1 - Canadian Healthcare System Flashcards
What is public policy?
How does it affect the health system?
- the conduct of public affairs
- a means for the administration (government) to achieve public goals & objectives
- should be reflective of the populations’ values and expectations
- “a statement of principle or intent that guides the selection of priorities and sets the direction of programs and actions of an individual, or organization or government”
- public policy drives the health system
Does Canada have a universal health care system?
Yes and No.
-It’s not as straight forward as say the UK (they definitely have universal health care system)
Who are two “grandfathers” of our healthcare system?
- Pierre Trudeau
- Tommy Douglas
What happened in Canada in 1867?
Confederation:
-BNA Act (British North American Act)
-Created and defined a federal dominion and provincial jurisdictions
What was included in Federal dominion of BNA act in 1867?
- Immigration
- Currency
- Defence
- Regulation of trade, banking, commerce, patents
- Revenue and taxation (Any mode or system of taxation, for any purpose)
- Indians and reserves
- Criminal law and penitentiaries
- Quarantine and marine hospitals
What was included in the provincial jurisdictions of BNA act in 1867?
- Revenue
- Via “direct taxation”, “licenses”, or from non-renewable resources, forestry, and “electrical energy”
- For provincial purposes only
- Education
- Hospitals
- Healthcare
Provincial jurisdiction was delegated health care authority, but …
- Paid little direct attention to health care
- Health was viewed as a private matter
- Municipalities, religious organizations and charities played central role in building hospitals and supporting the poor
- Actual provincial role of negligible
- Immediately prior to WWI, over 50% of national health and welfare costs were borne by municipalities
- at this time, no real medicines existed, penicillin wasn’t even invented yet.
- no management of chronic diseases
- ppl only sought medical attention if they had a trauma or needed surgery
1910’s to 1940’s:
What happened in between 1910’s to 1940’s ?
- Two world wars
- Great depression
1910’s to 1940’s:
Post WWI, there was high prevalence of ?
general disease amongst returning soldiers
1910’s to 1940’s:
Post WII, provinces did what?
pressured feds for help!
Feds began providing conditional grants for v.d. prevention and treatment
- First precedence for use of federal spending power on health care
- The peculiar origin of fed-proc fiscal “relations” for health care
1910’s to 1940’s:
In 1930’s came the ______, where provinces and municipalities were treated by bankruptcy due to burden of unemployment relief
depression
1910’s to 1940’s:
How were physician incomes affected during the depression?
they plummeted
*provinces such as SK had to guarantee minimum reimbursements to Dr’s to prevent them from leaving
1910’s to 1940’s:
Many provinces set up commissions that recommended establishing public health _____ ______
insurance plans
1910’s to 1940’s:
Which 2 provinces first passed legislation for provincial public health insurance plans? (note: it was never implemented)
Alberta (1935)
BC (1937)
1910’s to 1940’s:
Leadership was left to _____ where municipally-funded insurance programs were already in existence in many parts of the province. These became the foundations for the first provincial public health insurance program.
Saskatchewan
1910’s to 1940’s:
In the meantime, federal, provincial, and municipal governments faced financing chaos. Give 3 examples.
- All three were levying income taxes
- All governments in dire financial crisis
- Jurisdictional responsibility for health care financing unclear
What did the 1940 Report of Royal Commission on Dominion-Provincial Relations do?
Recognized imbalance:
- Feds had most of revenue generating power
- Provinces had disproportionate amount of spending responsibility
Called for federal role in:
- Unemployment insurance and income security (pensions)
- National standards for programs under provincial jurisdiction
- Equalization to recognize provincial disparities
What happened post WWII?
-Feds began mapping out legislation for post-war social reconstruction
What did the Heagerty Committee do ? (1942)
Recommended comprehensive national public health insurance plan through shared prov-fed contribution
-Legislation was drafted with consultation of CMA - never implemented due to dissent from multiple parties (ex. CMA vs CFA)
How did public respond in 1944 when asked if they would be willing to contribute a small portion of their income to national health plan that would provide medical and hospital care when they needed it?
Majority were willing (slide 13)
Describe Tommy Douglas’s involvement in SK healthcare?
- In 1944, Tommy Douglas and the co-operative commonwealth federation (CCF) party win provincial election
- In 1947, Douglas introduced a province-wide, universal hospital care plan
- BC and AB followed in 1949 and 1950
-In 1957, “Hospital Insurance & diagnostic Services Act”
What is the “Hospital Insurance & diagnostic Services Act” (1957) ?
