly funded system — unless the physican opts out of billing the publicly funded system altogether. Pharmaceutical costs are set at a global median by government price controls. Other areas of health care, such as dentistry and optometry, are wholly private.

[edit] History

[edit] 18th century

Hospitals were initially places which cared for the poor; others were cared for at home. In Quebec (formerly known as New France and then as Lower Canada), a series of charitable institutions, many set up by Catholic religious orders, provided such care.^[4] As the country grew, hospitals grew with them. They tended to be not-for-profit, and were run by municipal governments, charitable organizations, and religious denominations (both Catholic and Protestant). ^[5] These organizations tended to be at arm's length from government; they received subsidies from provincial governments to admit and treat all patients, regardless of their ability to pay. Dr. David Parker of the Maritimes was the first to operate using anesthetic. One of the first "modern" operations, the removal of a tumour, was performed by William Fraser Tolmie in British Columbia.

[edit] 19th century

The first medical schools were established in Lower Canada in the 1820s. These include the Montreal Medical Institution, which is today the faculty of medicine at McGill University. In the mid-1870s, Sir William Osler changed the face of medical school instruction throughout the West with the introduction of the hands-on approach. The College of Physicians and Surgeons of Upper Canada was established in 1839 and in 1869 was permanently incorporated. In 1834, William Kelly, a surgeon with the Royal Navy, introduced the idea of preventing the spread of disease via sanitation measures following epidemics of cholera. In 1871, female physicians Emily Howard Stowe and Jennie Kidd Trout won the right for women to be admitted to medical schools and granted licenses from the College of Physicians and Surgeons of Ontario. In 1883, Emily Stowe led the creation of the Ontario Medical College for Women, affiliated with the University of Toronto. In 1892, Dr. William Osler wrote the landmark text The Principles and Practice of Medicine, which dominated medical instruction in the West for the next 40 years. Around this time, 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. During this period, medical care was severely lacking for the poor and minorities such as First Nations^[6]

[edit] 20th century

The twentieth century saw the discovery of insulin by Frederick Banting and his colleagues, Charles Best, J.J.R. Macleod, and J.B. Collip^[7] in 1922. For this, Frederick Banting and J.J.R. Macleod of the University of Toronto won the 1923 Nobel Prize in Physiology and Medicine^[8]. Dr. Wilder Penfield, who discovered a successful surgical treatment for epilepsy called the "Montreal procedure," founded the Montreal Neurological Institute in 1934.

Tommy Douglas' (centre left) number one concern was the creation of Medicare. In the summer of 1962, Saskatchewan became the centre of a hard-fought struggle between the provincial government, the North American medical establishment, and the province's physicians, who brought things to a halt with a doctors' strike.

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 1950, Alberta 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.^[9]

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 programs. 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 after defeating the Saskatchewan Doctors' Strike in July.

[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."^[10]

[edit] Government involvement

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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 last 20 years and despite health care being a guaranteed right for First Nations due to the many treaties the government of Canada signed for access to First Nations lands and resources, the amount of coverage provided by the Federal government has diminished drastically for optometry, dentistry, and medicines. Status First Nations individuals only qualify for a set amount of visits to the optometrist and dentist, with a limited amount of coverage for glasses, eye exams, fillings, root canals, etc. 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. Regardless of federal efforts, healthcare for First Nations has generally not been considered effective^[11][12][13].

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

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. Some 65% of Canadians have some form of supplementary private health insurance; many of them receive it through their employers.^[14] There are also large private entities that can buy priority access to medical services in Canada, such as WCB in BC.

The Canadian system is for the most part publicly funded, yet most of the services are provided by private enterprises. Most doctors do not receive an annual salary, but receive a fee per visit or service.^[1] According to Dr. Albert Schumacher, former president of the Canadian Medical Association, an estimated 75 percent of Canadian 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."^[1]

The Canada Health Act of 1984 "does not directly bar private delivery or private insurance for publicly insured services," but provides financial disincentives for doing so. "Although there are laws prohibiting or curtailing private health care in some provinces, they can be changed," according to a report in the New England Journal of Medicine.^[15][16] 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 violated the Quebec Charter of Human Rights and Freedoms, 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.^[17]

[edit] Physician organization

Each province regulates its medical profession through a self-governing College of Physicians and Surgeons, which is responsible for licensing physicians, setting practice standards, and investigating and disciplining its members.

