Medicare (Canada)


 * This article refers to medicare, a name for Canada's public health insurance system. For similarly named programs in other countries, see Medicare.

The term medicare (in lowercase) (French: assurance maladie) is the unofficial name for Canada's universal public health insurance system. The formal terminology for the insurance system is provided by the Canada Health Act and the health insurance legislation of the individual provinces and territories.

Under the terms of the Canada Health Act, all Canadian citizens and landed immigrants are entitled to receive medically necessary hospital services, physician services and surgical-dental services. The system is funded by Canada's federal government via transfer payments to all provinces and territories, and is supported through taxes. All Canadians to receive medical care regardless of yearly income or ability to pay for the care. Some provinces charge health care premiums for coverage, but not on a fee for service basis. Canada's health institutions are either private and non-profit (such as university hospitals) or provincially run (such as Quebec's CLSC system). Almost all doctors are in private practice in self-employed and doctor-owned businesses. Since 2000 they have been allowed to incorporate (dates of authorization vary province to province), and they bill the medicare system on a fee for service basis. The system is known as a "public system" due to its public financing, but is not a nationalized system such as the UK's NHS because most services are provided by private enterprises, mainly physician-owned clinics.

The Health Care System in Canada is a universal access system, but some items or services are not covered, with inconsistency province to province, e.g., drug coverage, optometry, physical therapy. Some services that are available from salaried employees of government agencies and hospitals may also be purchased privately on a fee for service basis, e.g., psychological services, speech therapy, occupational therapy.

While often called a socialized-public system it is in fact merely publicly funded. Most services are provided by private enterprises. With rare exceptions, medical doctors are not on a government salary, but operate as independent businesses.

Services covered
Canada's healthcare system provides medical doctor-provided diagnostic, treatment and preventive services to every Canadian regardless of income level or station in life. The services of physicians are covered whether provided within a public hospital or a private-owned doctor's office. Services of non-physicians may not be covered at all, or covered only if the provider is a salaried employee of a governmental institution, e.g., physical therapist, occupational therapist, speech therapist, psychologist. There are minor variations province to province.

Each province in Canada manages its own healthcare system. For example, each province issues its own healthcare identification cards and negotiates with the federal government for money to cover healthcare costs. Each province may also provide its own prescription drug benefit plan. However, drug plans are provincial plans, not a requirement of the Canada Health Act. Provincial prescription drug benefit plans may be, adjusted for income, with a higher co-payment required or exclusion for those with higher personal incomes. The prescription drug benefit is usually comprehensive and rarely excludes a medication, though approval (adding the drug to the provincial formulary) may result in a medication being available in one province long before it is available in another, or never being funded. This is especially true of expensive drugs and poorer provinces, e.g., Avastin. Medications that are excluded may be approved under an "exceptional drug" program.

Dental care is not covered by any government insurance plans. Canadians rely on their employers, individual private insurance, pay cash themselves for dental treatments, or receive no care. Some targeted programs address the need of the young, the elderly or those who are on welfare.

The range of services for vision care coverage varies widely among the provinces. Generally, vision care is covered (cataract surgery, diabetic vision care, some laser eye surgeries required as a result of disease); the main exception is the standard vision test, which patients pay for if they have their eyes tested more than once within a two-year period. In Ontario, Alberta and Saskatchewan you are charged for every vision test that is taken.

Naturopathic services are covered in some cases, but homeopathic services are generally not covered. Chiropractic is partially covered in some provinces. Cosmetic procedures are not typically covered. Psychiatric services (provided by physicians) are covered, fee-for-service psychology services outside of hospitals or community based mental health clinics are not. Physical therapy, occupational therapy, speech therapy, nursing, and chiropractic services are not covered unless within hospitals.

Opinions on Medicare
Polling data in the last few years have consistently cited medicare as the most important political issue in the minds of Canadian voters. Along with peacekeeping, the CBC ran a poll that found medicare to be one of the most defining characteristics of Canada.

It has increasingly become a source of controversy in Canadian politics. Due to massive healthcare transfer payment cuts at the hands of recent federal governments, and the resulting shortfalls in provincial government budgets, combined with rising costs due to an aging population, quality of care provided has decreased through the past two decades.

Researchers examining the quality of the Canadian healthcare system cite several problems with the system: limited access to diagnostic equipment (such as MRIs and CT Scanners) and 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 as long as several years. There have been some wait-time improvements through 2005 and 2006. Even so, as of 2004, five million Canadians were without a family doctor.

Some politicians and think tanks have proposed removing barriers to the existence of a parallel private healthcare system. Though polling suggests support for such reforms has been increasing, it has yet to be adopted as official policy by any of the main federal political parties. There have been private clinics opened and operating in Canada, but they are few and far between. Canadians who pay for their own services at private clinics are not penalized or prevented from using the public healthcare system simultaneously.

