Medicare (Canada)
Overview
Medicare is the unofficial name for Canada
Canada
Canada is a North American country consisting of ten provinces and three territories. Located in the northern part of the continent, it extends from the Atlantic Ocean in the east to the Pacific Ocean in the west, and northward into the Arctic Ocean...

's publicly funded
Public sector
The public sector, sometimes referred to as the state sector, is a part of the state that deals with either the production, delivery and allocation of goods and services by and for the government or its citizens, whether national, regional or local/municipal.Examples of public sector activity range...

 universal health insurance system
Universal health care
Universal health care is a term referring to organized health care systems built around the principle of universal coverage for all members of society, combining mechanisms for health financing and service provision.-History:...

. The formal terminology for the insurance system is provided by the Canada Health Act
Canada Health Act
The Canada Health Act is a piece of Canadian federal 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...

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 copayment
Copayment
In the United States, the copayment or copay is a payment defined in the insurance policy and paid by the insured person each time a medical service is accessed. It is technically a form of coinsurance, but is defined differently in health insurance where a coinsurance is a percentage payment after...

.
Encyclopedia
Medicare is the unofficial name for Canada
Canada
Canada is a North American country consisting of ten provinces and three territories. Located in the northern part of the continent, it extends from the Atlantic Ocean in the east to the Pacific Ocean in the west, and northward into the Arctic Ocean...

's publicly funded
Public sector
The public sector, sometimes referred to as the state sector, is a part of the state that deals with either the production, delivery and allocation of goods and services by and for the government or its citizens, whether national, regional or local/municipal.Examples of public sector activity range...

 universal health insurance system
Universal health care
Universal health care is a term referring to organized health care systems built around the principle of universal coverage for all members of society, combining mechanisms for health financing and service provision.-History:...

. The formal terminology for the insurance system is provided by the Canada Health Act
Canada Health Act
The Canada Health Act is a piece of Canadian federal 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...

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 copayment
Copayment
In the United States, the copayment or copay is a payment defined in the insurance policy and paid by the insured person each time a medical service is accessed. It is technically a form of coinsurance, but is defined differently in health insurance where a coinsurance is a percentage payment after...

. Such services are defined as medically necessary services if provided in hospital, or by 'practitioners' (usually physicians). Approximately 70% of Canadian health
Health care in Canada
Health care in Canada is delivered through a publicly-funded health care system, which is mostly free at the point of use and has most services provided by private entities. It is guided by the provisions of the Canada Health Act. The government assures the quality of care through federal standards...

 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.

History

Tommy Douglas
Tommy Douglas
Thomas Clement "Tommy" Douglas, was a Scottish-born Baptist minister who became a prominent Canadian social democratic politician...

 made significant contributions to the first implementation, for hospital care, in the province of Saskatchewan
Saskatchewan
Saskatchewan is a prairie province in Canada, which has an area of . Saskatchewan is bordered on the west by Alberta, on the north by the Northwest Territories, on the east by Manitoba, and on the south by the U.S. states of Montana and North Dakota....

 in 1946. Alberta followed with a similar program in 1950. Soon thereafeter, John Diefenbaker
John Diefenbaker
John George Diefenbaker, PC, CH, QC was the 13th Prime Minister of Canada, serving from June 21, 1957, to April 22, 1963...

's (federal) government implemented the HIDS Act of 1957, which was adopted by all provinces by 1961. Lester B. Pearson
Lester B. Pearson
Lester Bowles "Mike" Pearson, PC, OM, CC, OBE was a Canadian professor, historian, civil servant, statesman, diplomat, and politician, who won the Nobel Peace Prize in 1957 for organizing the United Nations Emergency Force to resolve the Suez Canal Crisis...

