Universal Hospital Insurance Research Articles

Health Insurance and Canadian Public Policy, 2nd edition

Health Insurance and Canadian Public Policy, 2nd edition Jack Boan Health Insurance and Canadian Public Policy, 2nd edition by Malcolm Taylor. Montreal and Kingston: McGill-Queen’s University Press, 2009. 592 pp. Paper $34.95. This second edition is introduced lucidly and insightfully by Allan Maslove, Carleton University, who summarizes the book and concludes with two excellent points about its relevance to today’s debate about health care. Everyone interested in health care, including those who teach and do research in that field, will find this book very useful. The general public should be interested in the reissued book as they will discover just what a precious public policy medicare is. But they may be left with a question: How could there be so much dissension and acrimony today over medicare when elected representatives a generation ago voted unanimously to support it? This book will enable readers to identify the culprits. Not only is there a wealth of valuable data in Health Insurance and Canadian Public Policy that is still relevant, but the way Taylor presents the struggle for prepaid health insurance is as fascinating as it is informative. Until one reads about the infighting, and the difficulties reformers faced in order to get what we call medicare, we have no idea of the miracle that has come to pass. The author traces the process from 1919, when health insurance was a plank in the Liberal Party’s [End Page 118] platform, through the developments in Saskatchewan, which pioneered the municipal doctor movement, followed by the first universal hospital insurance plan in North America in 1947 and medical insurance in 1962. Then there were the efforts of the federal government, during the Second World War years and shortly after, to produce a plan that the provinces might like (but didn’t), and the Royal Commission on Health Services, which reported in 1964, recommending national prepaid medical insurance—all of which set the stage for some of the most interesting drama that could have been conceived. Ego-driven provincial premiers and disagreements within the federal Cabinet threatened to scuttle the whole thing, but finally, in December 1966 the Medical Care Insurance Act was passed in the House of Commons, practically unanimously. Taylor refers to the health charter that Emmett Hall, chairman of the Royal Commission on Health Services, had insisted on placing at the beginning of the report. The charter refers to the “enormous gap between our scientific knowledge and skills on the one hand, and our organizational and financial arrangements to apply them to the needs of men, on the other,” and recommended that the gap be closed through the full cooperation of the general public, the health professions, voluntary agencies, all political parties and governments, federal, provincial and municipal, directed towards the most effective use of the nation’s health resources to attain the highest possible levels of physical and mental well-being. (p. 343) The reader will have noticed the word cooperation in the health charter. Hall, evidently, had no doubt that there would be cooperation, after he had talked to so many people and read a multiplicity of briefs during the three years that the report was in the making. Dead wrong! Organized medicine and the insurance industry have been anything but cooperative, and that probably explains, as much as anything, why provincial governments across the country have had to take a bureaucratic, rather than a cooperative approach, to the dispensing of health services. Taylor, who died in 1994, discusses the developments in medicare since his first edition (1978), including the second Royal Commission that Hall undertook in the early 1980s, in which he himself was involved. (Taylor left the Commission soon after it got started, presumably because of the completely unrealistic time frame to meet the terms of reference.) He does an excellent job of presenting that Commission’s findings, including the explosive response from organized medicine. The 1962 Saskatchewan strike seems benign, he says, compared to the length and bitterness of the 1986 Ontario doctors’ strike. Taylor’s assessment of the behaviour of organized medicine in all this is interesting. Back in 1943, in what Taylor describes as organized medicine’s finest hour (p. 46...

Is RSBY India′s platform to implementing universal hospital insurance?

