From Wikipedia, the free encyclopedia
Under Lester Pearson's Liberal government, Canada's health care was expanded through the Medical Care Act, or Medicare,
to provide near-universal coverage to all Canadians "according to their
need for such services and irrespective of their ability to pay".
Current status
The
government guarantees the quality of care through federal standards.
The government does not participate in day-to-day care or collect any
information about an individual's health, which remains confidential
between a person and their physician.
Canada's provincially based Medicare systems are cost-effective because
of their administrative simplicity. In each province, each doctor
handles the insurance claim against the provincial insurer. There is no
need for the person who accesses healthcare to be involved in billing
and reclaim at all. Private health expenditure accounts for 30% of
health care financing. The Canada Health Act does not cover prescription drugs, home care or long-term care or
dental care Provinces provide partial coverage for children, those living in poverty and seniors.
Programs vary by province. In Ontario, most prescriptions for youths
under the age of 24 are covered by the Ontario health insurance plan if
no private insurance plan is available.
Competitive practices such as advertising are kept to a minimum,
thus maximizing the percentage of revenues that go directly towards
care. Costs are paid through funding from federal and provincial general
tax revenues which include income taxes, sales taxes and corporation
taxes. In British Columbia, taxation-based funding is supplemented by a
fixed monthly premium which is waived or reduced for those on low
incomes. In Ontario, there is an income tax identified as a health premium on taxable income above $20,000.
In addition to funding through the tax system, hospitals and medical
research are funded in part by charitable contributions. For example, in
2018, Toronto's
Hospital for Sick Children embarked on campaign to raise $1.3 billion to equip a new hospital. Charities such as the
Canadian Cancer Society provide assistance such as transportation for patients.
There are no deductibles on basic health care and co-pays are extremely
low or non-existent (supplemental insurance such as Fair Pharmacare may
have deductibles, depending on income). In general, user fees are not
permitted by the
Canada Health Act,
but physicians may charge a small fee to the patient for reasons such
as missed appointments, doctor's notes and for prescription refills done
over the phone. Some physicians charge "annual fees" as part of a
comprehensive package of services they offer their patients and their
families. Such charges are completely optional and can only be for
non-essential health options.
Benefits and features
Health
cards are issued by provincial health ministries to individuals who
enroll for the program in the province and everyone receives the same
level of care.
There is no need for a variety of plans because virtually all essential
basic care is covered, including maternity but excluding
mental health and
home care.
Infertility costs are not covered in any province other than Quebec, though they are now partially covered in some other provinces. In some provinces, private supplemental plans are available for those who desire private rooms if they are hospitalized.
Cosmetic surgery
and some forms of elective surgery are not considered essential care
and are generally not covered. For example, Canadian health insurance
plans do not cover non-therapeutic
circumcision.
These can be paid out-of-pocket or through private insurers. Health
coverage is not affected by loss or change of jobs, cannot be denied due
to unpaid premiums, and there are no lifetime limits or exclusions for
pre-existing conditions. The Canada Health Act deems that essential
physician and hospital care be covered by the publicly funded system,
but each province has reasons to determine what is considered essential,
and where, how and who should provide the services. The result is that
there is a wide variance in what is covered across the country by the
public health system, particularly in more controversial areas, such as
in-vitro fertilization,
gender reconstructive surgery,
midwifery or
autism treatments.
Canada (with the exception of the province of
Quebec)
is one of the few countries with a universal healthcare system that
does not include coverage of prescription medication (other such
countries are Russia and some of the former USSR republics even though
Russia is considering a switch to full coverage of many prescription
medications in the near future).
Residents of Quebec who are covered by the province's public
prescription drug plan pay an annual premium of $0 to $660 when they
file their Quebec income tax return.
Due to changes in the past 2 decades, at least some provinces have
introduced some universal prescription drug insurance. Nova Scotia has
Family Pharmacare, introduced in 2008 by Rodney MacDonald's Progressive
Conservative government.
However, residents do not automatically receive it through their
health card (they must register), and it covers a limited range of
prescriptions. No premiums are charged. A deductible and out-of-pocket
maximum for copayments are set as a percentage of taxable income of 2
years before.
Pharmaceutical medications are covered by public funds in some provinces for the elderly or indigent,
or through employment-based private insurance or paid for
out-of-pocket. In Ontario, eligible medications are provided at no cost
for covered individuals aged 24 and under. Most drug prices are negotiated with suppliers by each provincial government to control costs but more recently, the
Council of the Federation
announced an initiative for select provinces to work together to create
a larger buying block for more leverage to control costs of
pharmaceutical drugs. More than 60 percent of prescription medications are paid for privately in Canada.
Family physicians
(often known as general practitioners or GPs in Canada) are chosen by
individuals. If a patient wishes to see a specialist or is counselled to
see a specialist by their GP, a referral is made by a GP in the local
community. Preventive care and early detection are considered critical
and yearly checkups are recommended for everyone.
Efficiency of healthcare system
An
OECD
study in 2010 noted that there seemed to be variations in care across
geographical regions corresponding to the different provinces in Canada.
The study found that there was a difference in hospital admission rates
depending on the number of people and what province they lived in.
Typically, provinces with low population counts had higher hospital
admission rates due to there being a lack of doctors and hospitals in
the region.