's government subsequently expanded this policy to universal health care with the Medical Care Act in 1966.. Some have argued that these developments towards public national health care came as a result of the Saskatchewan government's health plan in 1961-1962 by Douglas and Woodrow Stanley Lloyd
Woodrow Stanley Lloyd
Woodrow Stanley Lloyd was a Canadian politician who succeeded Tommy Douglas as Premier of the Province of Saskatchewan. Douglas left provincial politics to become leader of the federal New Democratic Party....

, who became premier of the province when Douglas resigned to become the leader of the new federal New Democratic Party
New Democratic Party
The New Democratic Party , commonly referred to as the NDP, is a federal social-democratic political party in Canada. The interim leader of the NDP is Nycole Turmel who was appointed to the position due to the illness of Jack Layton, who died on August 22, 2011. The provincial wings of the NDP in...

.

Funding

Funding for the insurance plans comes from the general revenues of the Canadian provinces/territories, assisted by transfer payments from the federal government through the Canada Health Transfer
Canada Health Transfer
The Canada Health Transfer is the Canadian government's transfer payment program in support of the health systems of the provinces and territories of Canada...

. Some provinces charge health care premiums, but these are in effect taxes (since they are not tied to service use, nor to provincial health expenditures). The system is accordingly classified by the OECD as a tax-supported system, as opposed to the social insurance approaches used in many European countries.
Currently, patients do not pay out of pocket costs to visit their doctor. Boards in each province regulate the cost, which is then reimbursed by the federal government.

Delivery

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
Health regions of Canada
Health regions of Canada are used to administer public health to Canadians. Public health is primarily a provincial jurisdiction in Canada's federal system, so health regions are organized and given responsibilities by the provinces, causing differences among the health units across the country.-...

, 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 hospital
Teaching hospital
A teaching hospital is a hospital that provides clinical education and training to future and current doctors, nurses, and other health professionals, in addition to delivering medical care to patients...

s 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
National Health Service
The National Health Service is the shared name of three of the four publicly funded healthcare systems in the United Kingdom. They provide a comprehensive range of health services, the vast majority of which are free at the point of use to residents of the United Kingdom...

; 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". 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
Canada Health Act
The Canada Health Act is a piece of Canadian federal 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...

 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
Michael J. L. Kirby
Michael J. L. Kirby, OC is a Canadian politician. He sat in the Canadian Senate as a Liberal representing Nova Scotia. Currently, he is the Chair of the Mental Health Commission of Canada....

 committee of the Canadian Senate (see External links below). Similarly, the extent to which non-physician providers of primary care are funded varies; Quebec
Quebec
Quebec or is a province in east-central Canada. It is the only Canadian province with a predominantly French-speaking population and the only one whose sole official language is French at the provincial level....

 offers primary health care teams through its CLSC
CLSC
CLSCs in Quebec are free clinics which are run and maintained by the provincial government...

 system).

Drug coverage

Each province may also provide its own prescription drug benefit plan, although the Canada Health Act requires only coverage for pharmaceuticals delivered to hospital inpatients. Provincial prescription drug benefit plans differ across provinces. Some provinces cover only those in particular age groups (usually, seniors) and/or those on social assistance. Others are more universal. Quebec achieves universal coverage through a combination of private and public plans. Co-payments also vary. Provinces maintain their own provincial formularies, although efforts are underway to institute a Common Drug Review. Note that there is ongoing controversy in Canada, as in other countries, about inclusion of expensive drugs and discrepancies in their availability, as well as in what if any provisions are made for allowing medications not yet approved to be administered under "exceptional drug" provisions. Drug costs are contentious. Their prices are controlled by the Patented Medicine Prices Review Board
Patented Medicine Prices Review Board
The Patented Medicine Prices Review Board is a government agency in Canada which regulates drugs that are still under patent and which yet have no generic substitutes.This Board establishes the maximum prices that can be charged in Canada for patented drugs....

, otherwise called the PMPRB. The PMPRB's pricing formula ensures that Canada pays prices based on the average of those charged to selected countries; they are neither the highest, nor the lowest.