Background & objectives:In 2008, India's Labour Ministry launched a hospital insurance scheme called Rashtriya Swasthya Bima Yojana (RSBY) covering ‘Below Poverty Line’ (BPL) households. RSBY is implemented through insurance companies; premiums are subsidized by Union and States governments (75 : 25%). We examined RSBY's enrolment of BPL, costs vs. budgets and policy ramifications.Methods:Numbers of BPL are obtained by following criteria of two committees appointed for this task. District-specific premiums are weighted to obtain national average premiums. Using the BPL estimates and national premiums, we calculated overall expected costs of full roll-out of the RSBY per annum, and compared it to Union government budget allocations.Results:By March 31, 2011, RSBY enrolled about 27.8 per cent of the number of BPL households following the Tendulkar Committee estimates (37.6% following the Lakdawala Committee criteria). The average national weighted premium was 530 per household per year in 2011. The expected cost of premium to the union government of enrolling the entire BPL population in financial year (FY) 2010-11 would be 33.5 billion using Tendulkar count of BPL (or 24.6 billion following Lakdawala count), representing about 0.3 per cent (or 0.2%, respectively) of the total union budget. The RSBY budget allocation for FY 2010-11 was only about 0.037 per cent of the total union budget, sufficient to pay premiums of only 34 per cent of the BPL households enrolled by March 31, 2011.Interpretation & conclusions:RSBY could be the platform for universal health insurance when (i) the budget allocation will match the required funds for maintenance and expansion of the scheme; (ii) the scheme would ensure that beneficiaries’ rights are legally anchored; and (iii) RSBY would attract large numbers of premium-paying (non-BPL) households.

IS THE CANADIAN HEALTH CARE SYSTEM BETTER FOR NEUROLOGIC CARE?

Canada and the United States have much in common, including the world’s longest undefended border, but when it comes to health care, they have taken strikingly different paths in the last 40 years. The education and training of providers, including physicians and nurses, is similar, but major differences are seen in the organization and financing of health care. The net results of these differences are substantial and can be compared by examining specific measurements: costs, access, and health outcomes such as mortality, as well as less-easily quantified patient or provider satisfaction. I write from several perspectives; first, as a career academic neurologist and until 2003 Chair of a leading Canadian Department of Clinical Neurosciences, and now as Vice-President of Capital Health in Edmonton and Associate Dean Clinical Affairs at the University of Alberta. I have also lived, trained, and experienced the health care systems in the United States and England. The Canadian and American health care systems began to diverge in the late 1950s when Canada developed universal hospital insurance. Insurance for physician services was added a decade later. The overall system is guided by the Canada Health Act of 1984, which set out five principles: 1) public administration and payment; 2) comprehensiveness—must cover all medically necessary health services provided by hospitals and physicians; 3) universality—all insured services must be provided on “uniform terms and conditions,” to all citizens and residents; 4) portability—insured services must be paid for even if the patient is treated in another province; 5) accessibility—the plan must provide “reasonable access” to services and “reasonable compensation” to medical practitioners. This act defines Canadian “medicare,” a system where all citizens and residents are covered by the government for the direct costs of hospital and medical services, anywhere in the country. However, Canadians are not permitted to purchase “medically …

Is the Canadian health care system better for neurologic care?

Canada and the United States have much in common, including the world’s longest undefended border, but when it comes to health care, they have taken strikingly different paths in the last 40 years. The education and training of providers, including physicians and nurses, is similar, but major differences are seen in the organization and financing of health care. The net results of these differences are substantial and can be compared by examining specific measurements: costs, access, and health outcomes such as mortality, as well as less-easily quantified patient or provider satisfaction. I write from several perspectives; first, as a career academic neurologist and until 2003 Chair of a leading Canadian Department of Clinical Neurosciences, and now as Vice-President of Capital Health in Edmonton and Associate Dean Clinical Affairs at the University of Alberta. I have also lived, trained, and experienced the health care systems in the United States and England. The Canadian and American health care systems began to diverge in the late 1950s when Canada developed universal hospital insurance. Insurance for physician services was added a decade later. The overall system is guided by the Canada Health Act of 1984, which set out five principles: 1) public administration and payment; 2) comprehensiveness—must cover all medically necessary health services provided by hospitals and physicians; 3) universality—all insured services must be provided on “uniform terms and conditions,” to all citizens and residents; 4) portability—insured services must be paid for even if the patient is treated in another province; 5) accessibility—the plan must provide “reasonable access” to services and “reasonable compensation” to medical practitioners. This act defines Canadian “medicare,” a system where all citizens and residents are covered by the government for the direct costs of hospital and medical services, anywhere in the country. However, Canadians are not permitted to purchase “medically …

Universal Health Care: From the States to the Nation?

