Health care in Canada

Health care in Canada is delivered through a publicly funded healthcare system, which is mostly free at the point of use and has most services provided by private entities.^[1] It is guided by the provisions of the Canada Health Act of 1984.^[2]

Current status

The government assures the quality of care through federal standards. The government does not participate in day-to-day care or collect any information about an individual's health, which remains confidential between a person and his or her physician.^[3] Canada's provincially based Medicare systems are cost-effective partly because of their administrative simplicity. In each province, each doctor handles the insurance claim against the provincial insurer. There is no need for the person who accesses healthcare to be involved in billing and reclaim. Private health expenditure accounts for 30% of health care financing.^[4] The Canada Health Act does not cover prescription drugs, home care or long-term care, prescription glasses or dental care, which means most Canadians pay out-of-pocket for these services or rely on private insurance.^[3] Provinces provide partial coverage for some of these items for vulnerable populations (children, those living in poverty and seniors).^[3] Limited coverage is provided for mental health care.

Competitive practices such as advertising are kept to a minimum, thus maximizing the percentage of revenues that go directly towards care. In general, costs are paid through funding from income taxes. In British Columbia, taxation-based funding is supplemented by a fixed monthly premium which is waived or reduced for those on low incomes.^[5] There are no deductibles on basic health care and co-pays are extremely low or non-existent (supplemental insurance such as Fair Pharmacare may have deductibles, depending on income). In general, user fees are not permitted by the Canada Health Act, though some physicians get around this by charging annual fees for services which include non-essential health options, or items which are not covered by the public plan, such as doctors notes, prescription refills over the phone.^[3]

Benefits and features

A health card is issued by the Provincial Ministry of Health to each individual who enrolls for the program and everyone receives the same level of care.^[6] There is no need for a variety of plans because virtually all essential basic care is covered, including maternity. Infertility costs are not covered fully in any province other than Quebec, though they are now partially covered in some other provinces.^[7] In some provinces, private supplemental plans are available for those who desire private rooms if they are hospitalized. Cosmetic surgery and some forms of elective surgery are not considered essential care and are generally not covered. These can be paid out-of-pocket or through private insurers. Health coverage is not affected by loss or change of jobs, health care cannot be denied due to unpaid premiums (in BC), and there are no lifetime limits or exclusions for pre-existing conditions. The Canada Health Act deems that essential physician and hospital care be covered by the publicly funded system, but each province has some license to determine what is considered essential, and where, how and who should provide the services. The result is that there is a wide variance in what is covered across the country by the public health system, particularly in more controversial areas, such as midwifery or autism treatments.^[3]

Canada is the only country with a universal healthcare system that does not include coverage of prescription medication.^[8][9] Pharmaceutical medications are covered by public funds in some provinces for the elderly or indigent,^[10] or through employment-based private insurance or paid for out-of-pocket. Most drug prices are negotiated with suppliers by each provincial government to control costs but more recently, the Council of the Federation announced an initiative for select provinces to work together to create a larger buying block for more leverage to control costs.^[11] More than 60 percent of prescription medications are paid for privately in Canada.^[3] Family physicians (often known as general practitioners or GPs in Canada) are chosen by individuals. If a patient wishes to see a specialist or is counseled to see a specialist, a referral can be made by a GP. Preventive care and early detection are considered important and yearly checkups are encouraged.

Statistics

2012 saw a record year for number of doctors with 75,142. The gross average salary was $328,000. Out of the gross amount, doctors pay for taxes, rent, staff salaries and equipment.^[12] Recent reports indicate that Canada may be heading toward an excess of doctors,^[13] though communities in rural, remote and northern regions, and some specialities, may still experience a shortage.^[14][15]

Public opinion

Canadians strongly support the health system's public rather than for-profit private basis, and a 2009 poll by Nanos Research found 86.2% of Canadians surveyed supported or strongly supported "public solutions to make our public health care stronger."^[16][17] A Strategic Counsel survey found 91% of Canadians prefer their healthcare system instead of a U.S. style system.^[18][19]

A 2009 Harris/Decima poll found 82% of Canadians preferred their healthcare system to the one in the United States.^[20]

A 2003 Gallup poll found 25% of Americans are either "very" or "somewhat" satisfied with "the availability of affordable healthcare in the nation", versus 50% of those in the UK and 57% of Canadians. Those "very dissatisfied" made up 44% of Americans, 25% of respondents of Britons, and 17% of Canadians. Regarding quality, 48% of Americans, 52% of Canadians, and 42% of Britons say they are satisfied.^[21]

Economics

Canada has a publicly funded medicare system, with most services provided by the private sector. Each province may opt out, though none currently do. Canada's system is known as a single payer system, where basic services are provided by private doctors (since 2002 they have been allowed to incorporate), with the entire fee paid for by the government at the same rate. Most government funding (94%) comes from the provincial level.^[22] Most family doctors receive a fee per visit. These rates are negotiated between the provincial governments and the province's medical associations, usually on an annual basis. Pharmaceutical costs are set at a global median by government price controls.