The national doctors association is called the Canadian Medical Association^[18]; it describes its mission as "To serve and unite the physicians of Canada and be the national advocate, in partnership with the people of Canada, for the highest standards of health and health care. "^[19] Because health care is deemed to be under provincial/territorial jurisdiction, negotiations on behalf of physicians are conducted by provincial associations such as the Ontario Medical Association.^[20] The views of Canadian doctors have been mixed, particularly in their support for allowing parallel private financing. The history of Canadian physicians in the development of Medicare has been described by C. David Naylor. ^[21] Since the passage of the 1984 Canada Health Act, the CMA itself has been a strong advocate of maintaining a strong publicly-funded system, including lobbying the federal government to increase funding, and being a founding member of (and active participant in) the Health Action Lobby (HEAL).^[22]

However, there are internal disputes. In particular, some provincial medical associations have argued for permitting a larger private role. To some extent, this has been a reaction to strong cost control; CIHI estimates that 99% of physician expenditures in Canada come from public sector sources, and physicians—particularly those providing elective procedures who have been squeezed for operating room time—have accordingly looked for alternative revenue sources.

One indication of this internal dispute came when Dr. Brian Day of B.C. was elected CMA president in August 2007. Day is the owner of the largest private hospital in Canada and a vocal supporter of increasing private health care in Canada. The CMA presidency rotates among the provinces, with the provincial association electing a candidate who is customarily ratified by the CMA general meeting. Day's selection was sufficiently controversial that he was challenged—albeit unsuccessfully—by another physician. The newspaper story went on to note that "Day said he has never supported the privatization of health care in Canada, and accused his detractors of deliberately distorting his position." ^[23]

[edit] Criticisms

[edit] Wait times

One of the major complaints about the Canadian health care system is waiting times, whether for a specialist, major elective surgery, such as hip replacement, imaging procedures such as MRI or Cystoscopy, or specialized treatments, such as radiation for breast cancer. Studies by the Commonwealth Fund found that 57% of Canadians reported waiting 4 weeks or more to see a specialist; 24% of Canadians waited 4 hours or more in the emergency room.^[24]

A March 2, 2004, article in the Canadian Medical Association Journal stated, "Saskatchewan is under fire for having the longest waiting time in the country for a diagnostic MRI—a whopping 22 months." ^[25]

A February 28, 2006, article in The New York Times quoted Dr. Brian Day as saying, "This is a country in which dogs can get a hip replacement in under a week and in which humans can wait two to three years."^[26] The Canadian Health Coalition has responded succinctly to these claims, pointing out that "access to veterinary care for animals is based on ability to pay. Dogs are put down if their owners can’t pay. Access to care should not be based on ability to pay." ^[27] The CHC is one of many groups across Canada calling for increased provincial and federal funding for medicare and an end to provincial funding cuts as solutions to unacceptable wait times ^[28]. In a 2007 episode of ABC News's 20/20 titled "Sick in Amercia," host John Stossel cited numerous examples of Canadians who did not get the health care that they needed. ^[29]

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.^[30][31] However, the Fraser Institute's report is greatly at odds with the Canadian government's own 2007 report.^[32]

Since 2002, the Canadian government has invested $5.5 billion to address the wait times problem.^[33] In April 2007, Canadian Prime Minister Stephen Harper announced that all ten provinces and three territories would establish patient wait times guarantees by 2010. Canadians will be guaranteed timely access to health care in at least one of the following priority areas, prioritized by each province: cancer care, hip and knee replacement, cardiac care, diagnostic imaging, cataract surgeries or primary care.^[34]