A different study from the Canadian Institute for Health Information
also concluded that there seem to be differences in the efficiency of
care regionally.
Regions that were similar in factors such as education levels and immigration numbers were found to have different
efficiency
levels in health care provision. The study concluded if increased
efficiency of the current system was set as a goal, the death rate could
be decreased by 18%-35%.
A separate study from the Canadian Institute for Health Information
suggests multiple ways the efficiency of health care system could be
improved. The study notes that supporting physician leadership and
facilitating engagement of the care providers could reap great gains in
efficiency. Additionally, the study suggested facilitating the exchange
of information and interaction between health providers and government
figures as well as flexible funding would also contribute to improvement
and solve the problem of differences in regional care by allowing
regions to determine the needs of their general populace and meet those
needs more efficiently by allowing target-specific allocation of funds.
Statistics
A record number of doctors was reported in 2012 with 75,142 physicians. The
gross average salary was $328,000. Out of the gross amount, doctors pay for taxes, rent, staff salaries and equipment. Recent reports indicate that Canada may be heading toward an excess of doctors, though communities in rural, remote and northern regions, and some specialties, may still experience a shortage.
Public opinion
Canadians
strongly support the health system's public rather than for-profit
private basis, and a 2009 poll by Nanos Research found 86.2% of
Canadians surveyed supported or strongly supported "public solutions to
make our public health care stronger." A Strategic Counsel survey found 91% of Canadians prefer their healthcare system instead of a U.S. style system.
A 2009 Harris-Decima poll found 82% of Canadians preferred their healthcare system to the one in the United States.
A 2003 Gallup poll found 25% of Americans are either "very" or
"somewhat" satisfied with "the availability of affordable healthcare in
the nation", versus 50% of those in the UK and 57% of Canadians. Those
"very dissatisfied" made up 44% of Americans, 25% of respondents of
Britons, and 17% of Canadians. Regarding quality, 48% of Americans, 52%
of Canadians, and 42% of Britons say they are satisfied.
Economics
Canadian per capita health care spending by age group in 201X
Total Canadian health care expenditures in 1997 dollars from 1975 to 2009.
Canada has a publicly funded
medicare
system, with most services provided by the private sector. Each
province may opt out, though none currently does. 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 government funding (94%) comes from
the provincial level.
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. Pharmaceutical costs are set
at a global median by the government
price controls.
Hospital care is delivered by publicly funded hospitals in
Canada. Most of the public hospitals, each of which are independent
institutions incorporated under provincial Corporations Acts, are
required by law to operate within their budget.
Amalgamation of hospitals in the 1990s has reduced competition between
hospitals. As the cost of patient care has increased, hospitals have
been forced to cut costs or reduce services. Applying a
pharmacoeconomic
perspective to analyze cost reduction, it has been shown that savings
made by individual hospitals result in actual cost increases to the
provinces.
In 2009, the government funded about 70% of Canadians' healthcare
costs. This is slightly below the OECD average of public health
spending.
This covered most hospital and physician costs while the dental and
pharmaceutical costs were primarily paid for by individuals.
Half of private health expenditure comes from private insurance and the
remaining half is supplied by out-of-pocket payments. Under the terms
of the
Canada Health Act,
public funding is 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 out of hospital prescription medications,
assistive devices, physical therapy, long-term care, dental care and
ambulance services are covered.
Healthcare spending in Canada (in 1997 dollars) has increased
each year between 1975 and 2009, from $39.7 billion to $137.3 billion,
or per capita spending from $1,715 to $4089. In 2013 the total reached $211 billion, averaging $5,988 per person.
Figures in National Health Expenditure Trends, 1975 to 2012, show that
the pace of growth is slowing. Modest economic growth and budgetary
deficits are having a moderating effect. For the third straight year,
growth in healthcare spending will be less than that in the overall
economy. The proportion of Canada's gross domestic product will reach
11.6% in 2012 down from 11.7% in 2011 and the all-time high of 11.9% in
2010. Total spending in 2007 was equivalent to 10.1% of the gross domestic product which was slightly above the average for
OECD countries, and below the 16.0% of GDP spent in the United States.
In 2009, the greatest proportion of this money went to
hospitals ($51B), followed by
pharmaceuticals ($30B), and
physicians ($26B).
The proportion spent on hospitals and physicians has declined between
1975 and 2009 while the amount spent on pharmaceuticals has increased.
Of the three biggest health care expenses, the amount spent on
pharmaceuticals has increased the most. In 1997, the total price of
drugs surpassed that of doctors. In 1975, the three biggest health costs
were hospitals ($5.5B/44.7%), physicians ($1.8B/15.1%), and medications
($1.1B/8.8%) while in 2007 the three biggest costs were hospitals
($45.4B/28.2% ), medications ($26.5B/16.5%), and physicians
($21.5B/13.4%).
Healthcare costs per capita vary across Canada with Quebec
($4,891) and British Columbia ($5,254) at the lowest level and Alberta
($6,072) and Newfoundland ($5,970) at the highest.
It is also the greatest at the extremes of age at a cost of $17,469 per
capita in those older than 80 and $8,239 for those less than 1 year old
in comparison to $3,809 for those between 1 and 64 years old in 2007.