Dental care, eye care and other services

Dental care
Dentistry
Dentistry is the branch of medicine that is involved in the study, diagnosis, prevention, and treatment of diseases, disorders and conditions of the oral cavity, maxillofacial area and the adjacent and associated structures and their impact on the human body. Dentistry is widely considered...

 is not required to be covered by the government insurance plans. In Quebec, children under the age of 10 receive almost full coverage, and many oral surgeries are covered for everyone. Canadians rely on their employers, individual private insurance, pay cash themselves for dental treatments, or receive no care. In some jurisdictions, public health units have been involved in providing targeted programs to address the need of the young, the elderly or those who are on welfare. The Canadian Association of Public Health Dentistry tracks programs, and has been advocating for extending coverage to those currently unable to receive dental care.

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, Saskatchewan, and British Columbia, 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.

Opinions on Medicare

Polling data in the last few years have consistently cited medicare as among the most important political issues in the minds of Canadian voters. Along with peacekeeping
Peacekeeping
Peacekeeping is an activity that aims to create the conditions for lasting peace. It is distinguished from both peacebuilding and peacemaking....

, medicare was found, based on a CBC
Canadian Broadcasting Corporation
The Canadian Broadcasting Corporation, commonly known as CBC and officially as CBC/Radio-Canada, is a Canadian crown corporation that serves as the national public radio and television broadcaster...

 poll, to be among the foremost defining characteristics of Canada.

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. The World Health Organization, ranked Canada in 2000 as 30th worldwide in performance. 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.

2003 Accord

In 2003, the prime minister and the provincial premiers agreed upon priority areas for reinvestment. The 2003 First Ministers’ Accord on Health Care Renewal reaffirmed their commitment to the principles of the Canada Health Act. They indicated the following principles:

"Drawing from this foundation, First Ministers view this Accord as a covenant which will help to ensure that:
  • all Canadians have timely access to health services on the basis of need, not ability to pay, regardless of where they live or move in Canada;
  • the health care services available to Canadians are of high quality, effective, patient-centred and safe; and
  • our health care system is sustainable and affordable and will be here for Canadians and their children in the future."


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.

Evaluating claims about the system

Evaluating the accuracy of claims about the system is hampered by several factors. The highly decentralized nature of health care delivery means that good data is not always available. It is often difficult to distinguish compelling but atypical anecdotes from systemic problems. Considerable effort is being made to develop and implement comparable indicators to allow better assessment of progress. However, the Health Council of Canada — with a mandate to monitor and report on health reform — complained in 2007 that progress has stalled

The debate about health care has also become heavily ideological. The Fraser Institute
Fraser Institute
The Fraser Institute is a Canadian think tank. It has been described as politically conservative and right-wing libertarian and espouses free market principles...

, 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.

Wait times and access

Common complaints relate to access, usually to elective surgery (especially hip and knee replacement and cataract surgery) and diagnostic imaging. These have been the primary targets of health care reinvestment, and it appears that considerable progress has been made for certain services, although the implications for procedures not on the target list are unclear. Canadian physicians have been heavily involved, particularly in developing appropriateness criteria to ensure timely access for necessary care. It is estimated to have cost Canada's economy
Economy of Canada
Canada has the tenth largest economy in the world , is one of the world's wealthiest nations, and is a member of the Organization for Economic Co-operation and Development and Group of Eight . As with other developed nations, the Canadian economy is dominated by the service industry, which employs...

 $
Canadian dollar
The Canadian dollar is the currency of Canada. As of 2007, the Canadian dollar is the 7th most traded currency in the world. It is abbreviated with the dollar sign $, or C$ to distinguish it from other dollar-denominated currencies...

14.8 billion in 2007 to have patients waiting longer than needed for medical procedures.