- Federal legislation
- “50-50 cost sharing” of provincial and territorial costs for specified hospital and diagnostic services
- Provided universal coverage for a specific set of services under uniform terms and conditions (national standards)
- By 1961, all provinces have universal hospital insurance
Describe “Medical Care Insurance Act”. (1962)
- Introduced by Tommy Douglas (premier of SK)
- Province-wide universal insurance plan to provide doctor’s services to all its residents with no user fees
- Opposition by the physician group - Doctors on strike for 3 weeks
Describe the establishing national standards for medical insurance (slide 17)
1961-1964: Royal Commission on Health Services (the hall commission) recommended national “medicare” based on the SK model
1966: Federal “Medical Care Act”
- Cost share provincial and territorial costs for medical services provided by doctors outside hospitals
- 50-50 cost sharing subject to national standards
- 4 principles: universality, public administration, portability and comprehensiveness
- By 1972, all provinces and territories joined Medicare
What are the 4 principles we have to know ? EXAM
- Universality
- Public administration
- Portability
- Comprehensiveness
Universality:
___% of the insured residents of a province or territory must be entitled to the insurance services provided by the plans under uniform terms and conditions
100
Universality:
Provinces and territories generally require what?
that residents register with the plans to establish entitlement
Public administration:
Describe it
Health care insurance plans are to be administered and operated on a non-profit basis by the public authority, responsible to the provincial/territorial government and subject to audits of their accounts and financial transactions
Portability:
Describe it
A resident moving from one province/territory to another must continue to be covered for insured services by their home province during a minimum waiting period. This also applies to residents leaving the country
Comprehensiveness:
Describe it
All medically necessary services provided by hospitals and physicians must be insured
*Drugs are essential but they are not always covered
Describe the energy crisis in 1970
Energy crisis as a result of oil embargos:
- Significant inflation, rising unemployment, federal government in large deficits
- Tension between liberal-majority fed government (Trudeau) and conservative-majority provinces
What is the “Established Programs Financing Act” - 1977 ?
- Replaced 50-50 cost sharing with a block transfer that now includes both cash and tax points
- Transfer was bundled with education
- Transfer tied to federal economic growth
What is a tax point ?
slide 23
1) Fed lowers its tax rate to allow provinces to collect that “tax-point” themselves
2) “Tax-point contribution” is the cash equivalent: $100 per capita in this case
3) In theory, this is “contributed” in every year after the change
Describe block funding
- Removed feds from the business of determining the eligibility of provincial expenditures
- Acknowledge provincial constitutional authority in health
- Broke link between cash contributions by feds and provincial spending
- Weakened Ottawa’s ability to enforce pan-Canadian principles
- Problem in 1980s - overfilling by physicians and patients getting charged extra fees
Describe “Canada’s National-Provincial Health Program for the 1980s”
- To review how medicare had evolved since it’s introduction.
- Condemned extra billing and other user charges.
-Efforts made by Monique Begin (Minister of Health and Welfare) to end extra-billing and user fees were in vain. CMA saw extra-billing as a fundamental right.
Describe the Canada Health Act (1984)
- Consolidated preceding acts; added “accessibility” as the 5th principle.
- Accessibility: reasonable access by insured persons to medically necessary hospital and physician services must not be impeded by financial or other barriers (UPPAC = universality, portability, public administration, accessibility, comprehensiveness)
- Specified criteria that provinces must satisfy to quality for federal transfer payments
- Penalties for extra billings and user charges:
- Provinces fined $1 for every $1 in disallowed charges
-Legacy left by Pierre Trudeau
What are some federal roles of governments in health care?
- Setting and administering national principles for the system under the Canada Health Act
- Financial support to the provinces and territories
- Other functions, including the delivery of primary and supplementary services to certain groups of people (i.e. First nations living on reserve, veterans, etc.)
What are some provincial roles of governments in health care?
- Administration of their health insurance plans
- Planning and funding of care in hospitals and other health facilities
- Services provided by doctors and other health professionals
- Planning and implementation of health promotion and public health initiatives
- Negotiation of fee schedules with health professionals
Under the Canada Health Act, all necessary drug therapy administered within a Canadian ______ setting is insured and publicly funded
hospital
Under the Canada Health Act:
Outside of the hospital setting, who is responsible for administration of publicly-funded Rx drug benefit programs?
provincial and territorial governments
Canada Health Act, initially met with opposition, provide an example.
Ontario physician’s strike 1986 for 25 days
Post-CHA (Canada Health Act), all provinces/territories faced _____ health care cost.
rising
What was another problem post CHA?
