Medicare (Canada)

From Academic Kids

The term medicare (in lowercase) (French: assurance-maladie) is the unofficial name for Canada's universal public health insurance system. Under the terms of the Canada Health Act, the provinces provide all residents with health insurance cards, which entitle the bearer to receive free medical care for almost all procedures. Patients are free to choose their own doctor, hospital, etc. Health institutions are either private and not-for-profit (such as university hospitals) or state-run (such as Quebec's CLSC system). Doctors in private practice are entrepreneurs who bill the medicare system for their fees.

Contents

Services covered

While basic care from a doctor or a hospital is covered by the state to a greater degree than any other country in the world (except some Ex-Soviet countries, such as Russia), Canada compensates by having one of the most limited public health systems. Dental care is still almost wholly private, drugs are only partially covered, optometry is only partially covered and only in certain provinces. As a result the fraction of health spending that is covered by the government is lower in Canada than the average for a developed country.

There is also an increasing trend toward delisting services that medicare covers. For example ten years ago having vision checked was covered as needed in Ontario. Several years ago the Ontario government put a limit on tests of vision every two years. In 2004 the government delisted vision tests. It is still possible to have coverage to see an eye doctor in certain cases and if you were seeing an eye doctor the medical care would often include vision tests, but a patient would need to be referred by their family physician to a specialist (usually due to medical needs other than vision tests). The specialist then makes the decision on how often the patient should see them. However even when exceptions like this exist they are not well known. As a result it is often the more advantaged who manage to find their way through the system for coverage that is limited in these sorts of ways. Access can also depend on how much the referring doctor knows about the medicare system (for example that in some cases ophthalmology is covered in Ontario).

Opinions on medicare

Most Canadians highly value their medicare program. Polling data in the last few years have consistently cited it as the most important political issue in the minds of Canadian voters. Along with peacekeeping and the CBC a poll found medicare to be one the most defining characteristics of Canada. It has increasingly become a source of controversy in Canadian politics, mostly due to the common perception that the quality of care provided has been decreasing, particularly throughout the past two decades. Canadians are also concerned that the nation isn't living up to our own self image as world leaders in health care.

Commonly referenced problems include: limited access to diagnostic equipment (such as MRIs and CT Scanners), lengthy wait times for surgeries and serious physician shortages, which are particularly prevalent for General Practitioners(GP)/Family Doctors. In some parts of the country waiting times to acquire a GP have been quoted at several years. Some Canadians are also sent to the United States for treatment. As a result some right-wing pundits and think tanks have proposed introducing a two-tier healthcare system. Two-tier healthcare would have trouble being accepted by the Canadian public because Canada is an egalitarian socially democratic country, and generally citizens "skipping the line" is frowned on.

While complaints of a steadily worsening system are common, statistical justification for this is hard to locate, but becoming increasingly common. (see links below) Despite reports of growing wait lists and some funding cuts there has been no sign of any decrease in the overall health and well being of Canadians, and Canadians who experience the healthcare system still rate the experience as highly as anywhere else in the world. Canada has been maintaining its high level of health care relative to other developed nations. When Canadians are polled, they consistently rate health care as a high concern and medicare as something they are proud of, even if it doesn't live up to the world class standard that they expect. Looking at other polls it becomes obvious they are willing to pay to keep health care public (in aggregate of course, not everyone). The main concern is often that the money used actually go to health care. Also people would like to see solid, visible, results from these funding changes such as reduced waiting periods. This tracks the usual story arc of socialism where invisible infrastructure and maintenance accounts are robbed to continually provide "visible proof" that government domination of a sector provides superior results. For example there is a tax that is specific to health care in Alberta but which actually ends up going into general funds. Canadians are generally wary that they will come across similar problems at the moment in various reforms that are suggested.