According to a 2003 article by Lightman, "In-kind delivery in
Canada is superior to the American market approach in its efficiency of
delivery." In the US, 13.6 per cent of
GNP
is used in medical care. By contrast, in Canada, only 9.5 per cent of
GNP is used on the Medicare system, "in part because there is no profit
incentive for private insurers." Lightman also notes that the in-kind
delivery system eliminates much of the advertising that is prominent in
the US, and the low overall administrative costs in the in-kind delivery
system. Since there are no means tests and no bad-debt problems for
doctors under the
Canadian in-kind system, doctors billing and collection costs are reduced to almost zero.
History
Government involvement
The
various levels of government pay for about 70% of Canadians'
healthcare, although this number has decreased somewhat in recent years. The
Constitution Act, 1867
(formerly called the British North America Act, 1867, and still known
informally as the BNA Act) did not give either the federal or provincial
governments responsibility for healthcare, as it was then a minor
concern. However, the Act did give the provinces responsibility for
regulating hospitals, and the provinces claimed that their general
responsibility for local and private matters encompassed healthcare. 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
Judicial Committee of the Privy Council
decided that the administration and delivery of healthcare 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 healthcare 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 twenty
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's
Non-Insured Health Benefits
program has diminished drastically for optometry, dentistry, and
medicines. Status First Nations individuals qualify for a set number 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 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.
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 the 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.
Private sector
About
27.6% of Canadians' healthcare is paid for through the private sector.
This mostly goes towards services not covered or partially covered by
Medicare, such as
prescription drugs,
dentistry and
optometry.
Some 75% of Canadians have some form of supplementary private health
insurance; many of them receive it through their employers.
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. 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."
Capitation based models are used in some provinces as in place of or in parallel with the traditional fee for service model.
Physicians and medical organization
Canada,
like its North American neighbour the United States, has a ratio of
practising physicians to a population that is below the OECD average but a level of practising nurses that is higher than the OECD average, and below the US average in 2016.
Family physicians in Canada make an average of $202,000 a year.
Alberta has the highest average salary of around $230,000, while
Quebec
has the lowest average annual salary at $165,000, arguably creating
inter-provincial competition for doctors and contributing to local
shortages.
In 2018, to draw attention to the low pay of nurses and the declining
level of service provided to patients, more than 700 physicians,
residents and medical students in Quebec signed an online petition
asking for their pay raises to be canceled.
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. In 2008, the
Ontario Medical Association and the
Ontario government
agreed to a four-year contract with a 12.25% doctors' pay raise, which
was expected to cost Ontarians an extra $1 billion. Ontario's then-
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...".
In December 2008, the
Society of Obstetricians and Gynaecologists of Canada reported a critical shortage of
obstetricians and
gynecologists.
The report stated that 1,370 obstetricians were practising 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.
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;
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."
Because healthcare is deemed to be under provincial/territorial
jurisdiction, negotiations on behalf of physicians are conducted by
provincial associations such as the
Ontario Medical Association.
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. 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).
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 came in August 2007 when the CMA elected as president Dr.
Brian Day
of B.C., who owns the largest private hospital in Canada and vocally
supports increasing private healthcare 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.
Criticisms
Gender gap in healthcare
Disparities between men and women’s access to healthcare in Canada
have led to criticism, especially of healthcare privatization. While
most healthcare expenses remain covered by Medicare, privatization has
shifted payment for some medical services previously paid for publicly
to individuals and employer based supplemental insurance.
This shift has negatively affected women economically for two
reasons; first, because women are disproportionally poor and poorer than
men, individual payments are a greater burden;
second, because women disproportionally work part-time jobs and in
fields that do not offer supplemental insurance, in particular as
homemakers, they are less likely to have private insurance to cover the
costs of “services such as drugs."
The shift from public to private financing has also meant
additional labor for women to the extent that families disproportionally
rely on them to be caregivers. Less public financing has shifted care
to women, leaving “them with more support to provide at home.”
Women’s additional healthcare requirements further exacerbate the
gender gap. Although women make up approximately half of Canada's
population, they “receive the majority of healthcare in Canada." One reason for this extra care is due to gender specific healthcare needs, such as pregnancy.
Differences in wait times for diagnostic tests for women and men
also demonstrate a potentially harmful difference in healthcare. One
Canadian study reports, "mean wait times are significantly lower for men
than for women pertaining to overall diagnostic tests: for
MRI, 70.3 days for women compared to 29.1 days for men." Longer wait times have been associated with a higher risk of health complications.
There has been evidence that members in the
LGBT community,
especially those in poverty, receive treatment at less than
satisfactory levels. In a research study by Lori Ross and Margaret
Gibson, they argue that a flaw in the Canadian healthcare system with
respect to the LGBT community is that LGBT members are the highest
needing demographic of mental health services. This is due to reasons
that, according to the study, can be attributed by systemic
discrimination, and because of this they need to turn to mental health
services which are mainly private and not covered by the publicly funded
healthcare policy.
They make the argument that low income LGBT members might not be able
to afford these private programs and subsequently fall into deeper
mental health issues. In another research paper by Emily Colpitts, she
adds that for the case in Nova Scotia, members of the LGBT community are
left to read ambiguous language in their health policies. "Goins and
Pye found that the heteronormative and
gender-binary language
and structure of medical intake forms have the consequence of
alienating LGBT populations". She also adds that in the previous study
of queer and transgender women in Nova Scotia, patients experienced
significant discomfort in their meetings with healthcare providers and
feared that because of the language of health policy, they would not be
able to receive adequate healthcare based on their
sexual identities.