It is argued within Canada that despite wait times and funding cuts, Canadians receive a high standard of care, on par with what a privately insured American citizen would get in most cases. The Canadian system is much more affordable for certain items such as patented drugs and this difference in price has created a large prescription drug exporting industry in Canada. Older off-patent medicines tend to be somewhat more expensive due to less competition as entry into the Canadian market suffers from government barriers.

American opinion on Canadian medicare tends to be non-neutral, either supportive as in the preceeding paragraph and therefore desireable within the USA, or negative and not desireable. Opinions not supportive of medicare put forth issues as wait times and budget cuts having severly impaired the Canadian healthcare system, to the point where Canadian mothers have to go to the U.S. to deliver because of lack of room and nurses in Canadian hospitals.

Governments in Canada spend a smaller amount per capita on healthcare than governments in the United States, while almost every Canadian citizen is fully covered. In the United States a high percentage of the population is uncovered or only marginally covered, despite higher proportional spending along with large private investment. Even more people 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 has gone down not up).

The lack of competition has given healthcare unions a monoloply on essential services. Thus ensuring a very strong bargaining position. Nova Scotia is currently debating healthcare legislation aimed at removing the threat of striking healthcare workers and replacing it with binding arbitration.

Proposed reforms
One proposed solution for improving the Canadian healthcare system is to increase funding. Proponents of this approach 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. In fact, there is evidence that the percentage of total government expenditures spent on healthcare has been increasing, in part due to a higher percentage of older Canadians.

Other critics of healthcare state that increased funding will not solve systematic problems in the healthcare system including a rising cost of medical technology, infrastructure, and wages. These critics say that Canada's proximity to the United States causes a "Brain Drain" or 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. Some of these critics argue that increased privatization of healthcare would improve Canada's health infrastructure.

Critics of the systematic reform approach state that healthcare should be kept public, (public in funding only, as most services are provided by the private sector including doctors who in most cases are private corporations) in part because it separates Canadians from Americans by mandating equality and fairness in health care. Truth is that the system is not a true public system, as in Italy, where doctors are on a per capita salary. The Canadian Health care system is merely publicly funded, which most Canadians appreciate and desire. Making the system a true public system is an alternative to the current half public, half private system.

Much of the political discourse concerning the health care system, as it stands in the year 2006, appears to be politically motivated. First, there is a failure to appreciate and acknowledge that the system is not a true public system. Second, there is a failure to appreciate the system is also private: most services are provided by a private sector, the system is merely publicly funded. While the majority of discussions focus on whether to privatize or not, the question implies that the system is not private, which ignores the privatized component of the system, and more importantly falsely implies that the system is a true public system, which it is not; most doctors are self employed incorporated entities, they are not on a public salary.

Ontario's reform experiments
Since the early 1990s, Ontario has implemented several systematic reforms to reduce health care costs. Similar reforms have been implemented in other provinces.

User premiums
Currently in Ontario, people who earn salaries above $20,000 must pay an annual health care premium ranging from $300-$900. Funding for medicare in Ontario also comes in part from a dedicated Employer Health Tax (EHT) that ranges from 0.98%-1.95% of employer payroll. Eligible employers are exempted from EHT on the first $400,000 of payroll. British Columbia, Quebec, and Alberta charge similar premiums. Alberta charges $44 a month or $88 per family, though as Alberta approaches debt-free status, there has been talk of removing them.

Medical clinics
Ontario has increased the number of 24-hour drop-in medical clinic networks to reduce costs associated with treating off-hours emergencies in hospital emergency rooms.

Many Family Doctor Practices have created their own clinics, offering 24 hour service for their patients if needed. Each Doctor in the Practice takes a turn at being "on call" on a rotating basis. Patients who have family doctors belonging to these practices are able to have a doctor come to their home in extreme situations. There is no additional charge for these services as they are billed to the Province, the same as an office visit.

Hospitals in some major Canadian cities, such as London, Ontario, have restructured their Emergency services to share emergency treatment among several hospitals. One hospital may provide full emergency room care, while another sees patients who have broken limbs, minor injuries and yet another sees patients suffering cold, flu, etc.

Recently, the first nurse practioner-led office to relieve waiting times caused by a shortage of primary practioners was opened in Sudbury, Ontario.

Alternatives to fee-for-service
Ontario has also attempted to move the system away from bill for service and toward preventive and community-based approaches to healthcare. The Ontario government in the early 1990's helped develop many community health care centres, often in low-income areas, which provide both medical and social support which combines health care with programs such as collective kitchens, Internet access, anti-poverty groups and groups to help people quit smoking.

While funding has decreased for these centres, and they have had to cut back, they have had a lower cost than the traditional fee-for-service approach. Many of these centres are filled to capacity in terms of general doctors, and there are often fairly long waiting lists and the centres also utilize nurse practitioners, who reduce the workload on the doctors and increase efficiency.

