A Synopsis of Canada's Health Care System

As America's discontentment with our Health Care System (which includes quality of care and cost of insurance) continues to grow, let's take a look at how things are run with our neighbors up North, aye.


Daniel Cohn, a professor of public policy in Toronto's York University specializing in health policy, offers a detailed overview of Canada's Health Care System:

First off what Canada has: We don’t have one system, we have several. Each province runs its own show within a very lose federal framework. If they obey five general principles they get substantial grants. If they don’t obey the principles they can be fined (though the fines are often trivial and more meant to make a political point than to actually punish). The principles are universality (all permanent residents must be eligible for coverage), portability (coverage must be good whether the resident is at home or in another part of Canada), comprehensiveness (all medically necessary services provided by physicians, hospitals and diagnostic tests as defined by the province must be covered), public administration (the province must have a publicly managed not-for profit system for insuring people), [and] accessibility (services must be reasonably available in terms of timeliness, geography and no fees can be charged at point of service).

After that everything is up for debate. Some provinces insure things others don’t. Some provinces have premiums for health insurance, some have a dedicated portion of income tax, some fund it 100% out of general revenue. Some provinces have regional authorities that directly manage facilities, others (such as Ontario) leave that in the hands of charitable and not for profit corporations. Some provinces have aggressive programs to contract out care to for-profit firms (who provide treatment at no cost to the patient). One thing that is constant is that MDs are predominantly private and bill the provincial insurance schemes for their work, whether in their office or a hospital. They are not employed by the provincial governments. Some work on straight fee for service, others have different compensation, such as capitation. A lot of stuff is not covered and that is why most families have supplemental insurance for things like drugs, medical supplies and devices, dentistry and non-medically necessary stuff (such as private and semi-private rooms in hospitals). Low income families and seniors usually have public coverage for those things. As in the US marginal workers and entrepreneurs are the least likely to have this private coverage.

Second off public opinion: A few years back Matthew Mendelsohn did a meta-analysis of polling data on Canadian health care. He found that Canadians were well aware of the issues and options and had reached a considered opinion that our system works best for us. Canadians may want reform but not wholesale change. You can read the study on the website of The Commission on the Future of Health Care in Canada which commissioned the study. To date I have not seen anything that would lead me to believe that Mendelsohn’s conclusions are no longer valid. What is important is that Canadians did not just support the system because of the care they felt they were receiving, but because it resonated with their values, specifically that high quality health care is a right, and as a right ought to be available to all regardless of location or socio-economic status. [my emphasis]

I myself tested something similar with a study of attorneys in the province of Alberta. Attorneys are a relatively political informed group (so they know the issues), they are also a relatively prosperous group (the sort of people who could theoretically benefit from market-based care as they can afford it and would be attractive risks to insurers). Finally Alberta’s government has been among the least supportive of the present health system and has regularly sought to undermine it. The people I surveyed nevertheless overwhelmingly endorsed the present system. Most felt they would not get better care if privately financed care for medically necessary services were introduced. What turned the majority in favour of the present system into a landslide was a sizable portion which supported the present system even though they felt they would get better care if privately financed care were introduced for medically necessary services. I found decent evidence that these people based their support exclusively in the values promoted by the system. You can read that study "Canadian Medicare is there a Potential for Loyalty: Evidence from Alberta" in the Canadian Journal of Political Science 2005, Volume 38(2) [.pdf here].

This relationship of support for the system to values is why I am hesitant to give detailed advice to Americans. Let me just say whatever plan people develop, it had better fit the values of your society or it will never gain traction and might positively hurt you politically as the losers will fight back and whip up the fear of those who think they might be worse off as a result of your reforms.

As an aside let me quickly point out that the idea that scores of Canadians sneak across the boarder with private insurance to get medically necessary elective surgery is bogus. Although I have heard some radio ads for this sort of coverage (in the Greater Vancouver Area, but no where else) I have not found a major carrier that provides it. In other words, it is not a huge business or the Aetna’s of the world would be in on it. In fact most private insurance for what we call “extended care” the stuff provincial plans exclude, specifically refuse to pay for out of country care other than that which is related to an emergency (heart attack, broken arm, etc. on vacation or business trip). A couple of years back some researchers did a study of billing recorders in hospitals near the Canada US border and could find little or no documentary evidence that there was a transborder trade in elective surgeries. See SJ Katz et al. “Phantoms in the Snow: Canadians use of Health Care Services in the United States,” Health Affairs May/June 2002.

Finally, the reason the above noted sort of insurance is hard to find relates to what I see as the single biggest problem with the present system for financing US health care. It sucks as a business! In fact many Americans with private sector coverage for health costs don’t even have health “insurance” any more. What they in fact have is employer financed care which is “managed” by an insurance or similar firm. The insurance companies bailed on providing insurance and decided to focus on managing benefits as the risks in providing health insurance are just too unpredictable to accurately price in a way that will make the product both profitable and affordable to clients....

So that’s my little contribution. In sum health care for medically necessary care sucks as a business (and we don't even have your tort problem up here in Canada as judges not juries decide damage awards). Whatever you choose to do make sure it resonates deeply with the values of your society or people will not be willing to sacrifice their own interests. I just you hope you get it together before GM and Ford go bust and trigger a meta crisis in your health system.

***

So let's begin the discussion. What do we as Americans value? Specifically, what do you value? What is important to you? What do you believe to be the utmost truth and of the utmost importance in your heart of hearts?

For the local folks, you can check out what's going on at: http://www.wecandobetter.org/.