The term medicare (in lowercase) (assurance maladie) is the unofficial name for Canada's universal publicly funded health insurance system. 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.
Under the terms of the Canada Health Act, all "insured persons" (basically, legal residents of Canada, including permanent residents) are entitled to receive "insured services" without co-pays. Such services are defined as medically necessary services if provided in hospital, or by 'practitioners' (usually physicians).. Approximately 70% of Canadian health expenditures come from public sources, with the rest paid privately (both through private insurance, and through out-of-pocket payments). The extent of public financing varies considerably across services. For example, approximately 99% of physician services, and 90% of hospital care, are paid by publicly funded sources, whereas almost all dental care is paid for privately. Most doctors are self-employed private entities.
Canada uses a mix of public and private organizations to deliver health care; in turn, these organizations bill the provincial health authorities, with few exceptions. Hospitals are largely non-profit organizations, historically often linked to religious or charitable organizations. In some provinces, individual hospital boards have been eliminated and combined into quasi-private regional health authorities, subject to varying degrees of provincial control. Laboratory services are often delivered by for-profit investor-owned corporations.
With rare exceptions, medical doctors are small for-profit independent businesses. Historically, they have practiced in small solo or group practices and billed the medicare system on a fee for service basis. Unlike the practice in some other countries, hospital-based physicians were rarely hospital employees, and also billed the provincial insurance plans on a fee-for-service basis. Since 2000, physicians have been allowed to incorporate for tax reasons (dates of authorization vary province to province). However, efforts to achieve primary health care reform have increasingly encouraged physicians to work in multidisciplinary teams, and be paid through blended funding models, including elements of capitation and other 'alternative funding formulas'. Similarly, some hospitals (particularly teaching hospitals and rural/remote hospitals) have also experimented with alternatives to fee-for-service.
In summary, the system is known as a "public system" due to its public financing, but is not a nationalized system such as the UK's NHS; most medicare services are provided privately.
An additional complexity is that, because health care is deemed to be under provincial jurisdiction, there is not a "Canadian health care system". As noted, most providers are private, and may or may not coordinate their care. Publicly-funded insurance is organized at the level of the province/territory; each manages its own insurance system, including issuing its own healthcare identification cards (a list of the provincial medical care insurance programs is given at the end of this entry). Once care moves beyond the services required by the Canada Health Act - for which universal comprehensive coverage applies - there is inconsistency from province to province in the extent of publicly-funded coverage, particularly for such items as outpatient drug coverage and rehabilitation, as well as vision care, mental health, and long-term care, with a substantial portion of such services being paid for privately, either through private insurance, or out-of-pocket. Eligibility for these additional programs may be based on various combinations of such factors as age (e.g., children, seniors), income, enrollment in a home care program, or diagnosis (e.g., HIV/AIDS, cancer, cystic fibrosis).
The Canada Health Act requires coverage for all medically necessary care provided in hospitals or by physicians; this explicitly includes diagnostic, treatment and preventive services. Coverage is universal for qualifying Canadian residents, regardless of income level. Services of non-physicians working within hospitals are covered; but provinces can, but are not forced to, cover services by non-physicians if provided outside hospitals. Changing the site of treatment may thus change coverage. For example, pharmaceuticals, nursing care, and physical therapy must be covered for inpatients, but there is considerable variation from province to province in the extent to which they are covered for patients discharged to the community (e.g., after day surgery). The need to modernize coverage was pointed out in 2002 by both the Romanow Commission and by the Kirby committee of the Canadian Senate (see External links below). Similarly, the extent to which non-physician providers of primary care are funded varies; Quebec offers primary health care teams through its CLSC system).
The range of services for vision care coverage also varies widely among the provinces. Generally, "medically required" vision care is covered if provided by physicians (cataract surgery, diabetic vision care, some laser eye surgeries required as a result of disease, but not if the purpose is to replace the need for eyeglasses). Similarly, the standard vision test may or may not be covered. Some provinces allow a limited number of tests (e.g., no more than once within a two-year period). Others, including Ontario, Alberta and Saskatchewan, do not, although different provisions may apply to particular sub-groups (e.g., diabetics, children).