Midwives and hospital birthing reforms
Ontario and Quebec have recently licensed midwives, providing another option for childbirth which can reduce costs for uncomplicated births. Midwives remain close to hospital facilities in case the need for emergency care emerges. These births often cost much less than the traditional hospital delivery. Hospitals have also reformed their approach to birthing by adding private birthing areas, often with a hot tub (which is good for relieving pain without medication).

Privatization
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. Some politicians and medical professionals have proposed allowing public funding for these hospitals. Workers' Compensation Boards, the Canadian Military, the RCMP, federally incarcerated prisoners, and medical care for which an insurance company has liability (e.g., motor vehicle accidents) all pay for health care outside of the public systems in all provinces.

In Quebec, a recent legal change has allowed this reform to occur. In June 2005, the Supreme Court of Canada overturned a Quebec law preventing people from buying private health insurance to pay for medical services available through the publicly funded system and this ruling does not apply outside the province. See: Chaoulli v. Quebec (Attorney General).

In November 2005, the Quebec government announced that it would allow residents to purchase private medical insurance to comply with this ruling.

Private insurance from companies such as Blue Cross, Green Shield and Manulife have been available for many years to cover services not covered by Medicare, such as dental care and eye care. Private insurance is provided by many employers as a benefit.

The Canadian Medical Association (CMA) released a report in July 2007 endorsing private healthcare as a means to improve an ailing healthcare system. The current president of the CMA, Dr. Brian Day, is the owner of the largest private healthcare hospital in Canada and a proponent of mixed public and private healthcare in Canada.

Canadian Health Practitioner standards
It is generally accepted that physicians arriving in Canada from other countries must meet Canadian Health Practitioner standards. So there is concern that doctors from other countries are not trained or educated to meet Canadian standards. Consequently, doctors who want to practice in Canada must meet the same educational and medical qualifications as Canadian-trained practitioners, others suggest that the current regulatory bodies, the Canadian Medical Association, the Doctors Union, and the College of Physicians and Surgeons has created too much red tape to allow qualified doctors to practise in Canada. It should be noted that Canada's Health system is ranked 30th in the world, suggesting the logic of the doctor shortage defies the statistics. In fact according to a report by Keith Leslie of the Canadian Press in the Chronicle Journal, Nov 21, 2005, over 10,000 trained doctors are working in the United States, a country ranked 36th in the world. It would suggest money or the perception of better working conditions, or both, are resulting in an exodus of Canadian doctors (and nurses) to the USA.

It is important to recognize that many consider the doctor shortage in Canada to be a very severe problem impacting all sectors of health care. It may relate in part to the details of how doctors are paid; a detail often misunderstood. In Canada, almost all doctors receive a fee per-visit, not per-service. It has been suggested that this type of "fee-for-visit" payment system can encourage complexity, volume visits, repeat visits, referrals, and testing.

One consequence of the shortage in Canada is that a great many patients are left without family doctors, and trained specialists, making early intervention very difficult. As the article in the Toronto Star specially isolates, it is not so much a problem of a doctor shortage but of a shortage of 'licensed doctors'. Michael Urbanski states that Canada already has a hidden reserve of foreign-trained MDs eager to begin medical practice. "However, what's crucial to understanding the issue of doctor shortage in Ontario is that while the Liberal government is planning to go "poaching" for other countries' doctors, there are an estimated 4,000 internationally trained doctors right here in Ontario working at low-wage jobs."

A CBC report [6](August 21, 2006) on the health care system reports the following:

"Dr. Albert Schumacher, former president of the Canadian Medical Association estimates that 75 per cent of 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."

In a report by Keith Leslie of the Canadian Press in the Chronicle Journal, Nov 21, 2005, commenting on an Ontario Medical Association Report, prepared by the human resources committee states "The year 2005 finds the province in the midst of a deepening physician resources crisis". The report continues to report, "the government should make it easier for doctors from other provinces to work in Ontario and .... ". Here we  have signs of inter-provincial competition impacting the doctor shortage in one province over another. . Essentially, privatized healthcare is not a choice of interest for lower income Canadians, it is most likely to be unaffordable and unfair to those who suffer on a social standard.

Provincial insurance plans
Though the Canada Health Act provides national guidelines for healthcare, the provinces have exclusive jurisdiction over health under the constitution and are free to ignore these guidelines, although if they ignore the guidelines, the federal government may deny federal funding for healthcare. All provinces currently abide by the Canada Health Act in order to receive this funding; however the Alberta legislature has considered proposals to ignore the Act to allow them to implement reforms not allowed under the Act.

The federal government has no direct role in the delivery of medicine in the provinces and territories so each province and territory has its own independent public health insurance program. Under the Canada Health Act, each province and territory must provide services to members of plans in other provinces and territories.