Hospital care is delivered by publicly funded hospitals in Canada. Most of the public hospitals, each of which are independent institutions incorporated under provincial Corporations Acts, are required by law to operate within their budget.^[24] Amalgamation of hospitals in the 1990s has reduced competition between hospitals. As the cost of patient care has increased, hospitals have been forced to cut costs or reduce services. Applying perspective (pharmacoeconomic) to analyze cost reduction, it has been shown that savings made by individual hospitals result in actual cost increases to the Provinces.^[25]

In 2009, the government funded about 70% of Canadians' healthcare costs. This is slightly below the OECD average of public health spending.^[26] This covered most hospital and physician cost while the dental and pharmaceutical costs were primarily paid for by individuals.^[26] Half of private health expenditure comes from private insurance and the remaining half is supplied by out-of-pocket payments. Under the terms of the Canada Health Act, public funding is required to pay for medically necessary care, but only if it is delivered in hospitals or by physicians. There is considerable variation across the provinces/territories as to the extent to which such costs as out of hospital prescription medications, physical therapy, long-term care, dental care and ambulance services are covered.^[27]

Healthcare spending in Canada (in 1997 dollars) has increased each year between 1975 and 2009, from $39.7 billion to $137.3 billion, or per capita spending from $1,715 to $4089.^[28] In 2013 the total reached $211 billion, averaging $5,988 per person.^[29] Figures in National Health Expenditure Trends, 1975 to 2012, show that the pace of growth is slowing. Modest economic growth and budgetary deficits are having a moderating effect. For the third straight year, growth in healthcare spending will be less than that in the overall economy. The proportion of Canada’s gross domestic product will reach 11.6% in 2012 down from 11.7% in 2011 and the all-time high of 11.9% in 2010.^[30] Total spending in 2007 was equivalent to 10.1% of the gross domestic product which was slightly above the average for OECD countries, and below the 16.0% of GDP spent in the United States.^[31]

In 2009, the greatest proportion of this money went to hospitals ($51B), followed by pharmaceuticals ($30B), and physicians ($26B).^[32] The proportion spent on hospitals and physicians has declined between 1975 and 2009 while the amount spent on pharmaceuticals has increased.^[33] Of the three biggest health care expenses, the amount spent on pharmaceuticals has increased the most. In 1997 the total price of drugs surpassed that of doctors. In 1975 the three biggest health costs were hospitals ($5.5B/44.7%), physicians ($1.8B/15.1% ), and medications ($1.1B/8.8% ) while in 2007 the three biggest costs were hospitals ($45.4B/28.2% ), medications ($26.5B/16.5% ), and physicians ($21.5B/13.4% ).^[34]

Healthcare costs per capita vary across Canada with Quebec ($4,891) and British Columbia ($5,254) at the lowest level and Alberta ($6,072) and Newfoundland ($5,970) at the highest.^[22] It is also the greatest at the extremes of age at a cost of $17,469 per capita in those older than 80 and $8,239 for those less than 1 year old in comparison to $3,809 for those between 1 and 64 years old in 2007.^[22]

According to Lightman, “In-kind delivery in Canada is superior to the American market approach in its efficiency of delivery.” In the USA, 13.6 per cent of GNP is used on medical care. By contrast, in Canada, only 9.5 per cent of GNP is used on the medicare system, “in part because there is no profit incentive for private insurers.” Lightman also notes that the in-kind delivery system eliminates much of the advertising that is prominent in the USA, and the low overall administrative costs in the in-kind delivery system. Since there are no means tests and no bad-debt problems for doctors under the Canadian in-kind system, doctors billing and collection costs are reduced to almost zero.^[35]

History

18th century

Hospitals were initially places which cared for the poor; others were cared for at home. In Quebec (formerly known as New France and then as Lower Canada), a series of charitable institutions, many set up by Catholic religious orders, provided such care.^[36] As the country grew, hospitals grew with them. They tended to be not-for-profit, and were run by municipal governments, charitable organizations, and religious denominations (both Catholic and Protestant).^[37] These organizations tended to be at arm's length from government; they received subsidies from provincial governments to admit and treat all patients, regardless of their ability to pay. Dr. David Parker of the Maritimes was the first to operate using anesthetic. One of the first "modern" operations, the removal of a tumour, was performed by William Fraser Tolmie in British Columbia.

19th century

The first medical schools were established in Lower Canada in the 1820s. These included the Montreal Medical Institution, which is the faculty of medicine at McGill University today; in the mid-1870s, Sir William Osler changed the face of medical school instruction throughout the West with the introduction of the hands-on approach. The College of Physicians and Surgeons of Upper Canada was established in 1839 and in 1869 was permanently incorporated. In 1834, William Kelly, a surgeon with the Royal Navy, introduced the idea of preventing the spread of disease via sanitation measures following epidemics of cholera. In 1871, female physicians Emily Howard Stowe and Jennie Kidd Trout won the right for women to be admitted to medical schools and granted licenses from the College of Physicians and Surgeons of Ontario. In 1883, Emily Stowe led the creation of the Ontario Medical College for Women, affiliated with the University of Toronto. In 1892, Dr. William Osler wrote the landmark text The Principles and Practice of Medicine, which dominated medical instruction in the West for the next 40 years. Around this time, a movement began that called for the improved health care for the poor, focusing mainly on sanitation and hygiene. This period saw important advances including the provision of safe drinking water to most of the population, public baths and beaches, and municipal garbage services to remove waste from the city. During this period, medical care was severely lacking for the poor and minorities such as First Nations^[38]

20th century

The twentieth century saw the discovery of insulin by Frederick Banting and his colleagues, Charles Best, J.J.R. Macleod, and J.B. Collip^[39] in 1922. For this, Frederick Banting and J.J.R. Macleod of the University of Toronto won the 1923 Nobel Prize in Physiology and Medicine.^[40] Dr. Wilder Penfield, who discovered a successful surgical treatment for epilepsy called the "Montreal procedure", founded the Montreal Neurological Institute in 1934.