Another author, Judith MacDonnell, exemplifies that LGBT members,
especially childbearing lesbians, have trouble navigating through health
policy. She states in her study that LBGT women encounter challenges at
every point of the childbearing process in Canada and have to rely on
personal and professional means to receive information that they can
understand, such as in reproductive health clinics and
postpartum/parenting support.
Inequality in care for refugees
There may be gaps in knowledge about the
healthcare needs of refugees in Canada that public health initiatives and policies need to take into account.
Immigrants and refugees are among the groups most at risk for negative
health effects that result from persistent health disparities.
Disparities from race, socioeconomic status, poverty, citizenship
status, and other social factors exposed them to various inequalities. The healthcare needs of
refugees is unique in that they often require additional care than normal immigrants due to conditions in their home country.
The passing of the
Protecting Canada's Immigration System Act
in 2012 furthered inequalities in healthcare for refugees. The act
formed a tiered system that classified refugees and separated care based
on these classifications. Differing levels of care were provided to refugees based on the refugee's home country and other factors.
Protecting Canada's Immigration System Act also had an impact on
the levels of healthcare coverage for refugees provided by the Interim
Federal Health Program (IFHP). The reforms of 2012 saw cuts to coverage
for refugees by the IFHP which represents another unequal divide in
healthcare between the general populace and refugees.
Some of the results of the changes in the healthcare programs for refugees is that there appears to be a rise in
emergency room
(ER) visits due to lack of provisions of healthcare to refugees. This
effect worried some people in Canada who believed that the cost of
healthcare will rise due to an increase in ER visits from refugees that
have health concerns not cared for under IFHP.
The cuts to IFHP also made funding uncertain for programs that helped pay for ER costs, according to one study.
The changes came from the 2012 reforms, which suggested that refugees
receive a much lower level of care than the general populace in Canada.
In July 2014, Canada's Federal Court ruled that denying health
services to asylum seekers was "cruel and unusual treatment" and
therefore unconstitutional.
Open dialogue among policymakers, clinicians, and researchers and
working with settlement programs is essential to effectively respond to
challenges encountered by Canada's primary healthcare system with
regards to refugees, suggested one study.
Supporting primary care and focusing on social accountability training
in medical schools are needed to ensure sustainability of primary health
care system response to refugees.
Wait times
Health Canada, a
federal department,
publishes a series of surveys of the healthcare system in Canada based
on Canadians' first-hand experiences of the healthcare system.
Although life-threatening cases are dealt with immediately, some
services needed are non-urgent and patients are seen at the
next-available appointment in their local chosen facility.
The median wait time for diagnostic services such as MRI and CAT scans is two weeks with 86.4% waiting fewer than 90 days. The median wait time for elective or non-urgent surgery is four weeks with 82.2% waiting fewer than 90 days.
A 2016 study by the
Commonwealth Fund,
based in the U.S. found that Canada's wait time for all categories of
services ranks either at the bottom or second to the bottom out of the
group of eleven surveyed countries (Australia, Canada, France, Germany,
Netherlands, New Zealand, Norway, Sweden, Switzerland, the United
Kingdom and the United States). Canada's wait time on emergency services
is the longest among the eleven nations, with 29% of Canadians
reporting that they waited for more than four hours the last time they
went to an emergency department. Canada also has the longest wait time
for specialist appointments, with 56% of all Canadians waiting for over
four weeks. Canada ranks last on all other wait time categories,
including same or next-day appointments, same-day answers from doctors,
and elective surgeries, except for access to after-hour care which only
Sweden ranks lower. The study also noted that despite government
investments, Canada's wait time improvements are negligible when
comparing to the 2010 survey.
Dr. Brian Day
was once quoted 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."
Day gave no source for his two to three years claim. The Canadian
Health Coalition has responded succinctly to Day's 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."
Regional administrations of Medicare across Canada publish their own
wait-time data on the Internet. For instance, in British Columbia the
wait time for an elective hip replacement is currently a little under
ten weeks.
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.
Since 2002, the Canadian government has invested $5.5 billion to decrease wait times. In April 2007, 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 healthcare 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.
The current cultural shift towards evidence-based medicine is
burgeoning in Canada with the advent of organizations like Choosing
Wisely Canada.
Organizations like this hope to encourage and facilitate doctor-patient
communication, decreasing unnecessary care in Canada, and therefore
hopefully decreasing wait times.
In a 2007 episode of
ABC News's
20/20 titled "Sick in America," libertarian
John Stossel cited numerous examples of Canadians who did not get the healthcare that they needed. The
conservative Fraser Institute
found that 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, contradicting the Canadian government's 2007 report regarding itself.
An important waiting time issue is that waiting times for the
same procedures can vary wildly between hospitals and provinces. In the
province of Ontario, the average waiting time for a knee replacement is
an average of 115 days (3 months and 4 weeks); however, average waiting
times for individual hospitals vary from 45 days (1.5 months) to 397
days ( about 1 year and 1 month).
This waiting time was up by more than 50% from reported waiting times
in 5 Ontario hospitals from 1985-1990 (a median of 9.5 weeks, or about 2
months and 0.5 weeks), which was considered acceptable by most
patients.