While Canadians may not get the same very high standard of care that a wealthy US citizen will get, most Canadians are aware that Canadian citizens are by far better covered than an American without any private health insurance. The system is much more affordable for certain items such as on patented drugs and this difference in price has created a large prescription drug exporting industry in Canada. Older medicines that are off patent tend to be somewhat more expensive due to less competition as entry into the Canadian market suffers from government barriers. The Canadian governments spend the same amount per capita on health care as the United States governments, but almost every Canadian citizen is fully covered. In the United States there are large percentages of the population who are uncovered or only marginally covered, despite equally proportional spending along with large private investment. Even more are just a job loss away from not having coverage (although in most cases the employer must maintain health care with copayment of the patient for a period of time after employment in the United States.) though recent reforms have introduced individual health accounts in 2004 which are job independent. In Canada on the other hand, the waiting lists for some procedures and treatments can be very long. Tests such as MRI can have waiting lists that are months long, and procedures such as hip replacement can have waits that can be up to two years. Unlike other industrialized countries, in Canada citizens with money cannot by law pay for quicker service in a private clinic or hospital and must wait with everyone else. In Canada unlike every other industrialized country a two-tier system is considered practically immoral. Though some, who can afford the cost, elect to have tests and occasionally procedures performed at private health care facilities in other countries, usually in the United States.

Proposed reforms

Though most Canadian politicians and citizens acknowledge that there are some problems with the system, the proposed solutions often spark passionate debate. On one hand there are those who believe that the problem is simply one of under funding. They point to the rise of neo-conservative economic policies in Canada, and the associated reduction in welfare state expenditure (particularly in the provinces) from the 1980s onwards as the cause of degradation in the system. However, it is commonly estimated that costs associated with the medicare system have still been creeping upwards as a percent of total government expenditures. Again, many critics argue that neo-conservative governments merely made huge cuts to other programs as a reason for health care creeping to high percentages of government spending. The increasing costs are also directly linked to Canada's ageing population.

On the other hand, there is a small but growing minority who argue that the system in its current form is financially unsustainable. They suggest that the rising cost of medical technology, infrastructure and wages are partly to blame. Canada's proximity to the United States is also cited as a serious problem, on account of the infamous "Brain Drain" - a phenomenon which describes the 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. However it has been noticed lately that a significant portion of doctors and nurses that leave Canada to work in the US later return to Canada and practice there. (Please provide reference link to this statistic for verification)

There are other proposed reforms that come from the populist left and centre wings and also those with a special interest in health care. While right wing reforms often get more attention, there is a grass roots movement to try and keep medicare public in Canada and to avoid privatization. This is usually presented as a value the separates us from the Americans by mandating equality and fairness in health care.

Since the early 1990s Ontario, as with other provinces, has worked at trying to reduce health care costs. Some examples of ways that costs were reduced or could be reduced follow. None of these systems are forced on patients at the moment, but they attempt help to make the system more financially sustainable. This makes them substantially different from Health Maintenance Organizations (commonly referred to as HMOs in the US) and other somewhat similar looking attempts by the United States to reduce health care costs, which appear to have reduced the average patient's access to medical care. Therefore they have been better accepted by the public.

User premiums

Currently in Ontario, people with a high enough income must pay an annual health care premium. It can range from $300-$800, depending on one's annual income. This payment is charged for those having salary above CN$38,000. Funding for medicare in Ontario also comes from a dedicated employer tax that ranges from 0.98%-1.95% of employer profit over $200,000. Premiums are not new in Ontario however. They existed into the 1980's at which point they were replaced by the employer tax. Premiums also exist in British Columbia and Alberta, though as Alberta approaches debt-free status, there has been talk of removing them.

Medical clinics

Proposals to reduce costs have been varied. There is a movement in Ontario to try and expand 24-hour drop-in medical clinic network. This would mean that if someone were ill, no matter what the time of day, they would be able to see a doctor without going to a hospital. As many evening hospital visits are because there is no available medical service for problems that cannot wait until morning, it is likely that this would reduce costs considerably. A registration at a hospital costs at least $250, while a visit to a doctor is often less than $30 for a general doctor. It has been proposed that doctors working late hours would get paid more per visit as an incentive. Still, the savings quickly become clear. This development parallels the more well established US "urgent care" system of private clinics that compete with hospitals for simple medical emergencies.

Alternatives to fee-for-service

There is also a movement to try and move the system away from bill for service. The Ontario government in the early 1990's helped develop many community health care centres which provide both medical and social support. The emphasis is on medical care but the over-all approach is holistic. Collective kitchens, Internet access, anti-poverty groups and groups to help people quit smoking are common and funded in various ways. While funding has decreased for these centres, and they have had to cut back, they have been quite cost effective. They are often located in low income areas. If it is possible to reduce illness before it reaches a hospital a lot of money can be saved, although it is often hard to estimate how much and thus it is easier to cut these programs. Many of these centres are filled to capacity in terms of general doctors, and there are often fairly long waiting lists, although drop in health care is provided, often for those who have no other doctor. The centres also make use of nurse practitioners, who reduce the workload on the doctors and increase efficiency.