The early 20th century saw the first widespread calls for increased government involvement and the idea of a national health insurance system had considerable popularity. During the Great Depression, calls for a public health system were widespread. Doctors who had long feared such an idea reconsidered hoping a government system could provide some stability as the depression had badly affected the medical community. However, governments had little money to enact the idea. In 1935, the United Farmers of Alberta passed a bill creating a provincial insurance program, but they lost office later that year and the Social Credit Party scrapped the plan due to the financial situation in the province. The next year a health insurance bill passed in British Columbia, but its implementation was halted over objections from doctors. William Lyon Mackenzie King promised to introduce such a scheme, but while he created the Department of Health he failed to introduce a national program.

The beginning of coverage

It was not until 1946 that the first Canadian province introduced near universal health coverage. Saskatchewan had long suffered a shortage of doctors, leading to the creation of municipal doctor programs in the early twentieth century in which a town would subsidize a doctor to practice there. Soon after, groups of communities joined to open union hospitals under a similar model. There had thus been a long history of government involvement in Saskatchewan health care, and a significant section of it was already controlled and paid for by the government. In 1946, the Co-operative Commonwealth Federation government in Saskatchewan passed the Saskatchewan Hospitalization Act, which guaranteed free hospital care for much of the population. Tommy Douglas had hoped to provide universal health care, but the province did not have the money.

In 1950, Alberta's Social Credit party also introduced a public health care plan. Alberta, however, created Medical Services (Alberta) Incorporated (MS(A)I) in 1948 to provide prepaid health services. This scheme eventually provided medical coverage to over 90% of the population.^[41]

In 1957, the majority Liberal government under Louis St. Laurent passed the Hospital Insurance and Diagnostic Services Act^[42] to fund 50% of the cost of such programs for any provincial government that adopted them. The HIDS Act outlined five conditions: public administration, comprehensiveness, universality, portability, and accessibility. These remain the pillars of the Canada Health Act.

By 1961, all ten provinces had agreed to start HIDS Act programs. In Saskatchewan, the act meant that half of their current program would now be paid for by the federal government. Premier Woodrow Lloyd decided to use this freed money to extend the health coverage to also include physicians. Despite the sharp disagreement of the Saskatchewan College of Physicians and Surgeons, Lloyd introduced the law in 1962 after defeating the Saskatchewan Doctors' Strike in July.

Medical Care Act

The programs in Saskatchewan and Alberta proved a success and the federal government of Lester B. Pearson introduced the Medical Care Act in 1966 that extended the HIDS Act cost-sharing to allow each province to establish a universal health care plan -an initiative that was drafted and initiated by the Liberal party and supported by the New Democratic Party (NDP). It also set up the Medicare system. In 1984, the Canada Health Act was passed under a majority Liberal government, which prohibited user fees and extra billing by doctors. In 1999, Prime Minister Jean Chrétien and most premiers reaffirmed in the Social Union Framework Agreement that they are committed to health care that has "comprehensiveness, universality, portability, public administration and accessibility."^[43]

Government involvement

The various levels of government pay for about 70% of Canadians' healthcare, although this number has decreased somewhat in recent years.^[44] The Constitution Act, 1867 (formerly called the British North America Act, 1867, and still known informally as the BNA Act) did not give either the federal or provincial governments responsibility for healthcare, as it was then a minor concern. The Act did give the provinces responsibility for regulating hospitals, and the provinces claimed that their general responsibility for local and private matters encompassed healthcare. The federal government felt that the health of the population fell under the Peace, Order, and Good Government part of its responsibilities. This led to several decades of debate over jurisdiction that were not resolved until the 1930s. Eventually the Judicial Committee of the Privy Council JCPC decided that the administration and delivery of healthcare was a provincial concern, but that the federal government also had the responsibility of protecting the health and well-being of the population.