When I first heard of the Massachusetts state legislation, two things came to mind. One of them was a piece of Canadian history little known to Americans: universal care in that country began with the Canadian provinces, gradually spreading to its federal government. Is that kind of development possible in the United States? The other was the famous 1932 phrase of Supreme Court Justice Louis Brandeis that the states are the of democracy. Could the Massachusetts law serve as a for national universal health care? While the two questions are related, they raise different issues. The Canadian example bears on the direction and trajectory of health care reform, not on its content. Brandeis's phrase encompasses the nature of the reforms. The Massachusetts law is encouraging on both counts, but there are masons to be hesitant in one's hopes. The Canadian movement toward universal care began in 1947 in Saskatchewan. Tommy Douglas, then premier of that province, introduced universal hospital insurance, overturning decades of resistance. Nor was it all that popular with the province's physicians, who staged a famous but unsuccessful strike against it in 1962. As time went on, Alberta adopted similar policies and, most important, Canadian physicians-led by some socially prominent and influential doctors, sometimes called red tories--came to see the advantages of national universal care. In 1984 the last of a number of gradual steps led to the Canada Health Act, the cornerstone of present policy. That policy is a mixture of publicly funded and privately delivered health care, and it rests on five principles: universality, accessibility, comprehensiveness, portability, and public administration. That history is interesting, but its instructional--and inspirational-value for the United States is limited. Up until the 1950s or so, Canadian and American health care both consisted primarily of fee-for-service medicine, limited health insurance, and strong physician resistance to government-dominated health care. The paths of the two countries diverged partly because of cultural differences: Canada is a far more communitarian, less individualist country than the United States, with a strong welfare system, greater friendliness toward government, and a powerful commitment to the value of solidarity. Additionally, its parliamentary system allows for a more decisive pursuit of social goals than does ours. But while Canadian-U.S. historical and cultural differences are important, the idea of the states as laboratories is attractive. To serve effectively in that role, their example must be noted and well publicized, their innovative policies reasonably successful, and they must have policy ingredients that can be used in a national plan. Those elements were in place in the 1930s, when Justice Brandeis used the laboratory metaphor. Much of President Roosevelt's New Deal agenda came out of successful state programs. And, I would add, the times must be ripe to expand suggestive policies from the state to the national level, and to gain traction they must first spread among the states. The times may be ripening now. Once again talk of a health care crisis is in the air, and there is state movement beyond the Massachusetts example. Public opinion surveys show considerable discontent with American health care, the business community is increasingly distressed in trying to cope with ever-rising costs, and a long-awaited stimulus for serious reform may be at hand: middle-class alarm at a deteriorating situation for those previously well covered by insurance. The fact that a majority of personal bankruptcies in this country are occasioned by individual and family health care debts is a sobering figure. If the 46 million uninsured do not catch the congressional eye, maybe the steady increase of the uninsured and the rise in bankruptcies will. Yet some combination of hope and hesitation is in order before thinking that movement among the states may finally do the trick. …

Alberta's Provincial Travelling Clinic, 1924-42

Providing health services to sparsely populated, geographically isolated areas was a major challenge in many Canadian provinces before the advent of universal hospital insurance in the late 1950s, and universal physician insurance in the late 1960s. The task was especially daunting during the interwar depression years. Nonetheless, from 1924 to 1942, Alberta's Department of Public Health sponsored an itinerant Travelling Clinic during the summer which conducted physical examinations, dental examinations and treatment, tonsillectomies and other minor surgery, and vaccination against smallpox to children in frontier areas of the province. This article analyses Alberta's Travelling Clinic from a public policy perspective and concludes that through the Travelling Clinic, the Alberta government provided a health service valued by many settlers at nominal cost to itself.

