Canadian healthcare

Universal v. Selective Public Benefits:

"Universality" means available to everyone who falls into a classification (under 16, over 65, a legal resident of the province for more than 3 months) "Selectivity" means benefits are targeted at individuals with specified needs - i.e. there are eligibility criteria Universal government programs appeal to the middle class, avoid stigma and improve social solidarity Selective programs have the potential of greatest benefit for the least cost Trend in all western welfare states away from universal benefits (e.g. OAS, Family Allowances) toward targeted benefits (e.g. GIS, Child Tax Credit)

Portability

A resident that moves to a different province or territory is still entitled to coverage from their home province during a minimum waiting period. This also applies to residents which leave the country.

Canada Health Act

About fiscal transfers, not about health or health care Does not prohibit, in fact does not mention, private financing of health care or private health care facilities Instead, allows federal government to reduce cash transfer made to a province if the province permits charges to be made to patients for insured medical or hospital services ("medically necessary services") Does not apply to health services that were not part of the original hospital and health care insurance deals (1957 and 1966 respectively) Applies only to medically essential services provided by doctors and related essential hospital services Does not apply to home care, drugs, physiotherapy, non-hospital long term care, alternative therapies, dentistry, etc.. Unevenly enforced (some say not really enforced at all) Mistakenly thought to "ban" patient charges, or "prohibit" private care, or "forbid" private insurance -- it does none of those things

Public Administration:

All administration of provincial health insurance must be carried out by a public authority on a non-profit basis. They also must be accountable to the province or territory, and their records and accounts are subject to audits.

Accessibility

All insured persons have reasonable access to health care facilities. In addition, all physicians, hospitals, etc, must be provided reasonable compensation for the services they provide.

Universality

All insured residents are entitled to the same level of health care.

Comprehensiveness

All necessary health services, including hospitals, physicians and surgical dentists, must be insured

Drugs:

Amounts prescribed and prices rising rapidly Many new (expensive) drugs no better clinically than old (cheap) drugs International trade agreements make it hard for Canada to regulate Direct to consumer advertising

Major CMA report 1943

Argued against fee-for-service and user fees and for capitation and salary Condemned private and employer-based programmes as inequitable, costly and responsible for fragmentation of care Recommended a nation-wide network of multi-disciplinary health centres staffed by salaried nurses and doctors

Politics and Policy:

CCF won 1944 Saskatchewan provincial election CCF moved into federal politics Federal government reports in 1943 and 1945 (Heagerty and Marsh) recommended a national health care plan as part of post-war reconstruction

Federal Government

Currency, banking Fiscal policy Foreign affairs Defence Criminal justice Aboriginal affairs

Provincial Health Care Activities Before Medicare

Direct provincial services Asylums Public Health Nursing Communicable disease control Sanitoria, care centres for severely disabled, and cancer care

Federal Activities Before Medicare:

Direct services Health of immigrants/quarantine (beginning 1867) Veterans' hospitals and homes (beginning 1918) Cottage hospitals and nursing stations for Indians and Inuit (beginning 1950s) Public service health Regulatory services Safety of food, drugs and medical devices

Big issues facing the Canadian health care system

Drugs Primary care Wait lists for elective procedures Quality improvement/error reduction Role of private sector Sustainability

Provincial Government

Education Health Care Social Services Highways Property and civil rights Municipal and local gov't

Social Policy Implications of Classical Liberal Residualism

• Focus on the family • Claim that issues belong to and should be dealt with by the family is equivalent to withdrawing those issues from public scrutiny and debate • Tacitly supports prevailing, traditional private arrangements • Embeds gender power and politics, existing rights of spouses and parents, vests control over access of family members to family resources to existing family power relations

Worlds of Welfare Capitalism

• Liberal Regimes (England, US, Canada) • Conservative Regimes (Spain, Italy, Japan) • Social Democratic Regimes (Sweden, Denmark, Norway) • Hybrids (Germany - social democratic & conservative; France - conservative & liberal

Government is the last resort

• Only if individual fails • AND family fails • AND community fails • should government step in

Liberal residualism:

• Privileges personal freedom, privacy, the individual and non-governmental entities such as families, voluntary organizations, and private business • Downplays or ignores the potential downsides of personal and market (corporate) power over individuals • Emphasizes personal responsibility and self-reliance

five main principles in the Canada Health Act

• Public Administration: • Comprehensiveness: • Universality: • Portability: • Accessibility

Ideologies, values and social attitudes

• Residualism-in Liberal Societies. • Institutionalism- In social democratic societies.