By far the largest government health program is Medicare, which is actually ten provincial programs, such as OHIP in Ontario, that are required to meet the general guidelines laid out in the federal Canada Health Act. Almost all government health spending goes through Medicare, but there are several smaller programs. The federal government directly administers health to groups such as the military, and inmates of federal prisons. They also provide some care to the Royal Canadian Mounted Police and veterans, but these groups mostly use the public system. Prior to 1966, Veterans Affairs Canada had a large healthcare network, but this was merged into the general system with the creation of Medicare. The largest group the federal government is directly responsible for is First Nations. Native peoples are a federal responsibility and the federal government guarantees complete coverage of their health needs. For the last 20 years and despite health care being a guaranteed right for First Nations due to the many treaties the government of Canada signed for access to First Nations lands and resources, the amount of coverage provided by the Federal government's Non-Insured Health Benefits program has diminished drastically for optometry, dentistry, and medicines. Status First Nations individuals qualify for a set amount of visits to the optometrist and dentist, with a limited amount of coverage for glasses, eye exams, fillings, root canals, etc. For the most part First Nations people use the normal hospitals and the federal government then fully compensates the provincial government for the expense. The federal government also covers any user fees the province charges. The federal government maintains a network of clinics and health centres on Native Reserves. At the provincial level, there are also several much smaller health programs alongside Medicare. The largest of these is the health care costs paid by the worker's compensation system. Regardless of federal efforts, healthcare for First Nations has generally not been considered effective.^[45][46][47]

Despite being a provincial responsibility, the large health costs have long been partially funded by the federal government. The cost sharing agreement created by the HIDS Act and extended by the Medical Care Act was discontinued in 1977 and replaced by Established Programs Financing. This gave a bloc transfer to the provinces, giving them more flexibility but also reducing federal influence on the health system. In 1996, when faced with a large budget shortfall, the Liberal federal government merged the health transfers with the transfers for other social programs into the Canada Health and Social Transfer, and overall funding levels were cut. This placed considerable pressure on the provinces, and combined with population aging and the generally high rate of inflation in health costs, has caused problems with the system.

Private sector

About 27.6% of Canadians' healthcare is paid for through the private sector. This mostly goes towards services not covered or partially covered by Medicare, such as prescription drugs, dentistry and optometry. Some 75% of Canadians have some form of supplementary private health insurance; many of them receive it through their employers.^[48]

The Canadian system is for the most part publicly funded, yet most of the services are provided by private enterprises. Most doctors do not receive an annual salary, but receive a fee per visit or service.^[1] According to Dr. Albert Schumacher, former president of the Canadian Medical Association, an estimated 75 percent of Canadian health care services are delivered privately, but funded publicly.

"Frontline practitioners whether they're GPs or specialists by and large are not salaried. They're small hardware stores. Same thing with labs and radiology clinics ...The situation we are seeing now are more services around not being funded publicly but people having to pay for them, or their insurance companies. We have sort of a passive privatization."^[1]

"Although there are laws prohibiting or curtailing private health care in some provinces, they can be changed", according to a report in the New England Journal of Medicine.^[49][50] In June 2005, the Supreme Court of Canada ruled in Chaoulli v. Quebec (Attorney General) that Quebec's prohibition against private health insurance for medically necessary services laws violated the Quebec Charter of Human Rights and Freedoms, potentially opening the door to much more private sector participation in the health system. Justices Beverley McLachlin, Jack Major, Michel Bastarache and Marie Deschamps found for the majority. "Access to a waiting list is not access to health care", wrote Chief Justice Beverly McLachlin.

The Quebec and federal governments asked the high court to suspend its ruling for 18 months. Less than two months after its initial ruling, the court agreed to suspend its decision for 12 months, retroactive to June 9, 2005.^[51]

Physicians and medical organization

Canada, like its North American neighbour the United States, has a ratio of practicing physicians to population that is below the OECD average ^[52] but a level of practicing nurses that is higher than either the U.S. or the OECD average.^[53]

Family physicians in Canada make an average of $202,000 a year (2006, before expenses).^[54] Alberta has the highest average salary of around $230,000, while Quebec has the lowest average annual salary at $165,000, arguably creating interprovincial competition for doctors and contributing to local shortages.^[54]

In 1991, the Ontario Medical Association agreed to become a province-wide closed shop, making the OMA union a monopoly. Critics argue that this measure has restricted the supply of doctors to guarantee its members' incomes.^[55]

In September 2008, the Ontario Medical Association and the Ontarian government agreed to a new four-year contract that will see doctors receive a 12.25% pay raise. The new agreement is expected to cost Ontarians an extra $1 billion. Referring to the agreement, Ontario premier Dalton McGuinty said, "One of the things that we've got to do, of course, is ensure that we're competitive ... to attract and keep doctors here in Ontario...".^[56]

In December 2008, the Society of Obstetricians and Gynaecologists of Canada reported a critical shortage of obstetricians and gynaecologists. The report stated that 1,370 obstetricians were practicing in Canada and that number is expected to fall by at least one-third within five years. The society is asking the government to increase the number of medical school spots for obstetrics and gynecologists by 30 per cent a year for three years and also recommended rotating placements of doctors into smaller communities to encourage them to take up residence there.^[57]

Each province regulates its medical profession through a self-governing College of Physicians and Surgeons, which is responsible for licensing physicians, setting practice standards, and investigating and disciplining its members.

The national doctors association is called the Canadian Medical Association;^[58] it describes its mission as "To serve and unite the physicians of Canada and be the national advocate, in partnership with the people of Canada, for the highest standards of health and health care. "^[59] Because health care is deemed to be under provincial/territorial jurisdiction, negotiations on behalf of physicians are conducted by provincial associations such as the Ontario Medical Association. The views of Canadian doctors have been mixed, particularly in their support for allowing parallel private financing. The history of Canadian physicians in the development of Medicare has been described by C. David Naylor.^[60] Since the passage of the 1984 Canada Health Act, the CMA itself has been a strong advocate of maintaining a strong publicly funded system, including lobbying the federal government to increase funding, and being a founding member of (and active participant in) the Health Action Lobby (HEAL).^[61]

However, there are internal disputes. In particular, some provincial medical associations have argued for permitting a larger private role. To some extent, this has been a reaction to strong cost control; CIHI estimates that 99% of physician expenditures in Canada come from public sector sources, and physicians—particularly those providing elective procedures who have been squeezed for operating room time—have accordingly looked for alternative revenue sources.