The Canadian Health Care System: An Overview

I) X 3in Canada is a provincial responsibility, the "national" e n program is really made up of lo provincial and two cseA territorial plans. The provinces enacted their programs to take advantage of the so% cost-sharing of hospital and medical care costs offered by the federal government. Although universal insurance is only 25 years old, it was first discussed in 1919. However, it was not until 1945, after the depression and the second world war, that serious legislative steps were taken. Then the federal government first proposed a national system, based on the United Kingdom model. That model was rejected by the provinces because it was interpreted as a federal incursion into their jurisdictions (1). However, because hospital facilities were insufficient and, in many instances, outdated, the federal government did make planning and construction grants to the provinces. These grants established the concept of federal-provincial cost sharing for health care services. Armed with this promise, Saskatchewan followed by three additional provinces enacted universal hospital insurance plans. They then pressed the federal government to honor its 1945 funding commitment. Federal legislation was finally proclaimed in 1958, and by 1961 all the provinces enacted plans to take advantage of federal costsharing. The next year Saskatchewan adopted a universal medical care insurance plan, and six years later the federal government completed the cycle by offering cost-sharing to the provinces for universal medical care insurance. Although cost-sharing was on a 5o-50 basis, the federal legislation was written so that the subsidies were proportionally greater than 5o% of actual costs for the poorer provinces, and less than so% for the wealthier

The Canadian health care system: An overview

Although health care is a provincial responsibility in Canada, universal hospital insurance was fully adopted by 1961; universal medical insurance followed 10 years later. Each province enacted universal insurance after the federal government offered to pay 50% of provincial hospital and medical care costs. Hospital insurance had wide public and provider support but universal medical care insurance was opposed by organized medicine. The federal government soon realized that it had no control over total expenditures and no mechanisms for controlling costs. In 1977 it enacted Bill C-37 which limited total federal contributions and made those contributions independent of provincial health care expenditures so that increased costs had to be met by the provinces. Since private health care insurance for universal benefits is prohibited by the federal terms of reference for health insurance, the provinces must raise the money by taxes and (in some provinces) premiums. Although prohibited by the terms of reference of the universal program, some provinces have adopted hospital user fees and are allowing their physicians to bill patients in excess of provincial fee schedules. The 1980s have seen increased confrontations between the federal and provincial governmets and between the provinces and their providers. The issues are cost containment and control of the system. The provinces have two broad options. The first is more private funding through private insurance and user fees. The proposed new Canada Health Act will probably prohibit such charges. A second option involves greater control and management of the system by the provinces; this has already occured in Quebec. Greater control is vigorously opposed by physicians and hospitals. The Canadian solution to health insurance problems in the past has been moderation. Extreme moves in either direction would represent a break with tradition, but they may prove to be unavoidable.

Aspects of Medical Manpower under National Health Insurance in Canada

caGaGm ANAD A has had universal hospital insurance since 1961 S and universal medical care insurance since 1971. Medical care insurance was enacted: 1) as an inevitable consequence of universal hospital insurance, 2) because of its successfiul adoption in Saskatchewan, and 3) because the federal government accepted the recommendations of the 1964-1965 Royal Commission on Health Services (the Hall Commission) that it enact federal-provincial cost sharing for medical care insurance. In this paper we will examine the effect of universal medical care insurance on medical (and to a small extent nursing) manpower in Canada. We also will look at some of the current issues at the interface between governments and physicians. Although the analysis is national, health care in Canada is primarily a provincial responsibility and manpower policies are made at the provincial level. However, in the early days of universal medical insurance, federal contributions to the funding of medical education gave rise to a strong federal presence in medical manpower policy. Since the late 1970S, federal support of medical education and health care has decreased. With or without financial support of medical education at the federal level, medical manpower is a national resource in all of Canada except Quebec; licensure is donejointly by the nine anglophone provinces and movement of physicians among them is essentially unrestricted. In recommending universal medical care insurance in 1964-1965, the Hall Commission report made a number of assumptions (1): 1. The existing physician to population ratio of 1:857 was a minimum optimal ratio. This ratio had to be maintained or improved because of anticipated increased use due to unmet need and increased demand for services. 2. Population growth at existing rates would continue.