Naturopathic services are covered in some cases, but homeopathic services are generally not covered. Chiropractic is partially covered in some provinces. Cosmetic procedures are not typically covered. Psychiatric services (provided by physicians) are covered, fee-for-service psychology services outside of hospitals or community based mental health clinics are usually not. Physical therapy, occupational therapy, speech therapy, nursing, and chiropractic services are often not covered unless within hospitals. Some provinces, including Ontario include some rehabilitation services for those in the home care program, those recently discharged from hospitals (e.g., after a hip replacement), or those in particular age categories. Again, considerable variation exists, and provinces can (and do) alter their coverage decisions.
It has increasingly become a source of controversy in Canadian politics. As a recent report from the Health Council of Canada has noted "Herein lies one of the puzzles of Canadian health care: Canadians increasingly view the health care system as unsustainable and under threat, even as their own experiences with the system are mostly positive."
As analysts have noted, the root of the concern may be traced to successful cost control efforts in the mid 1990s, where public health expenditure per capita, in inflation-adjusted dollars, actually fell. These efforts arose from efforts by the federal government to deal with its deficit, which led to cuts in their transfers to the provinces, and in turn to squeezing hospital budgets and physician reimbursements. The number of physicians being trained was reduced. The result was seen in increased wait times, particularly for elective procedures. More recently, government has been reinvesting in health care, but public confidence has been slow to recover.
A number of studies have compared Canada with other countries, and concluded that each system has its own strengths and weaknesses. One widely-cited statistic which has been used to argue that Canada was under-performing came from the World Health Organization, which ranked Canada as 30th in 2000. However, the basis for these rankings has been highly contentious. As Deber noted, "The measure of "overall healthsystem performance" derives from adjusting "goal attainment" for educational attainment. Although goal attainment is in theory based on five measures (level and distribution of health, level and distribution of "responsiveness" and "fairness of financial contribution"), the actual values assigned to most countries, including Canada, were never directly measured. The scores do not incorporate any information about the actual workings of the system, other than as reflected in life expectancy. The primary reason for Canada's relatively low standing rests on the relatively high educational level of its population, particularly as compared to France, rather than on any features of its health system. Other countries had similar complaints, and the WHO has not repeated this ranking.
"Drawing from this foundation, First Ministers view this Accord as a covenant which will help to ensure that:
The accord set the following priority areas: primary health care, home care, catastrophic drug coverage, access to diagnostic/medical equipment and information technology and an electronic health record. The extent of progress in meeting reform goals has varied across these areas.
The debate about health care has also become heavily ideological. The Fraser Institute, a think tank supporting "competitive market solutions for public policy problems" is a frequent critic of medicare. It publishes yearly reports about wait times which are then used to argue that the system is both failing and unsustainable. Others criticize their methodology, which is based on physician perceptions rather than actual waits. Other complaints come from the political left, who object to 'privatization' (by which they usually mean a heavier involvement of for-profit providers). (See, for example, the Canadian Health Coalition web page. There are frequent debates in the media and on line between advocates and opponents of Canadian healthcare.
There are no barriers under the Canada Health Act to private clinics, although provincial governments may or may not permit them. Individual physicians can and do operate private clinics, but there are disputes as to whether surgical procedures can be performed. Two related issues have obstructed the growth of such clinics. One is regulatory - hospital-based quality assurance often failed to encompass them. This gap has been filled in most provinces, but sometimes only after celebrated incidents in which patients died in unregulated clinics, including one physician who performed cosmetic surgery in an Ontario hotel room. The second is economic - there may be no way for physicians to recoup the additional costs of running a surgical facility from their fees. Here, provinces can choose to offer 'facility fees' to these clinics, but doing so has often been contentious, particularly if hospitals felt that these costs would be better devoted to allowing them to increase their operating room time.