One indication of this internal dispute came when Dr. Brian Day of B.C. was elected CMA president in August 2007. Day is the owner of the largest private hospital in Canada and a vocal supporter of increasing private health care in Canada. The CMA presidency rotates among the provinces, with the provincial association electing a candidate who is customarily ratified by the CMA general meeting. Day's selection was sufficiently controversial that he was challenged—albeit unsuccessfully—by another physician. The newspaper story went on to note that "Day said he has never supported the privatization of health care in Canada, and accused his detractors of deliberately distorting his position." ^[62]

Criticisms

Wait times

Health Canada, a federal department, publishes a series of surveys of the health care system in Canada based on Canadians' first-hand experiences of the health care system.^[63]

Although life-threatening cases are dealt with immediately, some services needed are non-urgent and patients are seen at the next-available appointment in their local chosen facility.

The median wait time in Canada to see a special physician is a little over four weeks with 89.5% waiting fewer than 90 days.^[63]

The median wait time for diagnostic services such as MRI and CAT scans ^[64] is two weeks with 86.4% waiting fewer than 90 days.^[63]

The median wait time for elective or non-urgent surgery is four weeks with 82.2% waiting fewer than 90 days.^[63]

Another study by the Commonwealth Fund found that 57% of Canadians reported waiting 30 days (4 weeks) or more to see a specialist, broadly in line with the current official statistics. A quarter (24%) of all Canadians waited 4 hours or more in the emergency room.^[65]

Dr. Brian Day was once quoted as saying "This is a country in which dogs can get a hip replacement in under a week and in which humans can wait two-to-three years."^[66] Day gave no source for his two to three years claim. The Canadian Health Coalition has responded succinctly to Day's claims, pointing out that "access to veterinary care for animals is based on ability to pay. Dogs are put down if their owners can’t pay. Access to care should not be based on ability to pay." ^[67] Regional administrations of Medicare across Canada publish their own wait time data on the internet. For instance, in British Columbia the wait time for an elective hip replacement is currently a little under ten weeks.^[68] The CHC is one of many groups across Canada calling for increased provincial and federal funding for medicare and an end to provincial funding cuts as solutions to unacceptable wait times.^[69]

Since 2002, the Canadian government has invested $5.5 billion to decrease wait times.^[70] In April 2007, Prime Minister Stephen Harper announced that all ten provinces and three territories would establish patient wait times guarantees by 2010. Canadians will be guaranteed timely access to health care in at least one of the following priority areas, prioritized by each province: cancer care, hip and knee replacement, cardiac care, diagnostic imaging, cataract surgeries or primary care.^[71] The current cultural shift towards evidence-based medicine is burgeoning in Canada with the advent of organizations like Choosing Wisely Canada.^[72] Organizations like this hope to encourage and facilitate doctor-patient communication, decreasing unnecessary care in Canada, and therefore hopefully decreasing wait times.^[73]

In a 2007 episode of ABC News's 20/20 titled "Sick in America", libertarian John Stossel cited numerous examples of Canadians who did not get the health care that they needed.^[74] The conservative Fraser Institute found that treatment time from initial referral by a GP through consultation with a specialist to final treatment, across all specialties and all procedures (emergency, non-urgent, and elective), averaged 17.7 weeks in 2005,^[75] contradicting the Canadian government's 2007 report regarding itself.^[76]

Counter-criticism: Some longer wait times can benefit patients

It has been speculated and supported in data that the complete elimination of all waiting times is not ideal. When waiting lists arise through a prioritization process based on physician-determined medical urgency and the procedure's risk, (in contrast to patient's ability to pay or profitability for the physician), waiting lists can possibly help patients. It's been postulated that a system of immediate care can be detrimental for optimal patient outcomes, as unnecessary or unproven surgery might not be easily avoided if all patients are granted instant care. An example is the Canadian province of British Columbia, where, according to surgeon Dr. Lawrence Burr, 15 heart patients died in 1990 while on a waiting list for heart surgery. According to Robin Hutchinson, senior medical consultant to the Health Ministry's heart program, had the waiting list not existed and all patients given instant access to the surgery, the expected number of fatalities would have been 22 due to the operation mortality rate at that time. Hutchison noted that the BC Medical Association's media campaign did not make reference to these comparative statistics and focused on deaths during waiting for surgery. Since, ideally, waiting lists prioritize higher-risk patients to receive surgery ahead of those with lower risks, this helps reduce overall patient mortality. Consequently, a wealthy or highly insured patient in a system based on profit or ability to pay (as in the U.S.) may be pushed into surgery or other procedures more quickly, with a result in higher morbidity or mortality risk. This is in addition to the better-understood phenomenon in which lower-income, uninsured, or under-insured patients have their care denied or delayed, also resulting in worse health care.^[77]