Dealing With the Doctors: The Canadian Experience

The national health-care scheme in Canada was put in place in the 1950s and 60s. The initiative for massive state intervention in the provision of health care came from a social democratic Cooperative Commonwealth Federation (CCF) government in Saskatchewan in the late 1940s. Committed to a system of "socialized medicine" the CCF government elected in 1944 took its first tentative step in this direction in 1947 with the introduction of a universal hospital-insurance scheme and medical insurance for pensioners. Ten years later, a federal Liberal government enacted the Hospital Insurance and Diagnostic Services Act. This Act provided for 50 percent federal funding of hospital services in provinces with universal hospital insurance schemes. By 1961, all provinces and 99 percent of the Canadian population were covered by hospital insurance schemes.This article can also be found at the Monthly Review website, where most recent articles are published in full.Click here to purchase a PDF version of this article at the Monthly Review website.

Universal Hospital and Medical Care Insurance in Canada: Utilization and Cost Performance

jra *n5LTHOUGH the Canadian provinces have constitu{ tional responsibility for hospital and medical care, a universal program was established in Canada when the federal government offered 5o/5o sharing of hospital and, later, medical care costs (1). The terms of reference 3*4t2X c!.A required to qualify for federal cost-sharing are broad, and there is variation among the ten provinces, particularly in the case of supplemental benefits. Under the new 1977 funding arrangements, even greater variation can be expected. The 50 /5o cost sharing was calculated to pay the poorer provinces more than half their costs and the wealthier provinces slightly less than half. Revenue sharing has been retained in the new 1977 fiscal arrangements. How has the system performed since 1958 when universal hospital insurance began, and since 1968 which marked the beginning of universal medical insurance? Despite initial concerns, the universal plans themselves did not result in persistent runaway utilization, although there were sharp increases in hospital spending between 1958 and 1961 and in medical care spending between 1968 and 1971. The universal plans in Canada were built on existing provincial insurance programs. In the case of hospital insurance, five provinces already had universal insurance when the Hospital and Diagnostic Services Act was adopted and implemented, and there were varying degrees of insurance in the other provinces. No persistent utilization effect can be demonstrated after the universal hospital insurance was adopted, but it may well be that any utilization effect had already been absorbed by the public and private health insurance which predated the universal plan. Per-capita admissions and patient days in general and allied special hospitals (acute-care hospitals) increased between 1% and 2% per year in the 1950S and 196os. Since 1970, patient days per 1,ooo population have fallen slightly. The decrease has

Universal health insurance in Canada

This paper describes the universal health insurance program in Canada and identifies the historical events and social values leading to its adoption. Universal hospital insurance was adopted in 1958, ten years before medical insurance, as a result hospital-based patterns of practice were solidified. Through cost sharing, the federal government influenced the provinces to enact relatively uniform universal plans. From 1951 to 1971 health care expenditures rose rapidly to 7.3% of the gross national product (GNP), but have since decreased and stabilized at about 6.9%. In contrast, health care in the United States represents 8.6% of GNP. Hospital use also increased rapidly in Canada to 1970 but appears to have stabilized and decreased slightly in this decade. Physician incomes rose rapidly before 1971, but since then the increases have slowed and relative incomes of physicians have fallen. Althouth the percent of GNP spent for health care has leveled, there are still substantial annual increases in expenditures that are paid for by government. Two federal initiatives, Bill C-37 and the Lalonde Report, have their roots in cost containment; Bill C-37 transfers greater taxing authority from the federal government to the provinces. To meet the goal of containing costs, provincial governments are moving in the direction of regionalization, decentralization, and greater coordination. In the short term, the provinces have limited hospital budgetary increases to percentages less than the rate of inflation. Cost constraints may be long overdue. Imposing fiscal limits encourages rational planning. It does not appear that the health of Canadians will be adversely affected or essential benefits curtailed by present budgetary restrictions or reorganization.