-the public saw declining quality of care as a result of lack of funding and active supervision by the feds to enforce national standards
Describe the 1989-1992 economic recession
and how this changed in 1995
- Cash transfer to provinces diminished and eventually froze from 1990 to 1994
- By mid-1900’s transfers to provinces dropped by more than 10%
-In 1995, feds established Canada Health and Social Transfer (CHST) - new block grant bundled health, education and social services
Describe the 1997 Report of National Forum on Health
- Advocates re-investment of cash in federal health transfer
- Also calls for expansion of medicare coverage to include homecare and pharmacare
Describe the 1999 Social Union Framework Agreement signed by all provinces except for Quebec
- Broad reinvestment in social services that had been cut in 1990’s
- $11.5 billion injected back into CHST over 5 y ears, specifically for health care
- Feds agreed not to engage in exercising their spending authority without support of majority of provinces - end unilateral authority
- All parties reaffirm commitment to principles in CHA
Describe the 2002 The Romanow Report
- By Roy Romanow, head of the Commission on the Future of Health Care in Canada
- Total of 47 recommendations, with 3 underlying themes:
- Strong leadership and improved governance is needed to keep medicare a national asset
- The system needs to become more responsive and efficient as well as more accountable to Canadians
- Need to make strategic investments over the short term to address priority concerns, as well as over the long term to place the system on a more sustainable footing
Describe the 2003 Accord on Health Care Renewal
- $34 billion new federal transfers
- CHST broken into 2 separate transfers: Canada Health Transfer, Canada Social Transfer (includes education)
- Created the Health Council of Canada (“watchdog” to assess reforms/performance, Alberta opposed because of concerns about “federal intrusion”)
Describe the 2004 Health Accord
- Negotiated by federal and provincial governments
- Top up of the 2003 accord to a total of $41 billion funding in health care over 10 years, plus annual 6% increase of CHT (the ‘escalator’)
- Brings federal government’s share in health care back up to 25% from a low of 10.2% in 1998/1999
- $4.5 billion for meeting “meaningful reductions” in wait times in priority areas by March 2007
- Priority areas: cancer, cardiac, diagnostic imaging, joint replacements, sight restoration
- Provided long term funding for health care reform
- Commitments by federal/provincial/territorial governments to reaffirm values of the CHA
Describe the national pharmaceutical strategy (also created under the Health Accord of 2004)
- Catastrophic drug coverage
- Common national drug formulary
- Accelerated access to breakthrough drugs for unmet health needs
- Accelerated access to non-patented drugs
- Purchasing strategies
- Strengthen evaluation of real-world drug safety and effectiveness
- Prescribing behavior
- Develop e-prescribing and electronic health records
- Enhance analysis of cost-drivers, cost-effectiveness, best practices for drug plan policies
The Health Accord Act in 2004 expired in ____
2014
What did Harper do in 2011 ?
May 2011: Harper promised to continue the 6% increases in the CHT as part of the federal election campaign
Dec 2011: Harper administration announced that the federal government will continue to fund health care at 6% increase per year until April 2017, at which point federal health transfer increase tied to economic growth (GDP)
- Back to unilateral federal authority on health care spending
- Romanow: It’s a sad day for Canadian health care
Provinces always get 3% increase each year for health care. Explain
If federal is 5%, then provinces get 5%
If federal is 1%, then provinces still get 3%
Do we have universal health care?
It’s universal in the sense that it’s centrally funded
but it’s not universal because each province governs it’s own
How is health care funding/financing (how services are paid for) done in Canada?
predominantly public in Canada through taxation
How is health care delivery (how services are organized, managed and provided) in Canada?
largely private in Canada
What are examples of public funding and public delivery?
- public health (ex. vaccination)
- provincial psychiatric institutions
- home care in some provinces
What are some examples of public delivery but private financing?
- enhanced non-medical (ex. private room in hospital)
- enhanced medical (ex. prosthesis)
What are some examples of private (non profit) delivery but public funding?
- most hospitals
- addiction Tx
What are some examples of private (non profit) delivery and private funding?
some home care and nursing homes in some provinces
What are some examples of private (profit) delivery and public funding ?
- primary health care physicians
- ancillary services in hospitals (laundry, meal, maintenance, engineers)
- labs and diagnostic services in most provinces
What are some examples of private (profit) delivery and private funding ?
- cosmetic surgery
- long term care
- extended health care benefits (ex. Rx drugs, dental care, eye care)
- MRI and CT scan clinics in some provinces
- Some surgery clinics
What are some ongoing issues in health care system?
- fiscal crisis
- privatization
- current system’s emphasis on curative/acute medicine - less attention on prevention, public health or rehab
- rigid division of labour
- specialization versus primary care
- wait times
- equity
- national pharmacare
Is the Canadian health care system a national system?
- No, its pan-Canadian
- Single payer (federal), but 10+ provincial systems working in parallel with differences in costs/fees, scheduled items, and drug coverage
What are some federal programs in Canada?
- NIHB
- Veterans Affairs
- Armed Forces RCMP
- Corrections
Why may provincial programs vary?
Populations served, drugs covered - formularies, and cost containment strategies
- formulary
- generic substitution
- tendering
- reference-based pricing
- utilization agreements
Describe Ontario drug coverage
Ontario Drug Benefits Program:
-for over 65 years, special programs, trillium Programs (income based), generics
Describe Alberta drug coverage
over 65 years and special programs
Describe BC drug coverage
net family income based deductible, specialty programs, reference-based pricing
Describe Quebec drug coverage
covers only those ineligible for private insurance
Describe Atlantic Canada coverage
over 65 years and special programs
Describe Manitoba drug coverage
- Incombe based deductible
- Palliative care drug program
- Deductible equal payments through Manitoba Hydro
- EDS
- Home Cancer Drug Program