[edit] Medical professional shortage

Canada's shortage of medical practitioners causes problems.^[35] With 2.1 doctors per thousand population in 2006, Canada is well below the OECD average of 3.1. Canada's 8.8 nurses per thousand was also below the OECD average of 9.7.^[36] 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.^[37]

Doctors in Canada make an average of $202,000 a year (2006, before expenses).^[38] Alberta has the highest average salary of around $230,000, while Quebec has the lowest average annual salary at $165,000, creating interprovincial competition for doctors and contributing to local shortages.^[38]

In 1991, the Ontario Medical Association agreed to become a province-wide closed shop, making the OMA union a monopoly. Critics argue that this measure has restricted the supply of doctors to guarantee its members' incomes.^[39]

According to a 2007 article from CTV News, the Canadian medical profession is suffering from a brain drain. The article states, "One in nine trained-in-Canada doctors is practising medicine in the United States...If Canadian-educated doctors who were born in the U.S. are excluded, the number is one in 12." ^[40]

In September 2008, the Ontario Medical Association and the Ontarian government agreed to a new four-year contract that will see doctors receive a 12.25% pay raise. The new agreement is expected to cost Ontarians an extra $1 billion. Referring to the agreement, Ontario premier Dalton McGuinty said,"One of the things that we've got to do, of course, is ensure that we're competitive ... to attract and keep doctors here in Ontario...".^[41]

In December 2008, the Society of Obstetricians and Gynaecologists of Canada reported a critical shortage of obstetricians and gynaecologists. The report stated that only 1,370 obstetricians were practicing in Canada and that number is expected to fall by at least one-third within five years. The society is asking the government to increase the number of medical school spots for obstetrics and gynecologists by 30 per cent a year for three years and also recommended rotating placements of doctors into smaller communities to encourage them to take up residence there^[42].

[edit] Restrictions on privately funded health care

The Canada Health Act, which sets the conditions with which provincial/territorial health insurance plans must comply if they wish to receive their full transfer payments from the federal government, does not allow charges to insured persons for insured services (defined as medically necessary care provided in hospitals or by physicians). Most provinces have responded through various prohibitions on such payments. This does not constitute a ban on privately funded care; indeed, about 30% of Canadian health expenditures come from private sources, both insurance and out-of-pocket payments.^[43] The Canada Health Act does not address delivery. Private clinics are therefore permitted, albeit subject to provincial/territorial regulations, but they cannot charge above the agreed-upon fee schedule unless they are treating non-insured persons (which may include those eligible under automobile insurance or worker's compensation, in addition to those who are not Canadian residents), or providing non-insured services. This provision has been controversial among those seeking a greater role for private funding.

A February 28, 2006, article in The New York Times stated, "Accepting money from patients for operations they would otherwise receive free of charge in a public hospital is technically prohibited in this country, even in cases where patients would wait months or even years before receiving treatment...Canada remains the only industrialized country that outlaws privately financed purchases of core medical services." ^[44]

In a June 13, 2005, editorial, the Wall St. Journal wrote, "Canada is the only nation other than Cuba and North Korea that bans private health insurance," quoting Sally Pipes, head of the conservative think tank Pacific Research Institute and author of a recent book on Canada's health-care system. The statement is inaccurate, as Canada does not ban all private insurance; many Canadians have supplemental insurance. However, the editorial provides an example to illustrate its point: "When George Zeliotis of Quebec was told in 1997 that he would have to wait a year for a replacement for his painful, arthritic hip, he did what every Canadian who's been put on a waiting list does: He got mad. He grew even angrier when he learned it was against the law to pay for a replacement privately." ^[45]

In 2006, a Canadian court threatened to shut down one private clinic because it was planning to start accepting private payments from patients.^[46] According to The New York Times, although privately funded clinics are illegal in Canada, many clinics are opening anyway, because patients don't like the long waiting lists in the government system. ^[44]

Governments have responded through wait time strategies, discussed above, which attempt to ensure that patients will receive high-quality, necessary services in a timely manner. Nonetheless, the debate continues.

