Pushing Right against the Evidence: Turbulent Times for Canadian Health Care

Abstract

Throughout the history of Canadian Medicare, there have been those who have opposed the universal, publicly funded system and advocated for greater private sector involvement. Amidst widespread public dissatisfaction with some aspects of Canadian health care--wait lists for some medical services, inadequate out-of-hospital drug coverage, and difficulties in accessing primary care--a series of recent events has shifted the public debate toward privately financed medicine, even as more Americans have been drawn toward universal public coverage. Certainly Canadian health care is in need of system reform. However, in a remarkably short time, the debate about the direction of reform has been transformed from one rooted in rigorous policy science, careful consideration of the empirical evidence, and an explicit commitment to universality, solidarity, equity, and the efficiencies of a single-payer, publicly-funded, not-for-profit system to one dominated by support for private and profit-driven systems and cut loose from solid evidence about what promotes equitable, effective, efficient, and sustainable health care. In fact, the move toward privatization rests on the repudiation of evidence-based health policy. Canadian Medicare provides publicly funded, tax-supported coverage for almost all doctor and hospital health care costs. This system developed gradually after World War II and was codified in the 1984 Canada Health Act, which calls for universality, accessibility, comprehensiveness, portability, and public administration of a not-for-profit system. It is crucial to understand that the CHA applies to the public funding (federal and provincial) of designated services, primarily hospital and doctor-delivered care. The delivery of health care has always been provided by a mixture of public and private--not-for-profit and for-profit--providers. Since the beginning of Medicare, doctors have typically been self-employed agents billing a fee fixed through negotiation between the provincial medical association and the provinces. The key to understanding the egalitarian nature of the Canadian health care system is that, while some providers are for-profit, they almost all bill the publicly funded insurance plan so that patients are not required to pay anything when they receive care. User fees, copays, and deductibles are banned for services covered under the public plan. While 70 percent of the total cost of health care is covered by public insurance, there has always been a strong role for private out-of-pocket and employer-based insurance for services not covered publicly, such as podiatry, dentistry, and nonsurgical vision care. All told, about 30 percent of total health care costs in Canada are covered privately. Although combining public and private funding is in line with practice in other OECD countries, the Canadian strategy is unique. In most countries, public funding is for standard level of care, and private funding for a preferential level of care for the same service. Canada alone makes public funding available for some services and relies on private funding for others. In addition, however, both patients and doctors are able to opt out of the public system, although the conditions for doing so vary from province to province. In most provinces, doctors cannot be paid privately for services for which they also bill the public system. Some provinces prohibit the sale of private insurance for services that are covered by the public system--a restriction intended to protect the integrity of the public insurance system. As health care has expanded in scope, and as much of the delivery of care has shifted to home and community, pressures have built on cost and access, just as they have across the entire developed world. Canada has launched various provincial and federal initiatives to reform the system, adapt it to contemporary practice, and ensure its sustainability. The most recent federal initiative was the Commission on the Future of Health Care in Canada, known as the Romanow Report after its author, the former premier of Saskatchewan, Roy Romanow. …