Restrictions on privately funded healthcare

The Canada Health Act, which sets the conditions with which provincial/territorial health insurance plans must comply if they wish to receive their full transfer payments from the federal government, does not allow charges to insured persons for insured services (defined as medically necessary care provided in hospitals or by physicians). Most provinces have responded through various prohibitions on such payments. This does not constitute a ban on privately funded care; indeed, about 30% of Canadian health expenditures come from private sources, both insurance and out-of-pocket payments.^[78] The Canada Health Act does not address delivery. Private clinics are therefore permitted, albeit subject to provincial/territorial regulations, but they cannot charge above the agreed-upon fee schedule unless they are treating non-insured persons (which may include those eligible under automobile insurance or worker's compensation, in addition to those who are not Canadian residents), or providing non-insured services. This provision has been controversial among those seeking a greater role for private funding.

In 2006, the Government of British Columbia threatened to shut down one private clinic because it was planning to start accepting private payments from patients.^[79]

Governments have responded through wait time strategies, discussed above, which attempt to ensure that patients will receive high-quality, necessary services in a timely manner. Nonetheless, the debate continues.

Cross-border health care

The border between Canada and the United States represents a boundary line for medical tourism, in which a country's residents travel elsewhere to seek health care that is more available or affordable.

Canadians visiting the US to receive healthcare

Some residents of Canada travel to the United States for care. A study by Barer, et al., indicates that the majority of Canadians who seek healthcare in the U.S. are already there for other reasons, including business travel or vacations. A smaller proportion seek care in the U.S. for reasons of confidentiality, including abortions, mental illness, substance abuse, and other problems that they may not wish to divulge to their local physician, family, or employer.

• Canadians offered free care in the US paid by the Canadian government have sometimes declined it. In 1990 the British Columbia Medical Association ran radio ads asking, "What's the longest you'd wait in line at a bank before getting really annoyed? Five minutes? Ten minutes? What if you needed a heart operation?" Following this, the government responded, as summarized by Robin Hutchinson, senior medical consultant for the health ministry's heart program. Despite the medically questionable nature of heart bypass for milder cases of chest pain and follow-up studies showing heart bypass recipients were 25-40% more likely to be relieved of chest pain than people who stay on heart medicine, the "public outcry" following the ads led the government to take action:

"'We did a deal with the University of Washington at Seattle' said Hutchinson.. to take 50 bypass cases at $18,000 per head, almost $3,000 higher than the cost in Vancouver, with all the money [paid by] the province..In theory, the Seattle operations promised to take the heat off the Ministry of Health until a fourth heart surgery unit opened in the Vancouver suburb of New Westminster. If the first batch of Seattle bypasses went smoothly..then the government planned to buy three or four more 50-head blocks. But four weeks after announcing the plan, health administrators had to admit they were stumped. 'As of now..we've have nine people sign up. The opposition party, the press, everybody's making a big stink about our waiting lists. And we've got [only] nine people signed up! The surgeons ask their patients and they say, "I'd rather wait", We thought we could get maybe two hundred and fifty done down in Seattle..but if nobody wants to go to Seattle, we're stuck,'".^[77]

• In a Canadian National Population Health Survey of 17,276 Canadian residents, it was reported that 0.5% sought medical care in the US in the previous year. Of these, less than a quarter had traveled to the U.S. expressly to get that care.^[80]
• A 2002 study by Katz, Cardiff, et al., reported the number of Canadians using U.S. services to be "barely detectible relative to the use of care by Canadians at home" and that the results "do not support the widespread perception that Canadian residents seek care extensively in the United States."^[81]
• According to a September 14, 2007, article from CTV News, Canadian Liberal MP Belinda Stronach went to the United States for breast cancer surgery in June 2007. Stronach's spokesperson Greg MacEachern was quoted in the article saying that the US was the best place to have this type of surgery done. Stronach paid for the surgery out of her own pocket.^[82] Prior to this incident, Stronach had stated in an interview that she was against two-tier health care.^[83]
• When Robert Bourassa, the premier of Quebec, needed cancer treatment, he went to the US to get it.^[84]
• In 2007, it was reported that Canada sent scores of pregnant women to the US to give birth.^[85] In 2007 a woman from Calgary who was pregnant with quadruplets was sent to Great Falls, Montana to give birth. An article on this incident states there were no Canadian hospitals with enough neo-natal intensive beds to accommodate the extremely rare quadruple birth.^[86]
• A January 19, 2008, article in The Globe and Mail states, "More than 150 critically ill Canadians – many with life-threatening cerebral hemorrhages – have been rushed to the United States since the spring of 2006 because they could not obtain intensive-care beds here. Before patients with bleeding in or outside the brain have been whisked through U.S. operating-room doors, some have languished for as long as eight hours in Canadian emergency wards while health-care workers scrambled to locate care." ^[87]
• In 2010, Newfoundland and Labrador Premier Danny Williams traveled to the US for heart surgery.^[88]

