Boychuk FINAL- Web (Dec 2008)

8/3/2019 Boychuk FINAL- Web (Dec 2008)

1/361

The School of Policy Studies

www.ucalgar.ca/policstu

The Regulation o Priate Health Funding and Insurancein Alberta Under the Canada Health Act:A Coparatie Cross-Proincial Perspectie

Gerard W. BochukAssociate ProessorDepartent o Political ScienceUniersit o Waterloo

SuarThe range o options or provincial regulation o private unding and private insurance or health services

under the Canada Health Act (CHA) is much wider than conventionally thought. While provinces tend to be

considerably more restrictive than required by the CHA, existing legislation across the Canadian provinces

presents a wide and varied menu or reorm in the unding o health services. Given this, other actors

including provincial public opinion appear to more signifcantly constrain reorm than the CHA. The paper

considers these issues with a ocus on Alberta -- a province oten seen to stand at the oreront o health

care reorm in Canada.

SPS Research PapersThe Health Series

Volume 1 Issue 1 December 2008


2/361

ExECUTIvE SUmmARy

Four Ke Points

TherangeofoptionsforhealthfundingreforminAlbertathatareconsistentwiththeCHAismuchwiderthanisoftenthoughttobethecase.

AlbertasregulationofprivatefundingandinsuranceofhealthservicesismorerestrictivethanrequiredbytheCHAandismorerestrictivethanlegislationinanumberofotherprovinces.

ReformsthathavebeenproposedbytheGovernmentofAlbertainthepasthaveincludedsignicantreformswhichwerefullyconsistentwiththeCHA.

AlbertansarelessreceptivetoprivatefundingandinsuranceforhealthservicesthanCanadiansonaverage.

Specifcs

TheCHAallowsawiderangeoflatitudeinregulatingtheprivatepurchaseandinsuranceofhealthservices.TheCHAstipulatestheprincipleswhichprovincesmustfollowinprovidingnancialreimbursementundertheir

publichealthplans(inordertobeeligibleforfullfederaltransfers)butdoesnotrelatetothedeliveryofservicesorprecludeprivatepaymentorinsuranceofhealthservices.

TheCHAdoesnotrequirethatprovincesbantheprivatepurchaseofanytypeofhealthservicebutonlylimitstheconditionsunderwhichprivately-purchasedservicesmaybesubsidizedthroughthepublicprovincialplan.TheCHAdoesnotrequirethatmedicalpractitionersoperatefullyinsideof(oroutsideof)thepublicsystembut,rather,placesspeciclimitsonbillingproceduresforinsuredservices.TheCHAdoesnotrequirethatprovincesprohibitprivateinsuranceincludinginsuranceforotherwisepublicly-insuredservices.VirtuallyallfederaltransferreductionsundertheCHAhavebeenrelatedtouserfees.Theissueofextra-billing(physicianfeeschargedinadditiontothefeepaidunderthepublicplan)islessclear.

EnforcementoftheCHAbythefederalgovernmentislargelydiscretionary.InterpretationandenforcementoftheCHAremainsprimarilyaprerogativeofthefederalministerwithimportantareasremainingopentotheministersdiscretion.TheCHAlegislationisnotjusticiableitisneitheragreedtobybothparties,legallybindingoneitherparty,nordoesitcreateasetofcitizenentitlementswhichmaybeclaimedthroughthecourts.DiscerningthelimitsofCHArequirementsrequiresanunderstandingofpreviousfederalinterpretationsoftheCHAaswellaspracticesallowedinotherprovinces.

CurrentregulationinAlbertagoessignicantlybeyondCHArequirements.Albertasprohibitionoftheprovisionofcertainmedicalservicesoutsidethepublichealthsystem,requirementthatphysiciansoperateeithercomplete-lyinsidethepublicsystemoropt-outofpublicpaymentcompletely,andblanketbanontheprovisionofprivateinsuranceforotherwisepublicly-insuredhealthservicesareallnotrequiredbytheCHA.Otherprovincesallow

someorallofthesepractices.

ArangeofCHA-compliantoptionscanbedrawnfromcross-provincialcomparisons.Existingprovinciallegisla-tionelsewhereallowsforprivatefunding,privateprovisionofservices,andprivateinsuranceincludingthefollow-ing:

o norestrictionsontheprivatepurchaseofhealthserviceswherefullyprivatelyfunded;o norestrictionsontheprovisionofprivateinsuranceforhealthservices(restrictionsonlyonpublicreim-

bursementforhealthservices);o norestrictionsallowingnon-participatingphysicianstobillprivatelyatunrestrictedrateswithpatientsbe-

ingreimbursed(uptothepublicrateschedule)whileallowingpatientstoinsureforthedifference;