Health human resources

A related issue is the volume, and distribution, of health human resources. There are ongoing issues about the distribution of physicians, with the pendulum swinging from arguing that there were too many, to arguing that there were too few. As Ben Chan found, the major factor driving the drop in physician numbers was changes in training programs. Combined with such factors as changes in the hours worked by each physician , and a decrease in the proportion of doctors choosing to go into family practice, there were shortages in some areas, particularly for general practitioners (GP) / family doctors. One response has been to encourage 'primary care reform', including greater use of multidisciplinary health care teams. There are also ongoing issues regarding nurses. (See Nursing Health Services Research Unit, which links to some reports. CIHI also gives data about nursing.)

Delisting

Delisting is the term used in Canada
Canada
Canada is a North American country consisting of ten provinces and three territories. Located in the northern part of the continent, it extends from the Atlantic Ocean in the east to the Pacific Ocean in the west, and northward into the Arctic Ocean...

 when a province decides that a medical procedure will no longer be covered by Medicare in that province
Province
A province is a territorial unit, almost always an administrative division, within a country or state.-Etymology:The English word "province" is attested since about 1330 and derives from the 13th-century Old French "province," which itself comes from the Latin word "provincia," which referred to...

.

While Medicare is country wide, and is required to be portable and to have equal access, there are differences between what provinces will cover. In some cases, this has resulted in lost grants
Grant (money)
Grants are funds disbursed by one party , often a Government Department, Corporation, Foundation or Trust, to a recipient, often a nonprofit entity, educational institution, business or an individual. In order to receive a grant, some form of "Grant Writing" often referred to as either a proposal...

 to the provinces; in other cases it has not.

An example of a delisted service is circumcision
Circumcision
Male circumcision is the surgical removal of some or all of the foreskin from the penis. The word "circumcision" comes from Latin and ....

 in Ontario
Ontario
Ontario is a province of Canada, located in east-central Canada. It is Canada's most populous province and second largest in total area. It is home to the nation's most populous city, Toronto, and the nation's capital, Ottawa....

. It is still possible to have a boy circumcised in Ontario by a doctor
Physician
A physician is a health care provider who practices the profession of medicine, which is concerned with promoting, maintaining or restoring human health through the study, diagnosis, and treatment of disease, injury and other physical and mental impairments...

 but the parents must pay the cost.

The issue of delisting services is becoming increasingly a battleground in Canadian Medicare. In an effort to save health care money the provinces are increasingly delisting services; however, some delisted services are ones that could be considered "medically necessary". For example, except for seniors and children, eye exams to check vision are no longer covered in Ontario.

Parallel private debate

Some politicians and think tank
Think tank
A think tank is an organization that conducts research and engages in advocacy in areas such as social policy, political strategy, economics, military, and technology issues. Most think tanks are non-profit organizations, which some countries such as the United States and Canada provide with tax...

s have proposed removing barriers to the existence of a parallel private healthcare system. Others note that such systems act to erode cost control and impede equity.
Though polling suggests support for such reforms has been increasing, it has yet to be adopted as official policy by any of the main federal political parties.

Under federal law, private clinics are not legally allowed to provide services covered by the Canada Health Act. Regardless of this legal issue, many do offer such services. 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
Medical tourism
Medical tourism is a term initially coined by travel agencies and the mass media to describe the rapidly-growing practice of travelling across international borders to obtain health care...

), and that insured persons can still pay for uninsured services. These are both niche markets.

Opponents of Medicare often raise issues such as long wait times, a 'brain-drain' drawing qualified professionals away from Canada to other jurisdictions where working in the health care field is more profitable, and impairment of the Canadian health care system due to budget cuts. Fox News ran a story in 2007 reporting that during a period of above average numbers of births, at least 40 Canadian mothers of premature babies had to travel to the U.S. for treatment due to insufficient capacity for premature babies in British Columbia neonatal units. Nonetheless, Canada's Medicare system covered the health care costs of those mothers affected.

In 2003, the Government in Canada spent $2,998 USD per capita on healthcare as compared to $5,711 USD per capita 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.

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.

Proposed reforms

One proposed solution for improving the Canadian healthcare system is to increase funding. Proponents of this approach point to the rise of neo-conservative
Neoconservatism
Neoconservatism in the United States is a branch of American conservatism. Since 2001, neoconservatism has been associated with democracy promotion, that is with assisting movements for democracy, in some cases by economic sanctions or military action....

 economic policies in Canada and the associated reduction in welfare state
Welfare state
A welfare state is a "concept of government in which the state plays a key role in the protection and promotion of the economic and social well-being of its citizens. It is based on the principles of equality of opportunity, equitable distribution of wealth, and public responsibility for those...

 expenditure (particularly in the provinces) from the 1980s onwards as the cause of degradation in the system. In fact, there is evidence that the percentage of total government expenditures spent on healthcare has been increasing, in part due to a higher percentage of older Canadians.

Other critics of healthcare state that increased funding will not solve systemic 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
Brain drain
Human capital flight, more commonly referred to as "brain drain", is the large-scale emigration of a large group of individuals with technical skills or knowledge. The reasons usually include two aspects which respectively come from countries and individuals...

" 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 (partially because health care is not covered through taxation). Some of these critics argue that increased privatization of healthcare would improve Canada's health infrastructure. Others argue vehemently against it. For example, large resources are required to train and educate doctors. Since the number of available doctors is therefore limited, doctors working for a private system would not be working under the public system creating little to no net increase in available services.

Critics of greater privatization 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. This is in contrast to other states where doctors are on a per capita based salary. In this sense the Canadian Healthcare system is merely a publicly funded one where services are provided by a mixture of public and private entities, which most Canadians appreciate and desire. Changing the system to eliminate the balance between public and private service providers to a completely public system is one such alternative.

Ontario's reform experiments

Since the early 1990s, Ontario has implemented several systematic reforms to reduce health care costs. Similar reforms have been implemented in other provinces.

User premiums

Currently in Ontario, people who earn salaries above $20,000 must pay an annual health care premium ranging from $300–$900. Funding for medicare in Ontario also comes in part from a dedicated Employer Health Tax (EHT) that ranges from 0.98%-1.95% of employer payroll. Eligible employers are exempted from EHT on the first $400,000 of payroll. British Columbia and Quebec charge similar premiums. Alberta charged $44 a month or $88 per family until it abolished premiums in 2009.

Medical clinics

Ontario has increased the number of 24-hour drop-in medical clinic networks to reduce costs associated with treating off-hours emergencies in hospital emergency rooms.

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.

Recently, the first nurse practitioner-led office to relieve waiting times caused by a shortage of primary practitioners was opened in Sudbury, Ontario
Ontario
Ontario is a province of Canada, located in east-central Canada. It is Canada's most populous province and second largest in total area. It is home to the nation's most populous city, Toronto, and the nation's capital, Ottawa....

.

Alternatives to fee-for-visit or service

Ontario has also attempted to move the system away from bill for service or visit and toward preventive and community-based approaches to healthcare. The Ontario government in the early 1990s helped develop many community health care centres, often in low-income areas, which provide both medical and social support which combines health care with programs such as collective kitchens, Internet access, anti-poverty groups and groups to help people quit smoking.

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 practitioner
Nurse practitioner
A Nurse Practitioner is an Advanced practice registered nurse who has completed graduate-level education . Additional APRN roles include the Certified Registered Nurse Anesthetist s, CNMs, and CNSs...

s, who reduce the workload on the doctors and increase efficiency.

Midwives and hospital birthing reforms

Ontario and Quebec have recently licensed midwives, providing another option for childbirth which can reduce costs for uncomplicated births. Midwives remain close to hospital facilities in case the need for emergency care emerges. These births often cost much less than the traditional hospital delivery. Hospitals have also reformed their approach to birthing by adding private birthing areas, often with a hot tub (which is good for relieving pain without medication).

Privatization

Currently, privately owned and operated hospitals that allow patients to pay out-of-pocket
Out-of-pocket expenses
Out-of-pocket expenses are direct outlays of cash which may or may not be later reimbursed.In operating a vehicle, gasoline, parking fees and tolls are considered out-of-pocket expenses for the trip...

 for services cannot obtain public funding in Canada, as they contravene the "equal accessibility" tenets of the Canada Health Act
Canada Health Act
The Canada Health Act is a piece of Canadian federal 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...

. Some politicians and medical professionals have proposed allowing public funding for these hospitals. Workers' Compensation Boards, the Canadian Military, the RCMP, federally incarcerated prisoners, and medical care for which an insurance company has liability (e.g., motor vehicle accidents) all pay for health care outside of the public systems in all provinces.

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)
Chaoulli v. Quebec (Attorney General)
Chaoulli v. Quebec [2005] 1 S.C.R. 791, was a decision by the Supreme Court of Canada where the Court ruled that the Quebec Health Insurance Act and the Hospital Insurance Act prohibiting private medical insurance in the face of long wait times violated the Quebec Charter of Human Rights and...

.

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. Dr. Brian Day
Brian Day
Brian Day, MRCP , FRCS , FRCS , is a physician in Canada and was the 2007-2008 president of the Canadian Medical Association. He is known as Dr. Profit by opponents and Dr. Prophet by supporters for his advocacy of a role for private health care...

, who acted as President of the CMA in 2007/2008, is the owner of the largest private healthcare hospital in Canada and a proponent of mixed public and private healthcare in Canada.

Canadian Health Practitioner standards

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 Canadian Medical Association
Canadian Medical Association
The Canadian Medical Association , with more than 70,000 members, is the largest association of doctors in Canada and works to represent their interests nationally. It formed in 1867, three months after Confederation...

, the Ontario Medical Association
Ontario Medical Association
The Ontario Medical Association is a professional organization for physicians in Ontario, Canada founded in 1880. It represents and, to a certain degree, governs approximately 24,000 physicians in Ontario. The association's main office is located at 150 Bloor St. West in Toronto. The current...

, and the regulatory bodies (the provincial Colleges of Physicians and Surgeons
College of Physicians and Surgeons
There are several educational institutions that are called the College of Physicians and Surgeons:*The College of Physicians and Surgeons which merged with the University of Maryland School of Medicine...

) have created too much red tape to allow qualified doctors to practise in Canada. 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 [6](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.

Provincial insurance plans

Though the Canada Health Act
Canada Health Act
The Canada Health Act is a piece of Canadian federal 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...

 provides national guidelines for healthcare, the provinces have exclusive jurisdiction over health under the constitution
Constitution of Canada
The Constitution of Canada is the supreme law in Canada; the country's constitution is an amalgamation of codified acts and uncodified traditions and conventions. It outlines Canada's system of government, as well as the civil rights of all Canadian citizens and those in Canada...

 and are free to ignore these guidelines, although if they ignore the guidelines, the federal government
Government of Canada
The Government of Canada, formally Her Majesty's Government, is the system whereby the federation of Canada is administered by a common authority; in Canadian English, the term can mean either the collective set of institutions or specifically the Queen-in-Council...

 may deny federal funding for healthcare. All provinces currently abide by the Canada Health Act in order to receive this funding; however the Alberta
Alberta
Alberta is a province of Canada. It had an estimated population of 3.7 million in 2010 making it the most populous of Canada's three prairie provinces...

 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.

List of provincial programs

Province Name of plan
Alberta
Alberta
Alberta is a province of Canada. It had an estimated population of 3.7 million in 2010 making it the most populous of Canada's three prairie provinces...

Alberta Health Care Insurance Plan
British Columbia
British Columbia
British Columbia is the westernmost of Canada's provinces and is known for its natural beauty, as reflected in its Latin motto, Splendor sine occasu . Its name was chosen by Queen Victoria in 1858...

Medical Services Plan
Medical Services Plan
The Medical Services Plan of British Columbia is the government-administered single-payer health insurance scheme in the Canadian province of British Columbia, operating under the auspices of the country's national Medicare program...