Waiting times for knee replacements are much longer in Nova Scotia,
ranging from 88 days (almost 3 months) to 350 days (about 11.5 months),
with the hospitals in the middle range averaging 199 to 223 days (about 6
months 2.5 weeks to about 7 months 1.5 weeks).
Some patients wait significantly shorter times, while the longest
waits can be a good deal longer than the average. In contrast, Denmark
has had a 2-month waiting time guarantee for elective surgery (although
this may not always have been met, and does not itself show the rates of
surgery performed) (citation needed), while in Germany, the Netherlands
and Switzerland (all with near-universal coverage) the majority of
patients contacted reported waiting less than 1 month for elective
surgery (an average of 5 weeks for hip and knee replacements in the
Netherlands).
Surveys on waiting times for elective surgery show that the
percentage of patients who reported waiting a long time for elective
surgery increased greatly in the 1990's, suggesting that waiting times
were much shorter before then (citation needed). Anecdotal (and
therefore weak) evidence suggests that waiting times were not perceived
as a major problem by the public before cutbacks in the 1990's at a time
of greatly increased demand for health care (citation needed).
Another issue is total waiting time. Ontario knee replacement
recipients waited an average of 72 days to see an orthopedic surgeon (2
months 11 days), giving a total average waiting time of 177 days (about
5 months and 4 weeks) from referral to treatment.
Sometimes, waiting times can be affected by temporary specialist
shortages relative to demand rather than urgency, although patients
waiting on the same list are often triaged; the author of this paragraph
only waited a little over 3 months to see a dermatologist because of a
skin problem that itched slightly once a week and was not at all urgent
(in the early 2000s) in Halifax, Nova Scotia, while cumulative waiting
times (including referral to medical test to appointment with a surgeon
to radiation or cancer surgery) for cancer patients can be 2–3 months in
areas with long waiting times. Waiting lists for cancer treatment are
prioritized by level of urgency, but the triage process (while generally
accurate) can occasionally assign a low priority to what turned out to
be an urgent case.
Counter-criticism: Some longer wait times can benefit patients
It
has been speculated and supported in data (from a report conducted in
1998) that the complete elimination of all waiting times is not ideal.
When waiting lists arise through a prioritization process based on
physician-determined medical urgency and the procedure's risk, (in
contrast to patient's ability to pay or profitability for the
physician), waiting lists can possibly help patients. It has been
postulated that a system of immediate care can be detrimental for
optimal patient outcomes, as unnecessary or unproven surgery might not
be easily avoided if all patients are granted instant care.
An example is the Canadian province of
British Columbia,
where, according to surgeon Dr. Lawrence Burr, 15 heart patients died
in 1990 while on a waiting list for heart surgery. According to Robin
Hutchinson, senior medical consultant to the Health Ministry's heart
program, had the waiting list not existed and all patients given instant
access to the surgery, the expected number of fatalities would have
been 22 due to the operation mortality rate at that time. Hutchison
noted that the
BC Medical Association's
media campaign did not make reference to these comparative statistics
and focused on deaths during waiting for surgery. Since, ideally,
waiting lists prioritize higher-risk patients to receive surgery ahead
of those with lower risks, this helps reduce overall patient mortality.
Consequently, a wealthy or highly insured patient in a system based on
profit or ability to pay (as in the U.S.) may be pushed into surgery or
other procedures more quickly, with a result in higher
morbidity
or mortality risk. This is in addition to the better-understood
phenomenon in which lower-income, uninsured, or under-insured patients
have their care denied or delayed, also resulting in worse health care. It is also important that deaths
on
a waiting list are also not all due to the wait, since a patient
waiting for a knee replacement can die of an unrelated accident or
illness.
Restrictions on privately funded healthcare
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.
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.
In 2006, the Government of British Columbia threatened to shut
down one private clinic because it was planning to start accepting
private payments from patients.
Since 2008, Dr. Brian Day has been suing the British Columbia
government on the basis that the Canada Health Act is unconstitutional.
In 2016, the Government of Quebec was sued for passing Bill 20, which
allows and regulates add-on fees.
Cross-border health care
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.
Canadians visiting the US to receive healthcare
Some
residents of Canada travel to the United States for care. A study by
Barer, et al., indicates that the majority of Canadians who seek
healthcare in the U.S. are already there for other reasons, including
business travel or vacations. A smaller proportion seek care in the U.S.
for reasons of confidentiality, including abortions, mental illness,
substance abuse, and other problems that they may not wish to divulge to
their local physician, family, or employer.