Note that uninsured persons can pay for care (including medical tourism), and that insured persons can still pay for uninsured services. These are both niche markets.
American opinion on Canadian medicare tends to be non-neutral, either supportive as in the preceding paragraph and therefore desirable within the USA, or negative and not desirable. Opinions not supportive of medicare put forth issues such as wait times and budget cuts having severely impaired the Canadian healthcare system, to the point where Canadian mothers have to go to the U.S. to deliver because of lack of room and nurses in Canadian hospitals.
Governments in Canada spend a smaller amount per capita on healthcare than governments in the United States, while almost every Canadian citizen is fully covered. In the United States a high percentage of the population is uncovered or only marginally covered, despite higher proportional spending along with large private investment. Even more people are just a job loss away from not having coverage (although in most cases the employer must maintain health care with copayment of the patient for a period of time after employment in the United States has gone down not up).
The lack of competition has given healthcare unions a monopoly on essential services, thus ensuring a very strong bargaining position. Nova Scotia is currently debating healthcare legislation aimed at removing the threat of striking healthcare workers and replacing it with binding arbitration.
Other critics of healthcare state that increased funding will not solve systematic problems in the healthcare system including a rising cost of medical technology, infrastructure, and wages. These critics say that Canada's proximity to the United States causes a "brain drain" or migration of Canadian-trained doctors and nurses (as well as other professionals) to the United States, where private hospitals can pay much higher wages and income tax rates are lower. Some of these critics argue that increased privatization of healthcare would improve Canada's health infrastructure.
Critics of the systematic reform approach state that healthcare should be kept public, (public in funding only, as most services are provided by the private sector including doctors who in most cases are private corporations) in part because it separates Canadians from Americans by mandating equality and fairness in health care. Truth is that the system is not a true public system, as in Italy, where doctors are on a per capita salary. The Canadian Health care system is merely publicly funded, which most Canadians appreciate and desire. Making the system a true public system is an alternative to the current half public, half private system.
Many family doctor practices have created their own clinics, offering 24-hour service for their patients if needed. Each doctor in the practice takes a turn at being "on call" on a rotating basis. Patients who have family doctors belonging to these practices are able to have a doctor come to their home in extreme situations. There is no additional charge for these services as they are billed to the Province, the same as an office visit.
Hospitals in some major Canadian cities, such as London, Ontario, have restructured their emergency services to share emergency treatment among several hospitals. One hospital may provide full emergency room care, while another sees patients who have broken limbs, minor injuries and yet another sees patients suffering cold, flu, etc.
While funding has decreased for these centres, and they have had to cut back, they have had a lower cost than the traditional fee-for-service approach. Many of these centres are filled to capacity in terms of general doctors, and there are often fairly long waiting lists and the centres also utilize nurse practitioners, who reduce the workload on the doctors and increase efficiency.
In Quebec, a recent legal change has allowed this reform to occur. In June 2005, the Supreme Court of Canada overturned a Quebec law preventing people from buying private health insurance to pay for medical services available through the publicly funded system and this ruling does not apply outside the province. See: Chaoulli v. Quebec (Attorney General)
In November 2005, the Quebec government announced that it would allow residents to purchase private medical insurance to comply with this ruling.
Private insurance from companies such as Blue Cross, Green Shield and Manulife have been available for many years to cover services not covered by Medicare, such as dental care and eye care. Private insurance is provided by many employers as a benefit.
The Canadian Medical Association (CMA) released a report in July 2007 endorsing private healthcare as a means to improve an ailing healthcare system. The current president of the CMA, Dr. Brian Day, is the owner of the largest private healthcare hospital in Canada and a proponent of mixed public and private healthcare in Canada.