Institutionalism

• The other main social policy belief in capitalist democratic societies (other than residualism) • Unlike residualism, holds that health and social services are rights of citizenship and should be provided on uniform terms and conditions to all people who meet the program's eligibility criteria • Core values of solidarity and equity*

Canada Health Act 2

Emmett Hall recommended clear federal conditions on health transfers to provinces in his 1983 report on extra billing, balance billing and user fees Federal policy makers influenced by study by Barer and Stoddard that showed user fees had implications for equity and hence undermined a core goal of medicare

Canadian Examples of Institutionalism

Employment Insurance (social insurance) Canada Pension Plan (social insurance) Old Age Security (universal) Medicare (universal)

Federalism and Health Policy

Federal governments Written constitutions Divisions of powers Canada Act (1982) and British North America Act (1867) http://laws.justice.gc.ca/en/const/index.html Charter of Rights and Freedoms

Political dynamics

Federal provincial health conferences are about fiscal transfers, not health policy The federal government aims for more consistency across Canada and more accountability regarding provincial spending Provinces aim for maximum federal cash and minimum federal interference

Between 1945 and 1948, the federal government established

Grants-in-aid for health organization and planning (modelled on a similar US programme) Grants to provinces wishing to establish health insurance programmes Grants to provinces for hospital construction The Department of National Health and Welfare (now Health Canada)

Section 92 matters of sole provincial authority

Hospitals Property and civil rights Roads Matters of purely local concern

Provincial Health

Hospitals and medical care Regulation of health professions Communicable disease control and public health Mental health Addictions Maternal, child and school health Vital statistics and health information Cancer care

Health Care System Overview:

Hospitals were private not-for-profit corporations but were publicly funded through hospital insurance Medical services are privately provisioned but mostly publicly paid Allied health services and drugs are privately provisioned and sometimes partially insured Pharmaceuticals are the most rapidly rising cost -- more public money is now spent on them than on doctors' services Coverage for prescription drugs varies from province to province Many elements of community services are privately provisioned (typically by not-for-profits) under government contract Public health services have always been provided directly by government In Canada, about 70% of health care is publicly funded -- a lower proportion than in European countries but a higher proportion than in the US Wrong to assume health care services are publicly funded through unified, single tier system Political dynamics:

Quality Improvement:

Iatrogenesis Medical and nursing error Adverse drug reactions Hospital acquired infections Over and under servicing Health information and patient records

Medically necessary care free at point of service ("accessibility"):

In late 1970s and early 1980s, proliferation of user fees and "extra billing" in wake of provincial efforts to cut health care utilization, hospital budgets and payments to doctors

In sum:

Institutionalism emphasizes each person's responsibility toward others, membership in a community, and the concept of citizenship (rights and obligations associated with living together in a politically organized society) Institutionalism values protecting individuals from the power of others, including unfair gender relations, corporate power and personal power wielded by families, churches, etc.

Wait lists

More money or more management? Poor data Need for proper ongoing assessment/triage Need to manage better choke points such as OR scheduling, ICU capacity, ward capacity, etc. Human resources: nurse and technical staff shortages

How do we know health care is a provincial responsibility?

One important JCPC decision involved the Federal Employment and Social Insurance Act, which included national health care benefits (1935) It was challenged by the provinces and ruled unconstitutional, a ruling later accepted by the Canadian Supreme Court Result is that social welfare and health care programs fall under provincial jurisdiction

Primary health care

Problem of rural health care Acute shortage of physicians Scope of practice/role issues Alternative payment mechanisms Hard to serve populations Collapse of family practice/gp hospital interface Chronic disease management

Provincial regulatory services

Public health inspection Drinking water and waste water Health professions Regulation of hospitals, long term care facilities

Federal Health:

Safety of food, drugs and medical surgical supplies Promotion of health of Canadians Quarantine and health of immigrants Health of federal "wards" First Nations people on reserve Federal prisoners Federal public servants Members of armed forces

Section 91 items of exclusive federal authority

Trade Commerce Banking, currency and credit Criminal law Citizenship Defence Matters of peace, order and good government

Importance of NGOs

Voluntary sector/faith groups Seen as superior to public programs because no compulsory membership or taxes associated with them - "voluntary" Again, consigns issues which may be of public concern to private sphere and withdraws them from public scrutiny/debate Often means for individuals no support or limited support May also mean oppression (group dominance)

Canadian Healthcare Act

is a piece of Government of Canada legislation, adopted in 1984, which specifies the conditions and criteria with which the provincial and territorial health insurance programs must conform in order to receive federal transfer payments under the Canada Health Transfer. These criteria require universal coverage of all insured services (for all "insured persons").[1] "Insured health services" include hospital services, physician services, and surgical-dental services provided to insured persons, if they are not otherwise covered, for example by provincial workers' compensation programmes.

Canadian Medicare

is the national health care system of Canada. Canada has a publicly funded, single-payer health care system consisting of 13 provincial and territorial health insurance plans that provides universal health care coverage to Canadian citizens, permanent residents and certain temporary residents. It is administered on a provincial or territorial basis, within the guidelines set by the federal government.[1] The formal terminology for the insurance system is provided by the Canada Health Act and the health insurance legislation of the individual provinces and territories.

Residualism: the underlying value in Liberal Regimes like Canada:

• Construes collective social obligations narrowly and places emphasis on the role of the private market • Government involvement is not the first response, but the last resort • Between the individual and the state (government) is, first, the family, and second, the voluntary sector (churches, charities)