[edit] Cross-border health care

This section may require cleanup to meet Wikipedia's quality standards.

The border between Canada and the United States represents a boundary line for medical tourism, in which a country's residents travel elsewhere to seek health care that is more available or affordable.

[edit] Canadians visiting the U.S. to receive health care

Some residents of Canada travel to the United States in frustration with the limitations of their own health care system, as illustrated by the following examples:

• According to a September 14, 2007, article from CTV News, Canadian Liberal MP Belinda Stronach went to the United States for breast cancer surgery in June 2007. Stronach's spokesperson Greg MacEachern was quoted in the article saying that the US was the best place to have this type of surgery done. Stronach paid for the surgery out of her own pocket.^[47] Prior to this incident, Stronach had stated in an interview that she was against two-tiered health care.^[48]
• When Robert Bourassa, the premier of Quebec, needed cancer treatment, he went to the US to get it.^[49]
• In 2007, it was reported that Canada sent scores of pregnant women to the US to give birth.^[50] In 2007 a woman from Calgary who was pregnant with quadruplets was sent to Great Falls, Montana to give birth. An article on this incident states, "There was no room at any other Canadian neonatal intensive care unit."^[51]
• Champion figure skater Audrey Williams needed a hip replacement. Even though she waited two years and suffered in pain, she still did not get the surgery, because the waiting list was so long. So she went to the US and spent her own money to get the surgery.^[52]
• A January 19, 2008, article in The Globe And Mail states, "More than 150 critically ill Canadians – many with life-threatening cerebral hemorrhages – have been rushed to the United States since the spring of 2006 because they could not obtain intensive-care beds here. Before patients with bleeding in or outside the brain have been whisked through U.S. operating-room doors, some have languished for as long as eight hours in Canadian emergency wards while health-care workers scrambled to locate care." ^[53]

[edit] US citizens visiting Canada to receive health care

On the other hand, some US citizens travel to Canada for health-care related reasons:

• Many US citizens purchase prescription drugs from Canada, either over the Internet or by traveling there to buy them in person, because drug prices in Canada are substantially lower than in the US; this cross-border purchasing has been estimated at $1 billion annually.^[54]
• At least one Canadian entrepreneur is beckoning US residents to Canada for simple surgeries, such as knee and hip replacements.^[55] However, the article does not cite any actual patients who have responded to his offer.
• Because medical marijuana is legal in Canada but illegal in most of the US, many US citizens suffering from cancer, AIDS, multiple sclerosis, and glaucoma have traveled to Canada for medical treatment. One of those is Steve Kubby, the Libertarian Party's 1998 candidate for governor of California, who is suffering from adrenal cancer.^[56] Recent legal changes such as Proposition 215 may decrease this type of medical tourism from California only.

[edit] Canadian health care in comparison

The Canadian health care system is often compared to the US system. The US system spends the most in the world per capita, and was ranked 37th in the world by the World Health Organization in 2000, while Canada's health system was ranked 30th. The WHO ranking has been criticized by some for its choice of ranking criteria and statistical methods, and the WHO is currently revising its methodology and withholding new rankings until the issues are addressed.^[57][58]

Canada spent approximately 10.0% of GDP on health care in 2006, more than one percentage point higher than the average of 8.9% in OECD countries.^[36] According to the Canadian Institute for Health Information, spending is expected to reach $160 billion, or 10.6% of GDP, in 2007.^[59] This translates to $4,867 per person.

Most health statistics in Canada are at or above the G8 average.^[60] Direct comparisons of health statistics across nations is complex. The OECD collects comparative statistics, and has published brief country profiles.^[61]

[edit] See also

• Canadian Institute for Health Information
• Canadian and American health care systems compared
• Canada Health Act
• Medicare (Canada)

[edit] References

• Famous Canadian Physicians at Library and Archives Canada

[edit] External links

• Canadian Federalism and Public Health Care: The Evolution of Federal-Provincial Relations | Mapleleafweb.com
• 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

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