Manitoba
Manitoba
Manitoba is a Canadian prairie province with an area of . The province has over 110,000 lakes and has a largely continental climate because of its flat topography. Agriculture, mostly concentrated in the fertile southern and western parts of the province, is vital to the province's economy; other...

Manitoba Health
Manitoba Health
Manitoba Health is an agency of the Government of Manitoba. It is overseen by the Minister of Health, and provides information on various aspects of health care in Manitoba, Canada....

New Brunswick
New Brunswick
New Brunswick is one of Canada's three Maritime provinces and is the only province in the federation that is constitutionally bilingual . The provincial capital is Fredericton and Saint John is the most populous city. Greater Moncton is the largest Census Metropolitan Area...

Medicare
Newfoundland and Labrador
Newfoundland and Labrador
Newfoundland and Labrador is the easternmost province of Canada. Situated in the country's Atlantic region, it incorporates the island of Newfoundland and mainland Labrador with a combined area of . As of April 2011, the province's estimated population is 508,400...

Newfoundland and Labrador Medical Care Plan
Northwest Territories
Northwest Territories
The Northwest Territories is a federal territory of Canada.Located in northern Canada, the territory borders Canada's two other territories, Yukon to the west and Nunavut to the east, and three provinces: British Columbia to the southwest, and Alberta and Saskatchewan to the south...

NWT Health Care Insurance Plan
Nova Scotia
Nova Scotia
Nova Scotia is one of Canada's three Maritime provinces and is the most populous province in Atlantic Canada. The name of the province is Latin for "New Scotland," but "Nova Scotia" is the recognized, English-language name of the province. The provincial capital is Halifax. Nova Scotia is the...

Medical Service Insurance
Medical Service Insurance
The Medical Service Insurance is the Nova Scotian government's health insurance.The Medical Services Insurance Programs are administered by Medavie Blue Cross for the Nova Scotia government Department of Health Policy Directive.- Eligibility :...

Nunavut
Nunavut
Nunavut is the largest and newest federal territory of Canada; it was separated officially from the Northwest Territories on April 1, 1999, via the Nunavut Act and the Nunavut Land Claims Agreement Act, though the actual boundaries had been established in 1993...

Nunavut Health Care Plan
Nunavut Health Care Plan
The Nunavut Health Care Plan is the government health plan of the Canadian territory of Nunavut. All residents of Nunavut residing in the territory for at least three months with the intention of staying for at least twelve are eligible for coverage under the plan.- References :*...

Ontario
Ontario
Ontario is a province of Canada, located in east-central Canada. It is Canada's most populous province and second largest in total area. It is home to the nation's most populous city, Toronto, and the nation's capital, Ottawa....

Ontario Health Insurance Plan
Ontario Health Insurance Plan
The Ontario Health Insurance Plan is the government-run health insurance plan for the Canadian province of Ontario...

Prince Edward Island
Prince Edward Island
Prince Edward Island is a Canadian province consisting of an island of the same name, as well as other islands. The maritime province is the smallest in the nation in both land area and population...

Medicare
Quebec
Quebec
Quebec or is a province in east-central Canada. It is the only Canadian province with a predominantly French-speaking population and the only one whose sole official language is French at the provincial level....

Assurance maladie
Régie de l'Assurance Maladie du Québec
The Régie de l'assurance maladie du Québec is the government health insurance system in the province of Quebec, Canada. The English approximation is The Quebec Health Insurance Authority.Under the system, most residents of Quebec have basic health coverage...

 (RAMQ Medicare)
Saskatchewan
Saskatchewan
Saskatchewan is a prairie province in Canada, which has an area of . Saskatchewan is bordered on the west by Alberta, on the north by the Northwest Territories, on the east by Manitoba, and on the south by the U.S. states of Montana and North Dakota....