In 2005 Shona Holmes of Waterdown, Ontario, traveled to the Mayo Clinic after deciding she couldn't afford to wait for appointments with specialists through the Ontario health care system.^[89][90] She has characterized her condition as an emergency, said she was losing her sight, and portrayed her condition as life-threatening brain cancer. OHIP did not reimburse her for her medical expenses. In 2007 she joined a lawsuit to force the Ontario government to reimburse patients who feel they had to travel outside of Canada for timely, life-saving medical treatment. In July 2009 Holmes agreed to appear in television ads broadcast in the United States warning Americans of the dangers of adopting a Canadian style health care system. After her ad appeared critics pointed out discrepancies in her story, including that Rathke's cleft cyst, the condition she was treated for, was not a form of cancer, and was not life-threatening.^[91][92] In fact, the mortality rate for patients with a Rathke's cleft cyst is zero percent. ^[93]

US citizens visiting Canada to receive health care

Some US citizens travel to Canada for health-care related reasons:

• Many US citizens purchase prescription drugs from Canada, either over the Internet or by traveling there to buy them in person, because prescription drug prices in Canada are substantially lower than prescription drug prices in the United States; this cross-border purchasing has been estimated at $1 billion annually.^[94]
• Buying prescription drugs from even the most well respected internet pharmacies in Canada often results in a prescription filled from drugs sourced not from Canada but rather Caribbean nations or from eastern Europe. The Canadian online pharmacy that sells the drugs offers a Canadian price but buys at a still cheaper rate from third parties overseas. This has led to problems with prescriptions being filled with counterfeit drugs, which sometimes have no activity whatsoever. Some pharmacists have exited this business because of the ethical problems involved, and some less established internet sites may be knowingly selling fake drugs. In 2014, the largest online Canada drug retailer was forbidden by Health Canada from selling wholesale drug. Of the three primary entrepreneurs of online Canadian drugs sold to the United States, one is in jail, one exited the industry entirely, and the third is under investigation for criminal wrongdoing.^[95][96][97]
• Because medical marijuana is legal in Canada but illegal in most of the US, many US citizens suffering from cancer, AIDS, multiple sclerosis, and glaucoma have traveled to Canada for medical treatment. One of those is Steve Kubby, the Libertarian Party's 1998 candidate for governor of California, who is suffering from adrenal cancer.^[98] Recent legal changes such as Proposition 215 may decrease this type of medical tourism from California only.

Limited coverage for mental health

The Canada Health Act covers the services of psychiatrists, who are medical doctors with additional training in psychiatry. In Canada, psychiatrists tend to focus on the treatment of mental illness with medication.^[99] However, the Canada Health Act excludes care provided in a "hospital or institution primarily for the mentally disordered."^[100] Some institutional care is provided by provinces. The Canada Health Act does not cover treatment by a psychologist^[101][102] or psychotherapist unless the practitioner is also a medical doctor. Goods and Services Tax or Harmonized Sales Tax (depending on the province) applies to the services of psychotherapists.^[103] Some coverage for mental health care and substance abuse treatment may be available under other government programs. For example, in Alberta, the province provides funding for mental health care through Alberta Health Services.^[104] The cost of treatment by a psychologist or psychotherapist in Canada has been cited as a contributing factor in the high suicide rate among first responders such as police officers, EMTs and paramedics. According to a CBC report, some police forces "offer benefits plans that cover only a handful of sessions with community psychologists, forcing those seeking help to join lengthy waiting lists to seek free psychiatric assistance."^[105]

Limited coverage for vision care and dental services

Vision care varies by province or territory. For example, in Ontario, annual eye examinations (but not eyeglasses or contact lenses) are covered by OHIP for persons under 20 and those 65 and over. OHIP also covers a major eye exam once every 12 months for persons aged 20 to 64 who have medical conditions (such as diabetes) requiring regular eye examinations. Otherwise, eye examinations are not covered for persons 20 to 64.^[106] Although dental health may affect overall health, routine dental care is not covered. Certain dental surgery, when performed in hospital, is covered.^[106][107] Provinces and territories may offer specific programs for children. For example, Healthy Smiles Ontario is a program for children 17 and under in Ontario who do not have access to any form of dental coverage,^[108] e.g. through private insurance provided by a parent's employer.

Portability and provincial residency requirements

Canada Health Act defines insured persons as residents of a province. The Act defines a resident as: "a person lawfully entitled to be or to remain in Canada who makes his home and is ordinarily present in the province, but does not include a tourist, a transient or a visitor to the province."^[109] When traveling within Canada, a Canadian's health card from his or her home province or territory is accepted for hospital and physician services. This portability is implemented through a series of bilateral reciprocal billing agreements between the provinces and territories for hospital and physician services.^[109]