Canadians offered free care in the US paid by the Canadian
government have sometimes declined it. In 1990 the British Columbia
Medical Association ran radio ads asking, "What's the longest you'd wait
in line at a bank before getting really annoyed? Five minutes? Ten
minutes? What if you needed a heart operation?" Following this, the
government responded, as summarized by Robin Hutchinson, senior medical
consultant for the health ministry's heart program. Despite the
medically questionable nature of heart bypass for milder cases of chest
pain and follow-up studies showing heart bypass recipients were 25-40%
more likely to be relieved of chest pain than people who stay on heart
medicine, the "public outcry" following the ads led the government to
take action:
"'We did a deal with the University of Washington at
Seattle' said Hutchinson.. to take 50 bypass cases at $18,000 per head,
almost $3,000 higher than the cost in Vancouver, with all the money
[paid by] the province. In theory, the Seattle operations promised to
take the heat off the Ministry of Health until a fourth heart surgery
unit opened in the Vancouver suburb of New Westminster. If the first
batch of Seattle bypasses went smoothly..then the government planned to
buy three or four more 50-head blocks. But four weeks after announcing
the plan, health administrators had to admit they were stumped. 'As of
now..we've had nine people sign up. The opposition party, the press,
everybody's making a big stink about our waiting lists. And we've got
[only] nine people signed up! The surgeons ask their patients and they
say, "I'd rather wait", We thought we could get maybe two hundred and
fifty done down in Seattle..but if nobody wants to go to Seattle, we're
stuck,'".
An analysis using data from the 1996–1997 National Population Health
Survey (NPHS—a large survey representative of the Canadian
noninstitutionalized population, including 17,276 Canadian residents)
reported that 0.5% sought medical care in the US in the previous year.
Of these, less than a quarter had traveled to the U.S. expressly to get
that care.
This was supported by additional analysis performed from the American
side, using a structured telephone survey of all ambulatory care
clinical facilities located in specific heavily populated U.S. urban
corridors bordering Canada and discharge data for 1994–1998 from major
border states, and contacted key informants at each of
U.S. News and World Report's "America's Best Hospitals" to inquire about the number of Canadians seen in both inpatient and outpatient settings.
The authors characterized this rate of medical travel as "barely
detectable relative to the use of care by Canadians at home" and that
the results "do not support the widespread perception that Canadian
residents seek care extensively in the United States." A separate report issued privately rather than in a
peer reviewed journal by the
conservative Fraser Institute think tank
found that the percentage of Canadian patients who traveled abroad to
receive non-emergency medical care was 1.1% in 2014, and 0.9% in 2013,
with
British Columbia being the province with the highest proportion of its citizens making such trips.
Some Canadian politicians have traveled to the United States for treatment, which is viewed variously as ironic or cynical.
Prime Minister
Jean Chrétien traveled to the
Mayo Clinic twice in 1999 for medical care. Chrétien allegedly kept the visits a secret, with one occurring during a publicly announced ski trip to Vancouver.
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. Prior to this incident, Stronach had stated in an interview that she was against
two-tier health care.
When
Robert Bourassa, the premier of Quebec, needed cancer treatment, he went to the US to get it.
In 2010, Newfoundland and Labrador Premier
Danny Williams traveled to the US for heart surgery.
In 2007, it was reported that Canada sent scores of pregnant women to the US to give birth. 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 were no
Canadian hospitals with enough neonatal intensive beds to accommodate
the extremely rare quadruple birth.
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."
In 2005,
Shona Holmes of
Waterdown, Ontario,
traveled to the Mayo Clinic after deciding she couldn't afford to wait
for appointments with specialists through the Ontario health care
system.
She has characterized her condition as an emergency, said she was
losing her sight, and portrayed her condition as life-threatening brain
cancer. OHIP did not reimburse her for her medical expenses. In 2007 she
joined a lawsuit to force the Ontario government to reimburse patients
who feel they had to travel outside of Canada for timely, life-saving
medical treatment. In July 2009 Holmes agreed to appear in television
ads broadcast in the United States warning Americans of the dangers of
adopting a Canadian style health care system. After her ad appeared
critics pointed out discrepancies in her story, including that
Rathke's cleft cyst, the condition she was treated for, was not a form of cancer, and was not life-threatening. In fact, the mortality rate for patients with a Rathke's cleft cyst is zero percent.
Americans visiting Canada to receive healthcare
Some US citizens travel to Canada for health care related reasons. These reasons frequently involve seeking lower costs.
Many US citizens purchase
prescription drugs
from Canada, either over the Internet or by traveling there to buy them
in person, because prescription drug prices in Canada are substantially
lower than
prescription drug prices in the United States; this cross-border purchasing has been estimated at $1 billion annually.
Limited coverage
- Limited coverage for mental health
The Canada Health Act covers the services of
psychiatrists,
medical doctors with additional training in
psychiatry. In Canada, psychiatrists tend to focus on the treatment of mental illness with medication. However, the Canada Health Act excludes care provided in a "hospital or institution primarily for the mentally disordered." Some institutional care is provided by provinces. The Canada Health Act does not cover treatment by a
psychologist or
psychotherapist unless the practitioner is also a medical doctor.
Goods and Services Tax or
Harmonized Sales Tax (depending on the province) applies to the services of psychotherapists.
Some coverage for mental health care and substance abuse treatment may
be available under other government programs. For example, in Alberta,
the province provides funding for mental health care through Alberta
Health Services.
Most or all provinces and territories offer government-funded drug and
alcohol addiction rehabilitation, although waiting lists may exist.
The cost of treatment by a psychologist or psychotherapist in Canada
has been cited as a contributing factor in the high suicide rate among
first responders such as police officers,
EMTs and
paramedics.
According to a CBC report, some police forces "offer benefits plans
that cover only a handful of sessions with community psychologists,
forcing those seeking help to join lengthy waiting lists to seek free
psychiatric assistance."