Saskatchewan Medical Care Insurance Plan
Yukon
Yukon
Yukon is the westernmost and smallest of Canada's three federal territories. It was named after the Yukon River. The word Yukon means "Great River" in Gwich’in....

Yukon Health Care Insurance Plan

See also

  • Father of medicare
    Father of medicare
    Several individuals may be recognized as the father of medicare in Canada.*Tommy Douglas forwarded public health insurance as Premier of Saskatchewan from 1944 to 1961 and federal leader of the New Democratic Party from 1961 to 1971. Although Douglas is often credited as the "father of Medicare"...

  • Ontario Health Insurance Plan
    Ontario Health Insurance Plan
    The Ontario Health Insurance Plan is the government-run health insurance plan for the Canadian province of Ontario...

  • Medicare (Australia)
    Medicare (Australia)
    Medicare is Australia's publicly funded universal health care system, operated by the government authority Medicare Australia. Medicare is intended to provide affordable treatment by doctors and in public hospitals for all resident citizens and permanent residents except for those on Norfolk Island...

  • Medicare (United States)
    Medicare (United States)
    Medicare is a social insurance program administered by the United States government, providing health insurance coverage to people who are aged 65 and over; to those who are under 65 and are permanently physically disabled or who have a congenital physical disability; or to those who meet other...

  • National Health Service
    National Health Service
    The National Health Service is the shared name of three of the four publicly funded healthcare systems in the United Kingdom. They provide a comprehensive range of health services, the vast majority of which are free at the point of use to residents of the United Kingdom...

     (UK)
  • Canada Health Act
    Canada Health Act
    The Canada Health Act is a piece of Canadian federal 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...

  • Canada Health Transfer
    Canada Health Transfer
    The Canada Health Transfer is the Canadian government's transfer payment program in support of the health systems of the provinces and territories of Canada...

  • Canada Health and Social Transfer
    Canada Health and Social Transfer
    The Canada Health and Social Transfer was a system of block transfer payments from the Canadian government to provincial governments to pay for health care, post-secondary education and welfare, in place from the 1996-97 fiscal year until the 2004-05 fiscal year...

  • Indian Health Transfer Policy (Canada)
    Indian Health Transfer Policy (Canada)
    The Indian Health Transfer Policy of Canada, provided a framework for the assumption of control of health services by Aboriginal Canadians and set forth a developmental approach to transfer centred on the concept of self-determination in health. Through this process, the decision to enter into...

  • Health care in Canada
    Health care in Canada
    Health care in Canada is delivered through a publicly-funded health care system, which is mostly free at the point of use and has most services provided by private entities. It is guided by the provisions of the Canada Health Act. The government assures the quality of care through federal standards...

  • Canada's Health Care providers, 2007
    Canada's Health Care providers, 2007
    Canada’s Health Care Providers, 2007 is a reference on the country’s health care workforce. It looks at how the health provider landscape has evolved, examines the complexities of health human resources planning and management in the current environment and provides the latest information on supply...

  • Canadian Institute for Health Information
  • Canadian and American health care systems compared
    Canadian and American health care systems compared
    Comparison of the health care systems in Canada and the United States are often made by government, public health and public policy analysts. The two countries had similar health care systems before Canada reformed its system in the 1960s and 1970s. The United States spends much more money on...

  • Royal Commission on the Future of Health Care in Canada
  • Saskatchewan Doctors' Strike
    Saskatchewan Doctors' Strike
    The 1962 Saskatchewan Doctors' Strike was a 23-day labour action exercised by medical doctors in the Canadian province of Saskatchewan in an attempt to force the Co-operative Commonwealth Federation government of Saskatchewan to rescind its program of universal medical insurance...

     of 1962
  • Health Evidence Network of Canada
    Health Evidence Network of Canada
    The Health Evidence Network of Canada, more commonly known as EvidenceNetwork.ca, is a comprehensive and non-partisan online resource designed to help journalists covering health policy issues in Canada.-Background:...


External links

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