Each province has residency and physical presence requirements to qualify for health care coverage. For example, to qualify for coverage in Ontario, with certain exceptions, one must be physically present in Ontario for 153 days in any given 12-month period. Most provinces require 183 days of physical presence in any given 12-month period. Exceptions may be made for mobile workers, if the individual can provide documentation from his or her employer verifying that the individual's work requires frequent travel in and out of the province.^[110] Transients, self-employed itinerant workers (e.g. farm workers) who move from province to province several times within a year, and peripatetic retired or unemployed individuals who move from province to province (e.g. staying with various relatives, or living in a recreational vehicle) may find themselves ineligible for health coverage in any province or territory, even though they are Canadian citizens or landed immigrants physically present in Canada 365 days a year. "Snowbirds" (Canadians who winter in warm climates) and other Canadians who are out their home province or territory for a total of more than 183 days in a twelve-month period lose all coverage. A three-month waiting period is usually applied before coverage is reinstated after losing coverage.^[111] Students attending a university or college outside their home province are generally covered by the health insurance program of their home province, however, "Typically this coverage (while out-of-province but within Canada) is for physician and hospital services only."^[110] The Ontario Ministry of Health and Long Term Care, for example, states, "Therefore, when traveling outside of Ontario but within Canada, the ministry recommends that you obtain private supplementary health insurance for non-physician/non-hospital services."^[110] Such services might include prescription drugs, or ground and air ambulance services that might be covered in one's home province.^[112]

Comparison to other countries

The Canadian health care system is often compared to the US system. The US system spends the most in the world per capita, and was ranked 37th in the world by the World Health Organization in 2000, while Canada's health system was ranked 30th. The relatively low Canadian WHO ranking has been criticized by some for its choice of ranking criteria and statistical methods, and the WHO is currently revising its methodology and withholding new rankings until the topics are addressed.^[113][114]

Canada spent approximately 10.0% of GDP on health care in 2006, more than one percentage point higher than the average of 8.9% in OECD countries.^[115] According to the Canadian Institute for Health Information, spending is expected to reach $160 billion, or 10.6% of GDP, in 2007.^[116] This translates to $4,867 per person.

In a sample of 13 developed countries Canada was tenth in its population weighted usage of medication in 14 classes in 2009 and sixth in 2013. The drugs studied were selected on the basis that the conditions treated had high incidence, prevalence and/or mortality, caused significant long-term morbidity and incurred high levels of expenditure and significant developments in prevention or treatment had been made in the last 10 years. The study noted considerable difficulties in cross border comparison of medication use.^[117]

Most health statistics in Canada are at or above the G8 average.^[118] Direct comparisons of health statistics across nations is complex. The OECD collects comparative statistics, and has published brief country profiles.^{[119][120][121]}

Country	Life expectancy	Infant mortality rate	Physicians per 1000 people	Nurses per 1000 people	Per capita expenditure on health (USD)	Healthcare costs as a percent of GDP	% of government revenue spent on health	% of health costs paid by government
Australia	81.4	4.2	2.8	9.7	3,137	8.7	17.7	67.7
Canada	81.3	4.5	2.2	9.0	3,895	10.1	16.7	69.8
France	81.0	4.0	3.4	7.7	3,601	11.0	14.2	79.0
Germany	79.8	3.8	3.5	9.9	3,588	10.4	17.6	76.9
Japan	82.6	2.6	2.1	9.4	2,581	8.1	16.8	81.3
Sweden	81.0	2.5	3.6	10.8	3,323	9.1	13.6	81.7
UK	81	4.8	2.5	10.0	2,992	8.4	15.8	81.7
US	78.1	6.9	2.4	10.6	7,290	16.0	18.5	45.4

See also

• Canada Health Act
• Canada Health Transfer
• Canada Health and Social Transfer
• Canada's Health Care providers, 2007
• Canadian and American health care systems compared
• Chronic disease in Northern Ontario
• Health care compared - tabular comparisons of the US, Canada, and other countries not shown above.
• EvidenceNetwork.ca Evidence Network of Canadian Health Policy
• Indian Health Transfer Policy (Canada)
• Medicare (Canada)
• Royal Commission on the Future of Health Care in Canada
• Suicide in Canada

References

Bibliography

Further reading

• Caulfield, Timothy A; Von Tigerstrom, Barbara (2002). Health care reform & the law in Canada: meeting the challenge. University of Alberta Press. ISBN 0-88864-366-7. 
• Fierlbeck, Katherine (2011). Health Care in Canada: A Citizen's Guide to Policy and Politics. University of Toronto Press. ISBN 978-1-4426-0983-9. 
• Jacobs, Philip; Jonsson, Egon; Rapoport, John (2008). Cost Containment and Efficiency in National Health Systems : A Global Comparison. Wiley-VCH. ISBN 978-3-527-32110-0. 
• Institute, John Deutsch (2006). Study of Economic Policy Health Services Restructuring in Canada Conference. Economic Policy, Queen's University. ISBN 978-1-55339-075-6. 
• Marchildon, Gregory P (2006). Health systems in transition : Canada. University of Toronto Press. ISBN 978-0-8020-9400-1. 
• Raphael, Dennis (2007). Poverty and Policy in Canada: Implications for Health and Quality of Life. Canadian Scholars' Press. ISBN 978-1-55130-323-9 
• Mullner, Ross M (2009). Encyclopedia of health services research. SAGE. pp. 559–562. ISBN 978-1-4129-7194-2. 

External links

• Canadian Federalism and Public Health Care: The Evolution of Federal-Provincial Relations | Mapleleafweb.com
• CBC Digital Archives — The Birth of Medicare
• Canadian Health Services Research Foundation
• Data from the Canadian Institute for Health Information
  • National Health Expenditure Database
  • Exploring the 70/30 Split: How Canada's Health Care System Is Financed
  • National Physician Database

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