Health Care Canadian Style
Canada’s health-care system has been
described as a “symbol of
Canadian identity.” Health-care reformers in the U.S. can look to
their system for both approaches to emulate and problems to avoid.
Canadian identity.” Health-care reformers in the U.S. can look to
their system for both approaches to emulate and problems to avoid.
When the United States considers reforming
its health-care system, the Canadian health-care system is
often a point of reference. Canada provides universal coverage,
and Canadians, as a group, live longer and healthier than
residents of the U.S. In recent years, however, Canadians have
complained increasingly about shortages and wait lists for
services.
In Canada, with a
population of 31 million, responsibility for the health-care
system—which is called “Medicare”—is
divided between the federal government and Canada’s ten
provinces and three territories. The federal government makes
transfer payments to the provinces, and the provinces have
primary responsibility for organizing and delivering health
care. Most physicians in Canada have private practices, but
their payments come from the government.
Sharing payments
Prior to 1977, the Canadian federal
government was obliged to pay approximately 50 percent of
provincial health-care costs, and provinces paid most of the
remainder. Then the federal government altered the cost-sharing
arrangement to reduce its payments, and later began making
block grants to the provinces that covered not only health
care, but also social services and post-secondary education.
This had the effect of reducing the federal government’s
payments for health care by about one-third (or more, depending
on the accounting method).
In 1984, the federal
government passed a law effectively prohibiting physicians from
making direct charges to patients beyond what the government
was willing to pay under the fee schedules negotiated in each
province. If a province allowed any direct billing, the
province’s payments from the federal government would be
reduced dollar-for-dollar. The Canadian health-care system does
allow direct payments from patients for some services,
including prescription drugs and home-care services.
“Defining aspect of our
citizenship”
The philosophy behind Canada’s
health-care system was expressed by Roy Romanow, the former
premier of Saskatchewan, who was commissioned by the federal House of Commons to review the system and make recommendations
for its improvement. In his 2002 report, “Building on Values—The Future of Health
Care in Canada,” Romanow
said that the country’s Medicare system is a
“symbol of Canadian identity,” a “defining
aspect of our citizenship and expression of social
cohesion.” The report is on line at www.hc-sc.gc.ca/english/care/romanow/hcc0086.html
Romanow’s view is
shared by Sunil Patel, the president of the Canadian Medical Association, who is a family practitioner in Manitoba,
specializing in oncology and cardiology. “We do not need
a parallel private system,” said Patel in an interview.
“That would deny the needy access to care.”
Romanow’s report
came at a time when complaints about health shortages and
government management were increasing, and some in Canada were
arguing that for-profit corporations should play a greater role
in Canada’s health-care system. To those who wanted to
“use their money for the purchase of faster treatment
from a private provider for their loves ones,” Romanow
responded, “I believe it is a greater perversion of
Canadian values to accept a system where money, rather than
need, determines who gets access to care.... Canadians view
Medicare as a moral enterprise, not a business
venture.”
Until the early 1990s,
Canadians expressed high levels of satisfaction and confidence
with their health-care system, including when compared with
satisfaction surveys done in other countries. Then, following
restructuring and restrictions on funding, 46 percent of people
in Canada felt the changes harmed the quality of care (1998 survey),
and 59 percent said the health-care system required fundamental
changes (2001 survey).
By comparison, in 1998 only 18 percent of people in the U.S.
felt that recent changes in the health-care system had harmed
the quality of care.
Wait lists and queue-jumping
In Canada, the main complaints were about
shortages of health-care professionals and hospital beds.
Waiting times to see specialists sometimes exceeds six months.
In most Canadian provinces, life-threatening conditions are
handled well, but significant waits are common for elective
procedures, such as hip replacement, knee replacement, and
cataract surgery.
In addition, there are
serious backlogs for access to advanced diagnostic tests,
including MRIs and CT scans. The province of Saskatchewan has
the longest wait list in the country for diagnostic
MRIs—22 months. The Canadian
Association of Radiologists
calls the waiting time “almost criminal,” according
to a report in the Canadian Medical Association
Journal. “Timely access
to care is the number one issue,” said Patel. Without
timely access, he said, the conditions of patients worsen and
patients experience anxiety.”
Canadians who can
afford to do so, have jumped the queue by paying for diagnostic
tests in a private facility (in provinces that allow such
facilities) and then taking those results to a hospital to get
treatment before others who have not yet been able to obtain
diagnostic tests.
Canadians willing to spend more
Canada spends approximately 9.4 percent of
its gross domestic product (GDP) on health care. That is
slightly less than two-thirds of the proportion of GDP spent by
the United States, which spent 14.9 of GDP on health care in
2002. (In 2002, the average health-care expenditure per person
in the U.S. was $5,440.)
According to surveys done
by Romanow’s commission, Canadians are willing to pay
extra taxes for better health-care services—as long as
the tax is truly dedicated to health care and is not just a
general tax increase with proceeds funneled to other programs.
Following up on the report, Canada’s First Ministers have agreed to spend an additional $34.8 billion
(Canadian dollars) over five years on health care. In addition
to providing more funds for primary and specialty care, the
funds will go to improved home care, catastrophic drug
coverage, diagnostic equipment, better access to care in rural
areas, and information technology.
“Canadians are
sick and tired of the government playing football with their
health,” Patel comments. He adds, however, that he is
heartened by the government’s initial plans, but
“the proof of the pudding” will depend on the
government’s willingness to provide ongoing additional
funding for health care.
More health-care workers
The Canadian Medical Association and the
Romanow Report call for increasing the number of health-care
workers. The Canadian Medical Association has suggested
increasing the number of persons in each medical school class
(nationwide) by 16 percent—from 2,100 to 2,500. The
association also wants 120 post-graduate medical positions for
every 100 medical school graduates in Canada, thus allowing
enough training positions for all Canadian medical school
graduates as well as some foreign graduates. This year, Canada
has 67 fewer graduate medical positions than medical school
graduates.
There also are
proposals to provide more integrated health-care teams. As
described by one person who appeared before Romanow’s
commission, “[W]e have largely been training our health
professionals in silos. Then when they graduate, we call on
them to work together.”
To alleviate the shortage of health
professionals in rural areas, Romanow recommends providing more
training opportunities for physicians, nurses, and other
health-care professionals in rural areas. Studies found that
with such exposure, the number of professionals willing to
practice in rural areas increases.
