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How Does Canada's Health System Really Work?
By Ian Austen OTTAWA —

                                       

Canadians can be of two minds about their public health care system.

Tommy Douglas, a former premier of Saskatchewan, was voted “The Greatest Canadian” by the Canadian Broadcasting Corporation viewers for setting up what became the model for the country’s health system. And a survey last year partly sponsored by the federal government found that Canadians ranked “universal health care” among the 10 defining factors of their country (along with Niagara Falls, beavers, hockey and a robotic space arm).

At the same time, Canadians can be quick to complain about that very system. Their chief complaints include wait times, access to doctors, unusual treatments and specialized imaging equipment as well as its overall cost. Given that, it’s not surprising that Canada’s experience is being used to support the arguments of people on both sides of the American debate about health care.

But before judging Canada’s system, and its suitability as a model for the United States, let’s look at how the system’s financing developed. The biggest problem in assessing Canada is that there are, in fact, 15 different systems rather than a single, national program like Britain’s. Each of the 10 provincial and 3 territorial governments administers and delivers health care to most residents. On top of that, the federal government is responsible for native people who live on reserves, as reservations are known in Canada, as well as members of the military and their families.

While broad pieces of federal legislation provide overall guidance for each provincial system, they have nevertheless developed largely on a piecemeal basis since the 1960s. Adding to the complexity is the tendency of provincial governments to bicker amongst themselves while vigorously opposing any federal efforts to usurp their constitutional powers over health care. So when thinking about health care in Canada, bear in mind that for every general rule there can be a multitude of exceptions. C. David Naylor, a physician and health policy analyst who is president of the University of Toronto, succinctly summed up the system in the title of a book in 1986: “Private Practice, Public Payment.” Mr. Douglas’s socialist government in Saskatchewan introduced Canada’s first province-wide, government-financed health care system in 1962, immediately provoking a strike by doctors.

But it was a Royal Commission established at roughly the same time that ultimately provided the framework for the rest of the country. Canada’s health care insurance industry, which was growing quickly in the early 1960s, joined with the country’s medical association to campaign against publicly funded medical care for all but the poorest Canadians. The Royal Commission ultimately rebuffed them. Dr. Naylor’s analysis is that mixing public coverage with private insurance would be a bureaucratic mess that could cause public monies to subsidize for-profit medicine and insurance. But the doctors did get some of their demands.

Canadian physicians are not government employees. They retain a great deal of control over when, how and where they work. Instead of being paid salaries, most of them bill provincial governments on a fee-for-service basis. Canadian hospitals are also autonomous institutions that are generally, but not necessarily, governed by local health authorities. The details of how that operates become complicated very quickly. But for patients, it’s all invisible. They never see a bill for hospital treatments or services provided by their doctor. Some hospitals and physicians once imposed surcharges and service fees on patients, but the federal government shut down the practice in 1984 by cutting off health financing to provinces that allowed it. Similarly doctors cannot moonlight and provide basic medical services to patients who are willing to pay for faster or more attentive service.

That doesn’t mean, however, that Canadians do not have health care costs that they have to pay out of pocket or through private insurance. Most dental work, prescription drugs for people not at retirement age, and eyeglasses are among the many costs not covered. The Canadian Institute for Health Information estimates that governments covered about 70 percent of the 171.9 billion Canadian dollars (roughly $148 billion) spent on health care last year.

    spiegel.com


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