Midwives

Ontario has also recently licensed midwives and is teaching a new generation how to provide the help necessary for pregnant mothers. While midwifery cannot always take the place of a doctor, it can still reduce costs. If the mother wishes it and the birth appears uncomplicated, a hospital need not be involved. However, hospitals are now introducing birthing areas which contain their own suite, often with a hot tub (which is good for relieving pain without medication). These births often cost much less than the traditional manner of birth but are close to hospital facilities in case the need emerges. There have been occasional problems but overall the system has worked quite effectively.

Privatization

In recent years some on the political right-wing have called for an increased role for the private sector in the delivery of hospital medicare services. Currently, privately owned and operated hospitals that allow patients to pay out-of-pocket for services cannot obtain public funding in Canada, as they contravene the "equal accessibility" tenets of the Canada Health Act. Canada has the most public hospital system in the world: 98% of all Canadian hospital care is paid for by the state, while no other country covers more than 80%.

Many political scientists believe that removing the "equal accessibility" clause could be political suicide. This has gradually changed with the continuing problems with the health care system. Some have suggested relaxation of the rules of the Act to allow such private facilities to open and operate in tandem with the publicly funded system. It is argued that this would lessen the burden on the publicly funded system as many well-off citizens would simply choose to pay out-of-pocket or through private insurers for services rather than rely on the public system. However, such proposals have been met with a large degree of public hostility. As a compromise, some provincial governments have experimented with the concept of "public-private partnerships" (P3 Projects) or the contracting out of health services to private providers, whose services are paid for out of the public purse.

In a P3 project situation, a private company is granted licence to build a hospital, or other facility, and to manage maintenance and infrastructure services upon its completion. However, all health services in the facility continue to be paid for and administered solely by the public system. Advocates for P3 projects in Canada often cite the successful implementation of such facilities in the National Health Service (NHS) of the United Kingdom. A significant report by the UK National Audit Committee released in early 2003 reported much success with the P3 system. However the P3 system is itself still very controversial in the UK. In the Canadian province of Ontario, the government signed deals for the construction of several P3 facilities, including one for the William Osler Hospital in Brampton and the Royal Ottawa Hospital. However, the defeat of the Progressive Conservative government of Ernie Eves in Ontario on October 2, 2003 placed the status of these projects in jeopardy, as the newly elected Liberal premier, Dalton McGuinty, had campaigned against the use of P3 hospitals.

Due to the decentralized nature of the Canadian federation, the degree of privatization varies from province to province.

Barriers to foreign trained practitioners

One of the main issues regarding medicare is the resistance offered by the Canadian health system to foreign trained doctors called IMGs (international medical graduates). This is the opposite of what is happening in the US which is absorbing doctors from all over the world. In practice, little has been done to solve this issue all across Canada.

Many professions in Canada place barriers for entry by foreign trained people. This is done for a variety of reason, being the perceived lack of skill from the foreign professions or job protection to create an artificial scarcity of personnel in a field to keep the wages high.

Canadian health care in comparison

Despite the relatively high costs of providing health care in Canada's hinterland and the high wages necessary to compete with wages in the United States, Canada spends no more than the G7 average on health care as a percent of its GDP. Most health statistics in Canada are about average for the G7, and vastly better than the world average.

Country Life expectancy Infant mortality rate 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 % of health costs paid by private sector
Australia 80.0 5.6 1,741 9.2 16.8 67.9 32.1
Canada 79.3 5.6 2,163 9.5 16.2 70.8 29.2
France 79.3 5.7 2,109 9.6 13.7 76.0 24.0
Germany 78.2 5.2 2,412 10.8 16.6 74.9 25.1
Japan 81.4 4.1 2,627 8.0 16.4 77.9 22.1
UK 77.5 5.9 1,835 7.6 15.4 82.2 17.8
USA 77.0 6.4 4,887 13.9 17.6 44.4 55.6
Source: WHO (http://www3.who.int/whosis/core/core_process.cfm?option=3), note that these figures include all areas of health care including dentistry, optometry, and drugs.

See also: Canadian and American health care systems compared

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