It is generally accepted that physicians arriving in Canada from other countries must meet Canadian Health Practitioner standards. So there is concern that doctors from other countries are not trained or educated to meet Canadian standards. Consequently, doctors who want to practice in Canada must meet the same educational and medical qualifications as Canadian-trained practitioners, others suggest that the current regulatory bodies, the Canadian Medical Association, the Doctors Union, and the College of Physicians and Surgeons has created too much red tape to allow qualified doctors to practise in Canada. It should be noted that Canada's Health system is ranked 30th in the world, suggesting the logic of the doctor shortage defies the statistics. In fact according to a report by Keith Leslie of the Canadian Press in the Chronicle Journal, Nov 21, 2005, over 10,000 trained doctors are working in the United States, a country ranked 37th in the world. It would suggest money or the perception of better working conditions, or both, are resulting in an exodus of Canadian doctors (and nurses) to the USA.
It is important to recognize that many consider the doctor shortage in Canada to be a very severe problem affecting all sectors of health care. It may relate in part to the details of how doctors are paid; a detail often misunderstood. In Canada, almost all doctors receive a fee per-visit, not per-service. It has been suggested that this type of "fee-for-visit" payment system can encourage complexity, volume visits, repeat visits, referrals, and testing.
One consequence of the shortage in Canada is that a great many patients are left without family doctors, and trained specialists, making early intervention very difficult. As the article in the Toronto Star specially isolates, it is not so much a problem of a doctor shortage but of a shortage of 'licensed doctors'. Michael Urbanski states that Canada already has a hidden reserve of foreign-trained MDs eager to begin medical practice. "However, what's crucial to understanding the issue of doctor shortage in Ontario is that while the Liberal government is planning to go "poaching" for other countries' doctors, there are an estimated 4,000 internationally trained doctors right here in Ontario working at low-wage jobs."
A CBC report (August 21, 2006) on the health care system reports the following:
Dr. Albert Schumacher, former president of the Canadian Medical Association estimates that 75 per cent of health-care services are delivered privately, but funded publicly. "Frontline practitioners whether they're GPs or specialists by and large are not salaried. They're small hardware stores. Same thing with labs and radiology clinics …The situation we are seeing now are more services around not being funded publicly but people having to pay for them, or their insurance companies. We have sort of a passive privatization.
In a report by Keith Leslie of the Canadian Press in the Chronicle Journal, Nov 21, 2005, commenting on an Ontario Medical Association Report, prepared by the human resources committee states "The year 2005 finds the province in the midst of a deepening physician resources crisis". The report continues to report, "the government should make it easier for doctors from other provinces to work in Ontario and .... ". Here we have signs of inter-provincial competition affecting the doctor shortage in one province over another.. Essentially, privatized healthcare is not a choice of interest for lower income Canadians, it is most likely to be unaffordable and unfair to those who suffer on a social standard.
Though the Canada Health Act provides national guidelines for healthcare, the provinces have exclusive jurisdiction over health under the constitution and are free to ignore these guidelines, although if they ignore the guidelines, the federal government may deny federal funding for healthcare. All provinces currently abide by the Canada Health Act in order to receive this funding; however the Alberta legislature has considered proposals to ignore the Act to allow them to implement reforms not allowed under the Act.
The federal government has no direct role in the delivery of medicine in the provinces and territories so each province and territory has its own independent public health insurance program. Under the Canada Health Act, each province and territory must provide services to members of plans in other provinces and territories.
|Province||Name of plan|
|Alberta||Alberta Health Care Insurance Plan|
|British Columbia||Medical Services Plan|
|Newfoundland and Labrador||Newfoundland and Labrador Medical Care Plan|
|Northwest Territories||NWT Health Care Insurance Plan|
|Nova Scotia||Medical Service Insurance|
|Nunavut||Nunavut Health Care Plan|
|Ontario||Ontario Health Insurance Plan|
|Prince Edward Island||Medicare|
|Quebec||Assurance maladie (RAMQ Medicare)|
|Saskatchewan||Saskatchewan Medical Care Insurance Plan|
|Yukon||Yukon Health Care Insurance Plan|