Limited coverage for oral health
Oral healthcare
is essential in one's life and is necessary for the overall quality and
health of one's self. "Although since dental diseases are usually
non-life-threatening it tends to be seen on the back burner of public
health. Based on a wide range of metrics, we can state definitively that
Canada is among the world leaders when it comes to the overall oral
health of its citizens."
Dental healthcare in Canada may have more positives than other
countries but still needs work. Having said this, more recently the
focus of dental healthcare in Canada has been found to be one of an
issue more than a benefit. "Equity in dental care use has recently
gained more prominence as a health policy issue in Canada and in other
OECD nations." It is said that among the
OECD
countries, Canada ranks approximately second to last in the department
of public financing of oral healthcare. Those who are in need of dental
care are usually responsible for the finances and some may benefit from
certain actions such as coverage available through employment, under
provincial plans, or private dental care plans. "As opposed to its
national system of public health insurance, dental care in Canada is
almost wholly privately financed, with approximately 60% of dental care
paid through employment-based insurance, and 35% through out-of-pocket
expenditures [7,8]. Of the approximately 5% of publicly financed care
that remains, most has focused on socially marginalized groups (e.g.,
low-income children and adults), and is supported by different levels of
government depending on the group insured [9]."
It is sadly true that compared to primary care checkups, dental care
checkups are highly relied on the ability of people being able to pay
those fees. While viewing studies done in the cities of
Quebec as well as
Ontario
a few interesting facts were seen. For example, studies in Quebec
showed that there was a strong relation among dental services and the
socioeconomic factors of income and education whereas in
Ontario
older adults heavily relied on dental insurance with visits to the
dentist. "According to the National Public Health Service in 1996/1997,
it showed a whopping difference of people who were in different classes.
About half of Canadians aged 15 or older (53%) reported having dental
insurance (Table 1). Coverage tended to be highest among middle-aged
people. At older ages, the rate dropped, and only one-fifth of the
65-or-older age group (21%) was covered."
Attributes that can contribute to these outcomes is household income,
employment, as well as education. Those individuals who are in the
middle class may be covered through the benefits of their employment
whereas individuals who are older may not due to the fact of retirement.
- Limited coverage for physiotherapy, occupational therapy and massage therapy
Coverage for services by
physiotherapists,
occupational therapists (also known as OTs) and Registered
Massage Therapists
(RMTs) varies by province. For example, in Ontario the provincial
health plan, OHIP, does cover physiotherapy following hospital discharge
and occupational therapy
but does not cover massage therapy. To be eligible for coverage for
physiotherapy in Ontario, the insured individual has to have been
discharged as an inpatient of a hospital after an overnight stay and
require physiotherapy for the condition, illness or injury for which he
or she was hospitalized, or be age 19 or younger or age 65 or older.
- Limited coverage for podiatry
Coverage varies for care related to the feet. In Ontario, as of 2019,
Medicare covers between $7–16 of each visit to a registered
podiatrist up to $135 per patient per year, plus $30 for x-rays.
Although the elderly, as well as diabetic patients, may have needs that
greatly exceed that limit, such costs would have to be covered by
patients or private supplemental insurance.
- Limited coverage for sex reassignment surgery
As of 2014, most, but not all provinces and territories provide coverage for
sex reassignment surgery (also known as gender confirming surgery) and other treatment for
gender dysphoria. In Ontario, sex reassignment surgery requires prior approval before being covered.
- Limited coverage for assistive devices
There are wide discrepancies in coverage for various assistive
devices such as wheelchairs and respiratory equipment in Canada.
Ontario, which has one of the most generous programs, pays 75% of the
cost for listed equipment and supplies for persons with a disability
requiring such equipment or supplies for six months or longer.
The program does not have age or income restrictions. As with other
health coverage, veterans and others covered by federal programs are not
eligible under the provincial program. Only certain types of equipment
and supplies are covered, and within categories only approved models of
equipment from approved vendors are covered, and vendors may not charge
more than specified prices established by the government.
Coverage for seniors
As
people grow older the need for care tends to grow stronger and the need
for a well-rounded healthcare plan rises. Because Canada's public
policies come from the federal government as well as the provincial
governments, these two need to work together in order to create a
healthcare plan that is beneficial. There are quite a few plans in which
one, 65 years of age or older, can apply for in order to ensure they
are covered. These include:
Old Age Security (OAS),
Guaranteed Income Supplement (GIS), Allowance and,
Canada Pension Plan
(CPP). The OAS is one in which citizens who have lived in Canada for 10
or more years and are of age 65 or older can apply for. Those who have
received the benefit of OAS and have a low income can then apply for the
GIS. If a person has received the GIS, their spouse between the ages of
60–64 can apply for Allowance. Moving along, those who are in the
workforce tend to put money aside for the Canada Pension Plan (CPP) by
the time they reach age 65. The CPP is essentially a social insurance
program preparing individuals for retirement. To those who obtain the
CPP, they receive the benefit of the plan paying for things such as
retirement, disability, children's benefits, and more. "You must apply
for OAS, GIS, the Allowance, CPP and other federal programs. You will
not receive them automatically."
Although there are these beneficial plans, the need for a better plan
of action for seniors is in effect. Out of the approximately 39 million
people in Canada, roughly 6 million of these people consist of seniors.
"Given these challenges, it is not surprising that nine in ten (90%)
Canadians agree that Canada requires a national seniors strategy to
address needs along the full continuum of care."
