Canada: a kinder, gentler health care system?

Abstract

Much interest has been shown in the Canadian health care system as a possible model for consideration in the current debate about the future of health care in the United States. This column considers some of the positive and negative features of the Canadian system. As one who trained in psychiatry in the U.S. and who has been a residency training director in both countries, I have firsthand practical knowledge of both systems. In response to the question of whether the Canadian system is “kinder” and “gentler” (to use George Bush’s terms from another context) compared with the U.S. system, the most realistic answer is a resounding “yes and no.” Both systems are undergoing major changes in dealing with similar issues, but they clearly differ in how these changes are being played out. In both countries it is as yet unclear how the next stable period will be configured—as suming the pace of change will eventually slow down. I will build my comments around ten topics widely cited in the current professional press. Ten topics of concern Universality. The Canadian system is a totally universal insurance plan. Physicians are paid on a fee-for-service basis, although salaried positions and some health maintenance organizations have gradually emerged over the past decade. The current Canadian system is a nationalized insurance system similar to Medicare in the U.S., not a nationalized delivery system like the National Health Service in the United Kingdom. The Canadian population considers health care a top priority. Few physicians would want to see the universal coverage changed. Canadians regard tying health care to employment as an American anomaly. All citizens are considered to have a right to equal access to all services. Insured services, however, are restricted to those provided by a physician. Services provided by other mental health clinicians are not covered unless the clinician delivers the services as an employee of a hospital. Approximately 14 per cent of the health care budget is consumed by mental health services. Parity. Psychiatric services have absolute parity with the rest of medicine. When the Canada Health Act was introduced in the 1960s, psychiatric leaders emphatically supported this principle and have worked hard to maintain close collegial alliances with all parts of the medical profession. The act sets out general national standards that must be met by each province. They are comprehensiveness (care available for every citizen at all ages), universality (coverage of all mental, surgical, and medical conditions), portability between provinces, accessibility, and public administration (a single-payer model). The actual delivery of health care is a provincial responsibility. In 1984 the Canada Health Act further defined and reaffirmed the five principles as follows: