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A SINGLE PAYER, UNIVERSAL HEALTH SYSTEM

The Canadian Model in light of new U.S. Proposals

Gregory P. MarchildonPierre-Gerlier Forest

Woodrow Wilson International Center for ScholarsWashington, DC,

September 23, 2003

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THE CANADIAN MODEL Does one exist? If so, can we describe its unique

and/or essential components? How much of Canadian health care

actually within the model? How did we end up with this

particular model?

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EXISTENCE OF MODEL? Goes beyond having unique system

of public health care (after all, every OECD country does!)

Having aspects that are of sufficient interest to others

Canada recognized by others as having a model worth examining and (in some cases) emulating

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MODEL: COMPARISON OF OUTCOMES AND SERVICE Generally good health outcomes Public and Population Health Nature of Health Services

Services provided Training of providers Expectations of patients

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FOUR ESSENTIAL COMPONENTS OF MODEL Hospital care Primary physician care Provincial-federal tax-financed

system Provincial control and

administration, private and mixed delivery, and federal principles

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HOSPITAL CARE Hospitalization introduced in SK in

1947 HIDSA (1957) and national

implementation (1958-61) Universal access without user fee Public and NFP delivery unaffected Hospital Construction = more beds

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PRIMARY PHYSICIAN CARE 1962: Saskatoon Compromise

Guarantee of provincial autonomy Basket of services and remuneration: medical

associations and provincial governments MCA of 1966 and implementation on

national basis (1968-72) Universal access with limited (but

eventually no) user fees Private FFS delivery within provincial

plans and federal principles

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F/P TAX FINANCED SYSTEM Versus social insurance and co-pays Tax revenues (GRF) of both orders of

government Complex history of F/P funding

arrangements: a) shared-cost; b) EPF cash/tax; c) CHST block

Progressive financing depends on tax sources and incidence

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FEDERAL PRINCIPLES AND FRAMEWORK FOR SYSTEM Nature of HIDSA and bilateral agreements Broad principles of MCA Severing of funding from policy objectives

(EPF) The Canada Health Act (CHA), 1984 Long-term decline in federal funding Sept. 2000 Agreement and Feb. 2003

Accord

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PROVINCIAL CONTROL AND ADMINISTRATION Constitutional authority and

responsibility primarily provincial Developed provincially since 1945 Innovation and variation across

provinces Provincial Studies, Reports, and

Current Initiatives

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PUBLIC, PRIVATE AND MIXED DELIVERY Predominantly non-governmental Historic evolution of hospitals Physician “Entrepreneurs” Emergence of RHAs Big business (PFP & NFP) largely

absent from acute & primary care

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CHARACTERISTICS OF CANADIAN MODEL Narrow but deep coverage (complete

coverage for 42% of all health services Parallel private tier prohibited or

discouraged (private insurance for CHA-covered services)

But enormous variation in funding, administration and delivery of non-insured services including prescription drugs, vision care, dental care, etc.

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WHAT HEALTH SPENDING INCLUDED IN MODEL Traditional hospital services and

primary care services: 42.4% Provincial plans provide non-CHA

services beyond this: 25.2% Private health services: 27.4% Add in another 5% for direct federal

services

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CURRENT CHALLENGES TO CANADIAN MODEL Universal versus targeted access (cost) Single-payer administrative system

(competition) Prohibition on user fees for CHA services

(incentive effects) Legislated single-tier Declining tolerance for variation within

Canada and with US: quality, access, and equity

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GENERAL CHALLENGES TO CANADIAN HEALTH CARE Timely access (waiting lists) Quality services and evidence-based

practice Movement away from hospital care Nature and quality of primary care Drug therapies: appropriateness and cost Providers: number, morale, etc. Patient involvement v. citizen

engagement?

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CHALLENGES re: CANADIAN AND U.S. MODELS

Governance Finance Coverage/ethics Outcomes