In order to ensure maximum coverage of the elderly a few things need to
be in order. For starters, having a shorter wait time for these
seniors. As individuals grow older the more care is needed in order to
ensure a healthy body and lifestyle and wait times can put a damper on
this. Next, having specialized physicians who are knowledgeable with
handling seniors in a gentle and well-equipped way. "Restrictions on
government funding has limited access to care—wait-lists are routine,
and Canadians are increasingly having difficulties accessing the
services of family physicians. The system has not kept up with the
demands and expectations of the patient."
This puts stress on those seniors and the need to ensure everyone is
taken proper care of is essential having said that Canada is known to
'leave no Canadian behind'. And lastly, having continual care for these
elders is essential in ensuring the finest
health care
available for those in need. It is stated that individuals ages 55–64,
"Over half (55 per cent) have savings that represent less than one
year's worth of the resources they need to supplement government
programs like OAS/GIS and CPP/QPP. And fewer than 20 per cent have
enough savings to support the supplemented resources required for at
least five years."
With this being said, in order to ensure the coverage of all seniors,
the expansion of public policies are in need. And to reiterate the
federal government, as well as the provincial government, should work
together to create enhanced opportunities for these individuals.
Nursing homes and home care
There appear to be some problems within the
nursing home/
home care subsection of health care in Canada, and scholars and advocates point to an increasingly complex care system,
occupational hazards,
and an overall shortage of workers willing to work in this field as the
main causes. Authors Ruth Lowndes and James Struthers in their
dissertation say that there has been an intensification of job
precarity, inadequate staffing levels as well as increasingly complex
needs including different types of routinized, assembly-lines types of
work, and cost-cutting on equipment and supplies. They also point out
that within increasing elder
population, the supply of workers is not meeting the demand required to provide adequate care.
This idea couples with another study that as we enter the 2020s and
30's, the equipment and processes that nurses undergo will become
progressively composite. This then leads to the need for higher
training and instruction to the existing nurses including the reliance
on them to think critically and execute real-time, evidence-based care
decisions which all point to a need to re-conceptualize HCAs.
In addition, it has been discovered that there are myriad possible
occupational hazards for workers in home care. Researcher Matthew Wong
uses
chi-square analysis and
posthoc pairwise tests with a
Bonferroni correction
to find out that occupational hazards home care nurses experience,
although depending on the type of geographical setting (rural, town,
suburban, urban areas), it is common to find that aggressive pets,
environmental tobacco smoke, oxygen equipment, unsafe neighborhoods and
pests, hinder a quality performance by the nurse from occurring.
Portability and provincial residency requirements
Canada
Health Act covers residents of Canada, which are persons "lawfully
entitled to be or to remain in Canada who makes his home and is
ordinarily present in the province, but does not include a tourist, a
transient or a visitor to the province."
When traveling within Canada, a Canadian's health card from his or her
home province or territory is accepted for hospital and physician
services.
Each province has residency and physical presence requirements to
qualify for health care coverage. For example, to qualify for coverage
in Ontario, with certain exceptions, one must be physically present in
Ontario for 153 days in any given 12-month period. Most provinces
require 183 days of physical presence in any given 12-month period.
Exceptions may be made for mobile workers, if the individual can provide
documentation from his or her employer verifying that the individual's
work requires frequent travel in and out of the province.
Transients, self-employed itinerant workers (e.g. farm workers) who
move from province to province several times within a year, and
peripatetic retired or unemployed individuals who move from province to
province (e.g. staying with various relatives, or living in a
recreational vehicle) may find themselves ineligible for health coverage
in any province or territory, even though they are Canadian citizens or
landed immigrants physically present in Canada 365 days a year.
"Snowbirds" (Canadians who winter in warm climates) and other Canadians
who are out their home province or territory for a total of more than
183 days in a twelve-month period lose all coverage, which is reinstated
after a three-month waiting period.
Students attending a university or college outside their home province
are generally covered by the health insurance program of their home
province, however, "Typically this coverage (while out-of-province but
within Canada) is for physician and hospital services only."
The Ontario Ministry of Health and Long Term Care, for example, states,
"Therefore, when traveling outside of Ontario but within Canada, the
ministry recommends that you obtain private supplementary health
insurance for non-physician/non-hospital services."
Such services might include prescription drugs, or ground and air
ambulance services that might be covered in one's home province.
Comparison to other countries
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 relatively low Canadian 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 topics are addressed.
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. According to the
Canadian Institute for Health Information, spending is expected to reach $160 billion, or 10.6% of GDP, in 2007. This translates to $4,867 per person.
In a sample of 13 developed countries Canada was tenth in its
population weighted usage of medication in 14 classes in 2009 and sixth
in 2013. The drugs studied were selected on the basis that the
conditions treated had a high incidence, prevalence and/or mortality,
caused significant long-term morbidity and incurred high levels of
expenditure and significant developments in prevention or treatment had
been made in the last 10 years. The study noted considerable
difficulties in cross border comparison of medication use.
A 2017
cost-effectiveness analysis by the
Fraser Institute
showed that "although Canada ranks among the most expensive
universal-access health-care systems in the OECD, its performance for
availability and access to resources is generally below that of the
average OECD country, while its performance for use of resources and
quality and clinical performance is mixed."
x.jpg)