3/36


4/3613

InrecentdebatesoverhealthcarenancingreforminAlberta,theoptionsforreformhavetypicallybeenportrayedasadichotomybetweenmarginaladjustmentstothestatusquoversusbroad-reachingchangewhichwouldnecessarilyentailviolationoftheCanada Health Act (CHA).Thepaperexaminesthescopefortheredenitionofthepublic/privatedivideinhealthfundingundertherubricoftheCHA.Insodoing,thepaperprovidesanoverviewoftheexistingregulatorystatusquoincludingtherequirementsoftheCHAandtheenforcementoftheCHAtodate.Secondly,itexaminestheregulationofprivatefundingandinsuranceinAlbertafromacross-provincial

comparativeperspectiveinlightofexistingregulationinotherprovinces.Thirdly,thepaperconsidersreformsthathavebeenproposedinAlberta(includingtheMazankowskiReportandHealth Policy Framework, 2006)inlightofCHArequirements,practicesinotherprovinces,aswellasrecentreformproposalsinotherprovinces.Finally,thepaperprovidesareviewofexistingpublicopinionpollingrelatingtopublicsupportforprivatepaymentforquicker/enhancedservices,privateinsuranceaswellasvarioushealthinsurancescenariosandconsidersthepoliticalimplicationsforhealthnancereform.Usingacross-provincialcomparativeperspective,thepaperarguesthatnoprovinceallowsprivatefundingandinsuranceforhealthservicestothefullextentavailableundertheCHAand,secondly,thatAlbertaiscurrentlymorerestrictiveinitsregulationofprivatefundingandinsuranceofhealthservicesthananumberofprovinces.

DespitetheconventionalportrayalofadichotomybetweenmarginaladjustmentstothecurrentsystemoffundinghealthservicesundertheCHAandmorefar-reachingchangesthatviolatetheCHA,theempiricalndingspresentedhereimplythattherangeofoptionsforhealthfundingreforminAlbertaundertheCHAismuchwiderthanconventionallythoughttobethecase.Whilethepaperdoesnotassessthelikelyeffectsordesirabilityofvariousreforms,itarguesthatsignicantreformispossibleundertheCHAandthatthemainconstraintsonsuchreformaremorelikelytolieinpatternsofprovincialpublicsupportforvariousreformoptionsthanintheconstraintsposedbytheCHA.

REGULATION OF PRIvATE FUNDING AND INSURANCE FOR HEALTH SERvICES UNDER THE CHA

Asthelegislationitselfstates,theprimarypolicyobjectiveoftheCHAistofacilitatereasonableaccesstohealth

serviceswithoutnancialorotherbarriers.1Insodoing,theCHArequiresthat,inordertoqualifyforfullfederalfunding,provincialpublichealthinsurancecoveragebeuniversallyavailableonuniformtermsandconditionswithoutanybarrierstoreasonableaccessincludingbarriersofanancialnature.2Inpursuitoftheseoutcomes,theCHAplacesthreetypesofrestrictionsontransferstoprovincesconditions,criteria(withprovisionsfordiscretionarypenalties),andnon-discretionarypenaltiesfortwodenedpractices(extra-billinganduserfees).3

ThetwoconditionsoftheCHAarethatprovincialgovernmentsprovidethefederalMinisterwithinformationrequiredforthepurposesofadministeringtheActandthatprovincialgovernmentsgiverecognitiontofederaltransfersinadvertisingandpromotionalmaterialrelatedtoinsuredhealthservices.4Inadditiontothesenon-substantiveconditions,theoverarchingpolicygoalofreasonableaccesstohealthserviceswithoutnancialorotherbarriersisembodiedinthevecriteriaoftheCHA:universality(publicinsurancecoveragemustbeavailable

onuniformtermsandconditionstoallprovincialresidents),comprehensiveness(publicinsurancemustcoverallmedically-necessaryphysicianandhospitalservices),accessibility(reasonableaccesstoinsuredservicesisnottobeimpairedbychargesorothermechanismsandreasonablecompensationmustbemadetophysiciansforprovidinginsuredservices),portability(residentsmustbecoveredwhentheyaretemporarilyoutoftheprovince)andpublic

1Canada Health Act, 1984,s.3.Accessedonline(13/05/08)athttp://laws.justice.gc.ca/en/c-6/17077.html.2Canada Health Act, 1984,s.6.3User-feesaredenedaschargesbyafacilityincaseswherephysicianfeesarecoveredbytheprovincialhealthinsuranceplanandextra-billingoccurswhereaphysiciandirectlybillstheprovincialhealthplanforaserviceandsimultaneouslybillsthepatientanadditionalamountfortheservice.4Canada Health Act, 1984,s.13.


5/361

administration(apublicagencymustadministerthepublicplan).Theenforcementmechanismfortheseveprinciplesisthefederalabilitytowithholdfederalscaltransfersonadiscretionarybasis.5NoprovincehasyetbeenpenalizedforaviolationofanyofthevecriteriaoftheCHA.6

InadditiontothediscretionaryenforcementofthevecriteriaoftheAct,theCHAalsosetsprovisionsformandatorydeductionsfornon-compliancewithitsprovisionsregardinguser-feesandextra-billingwhicharespelledoutinseparatesectionsoftheAct.Thus,theCHAprovidesfordollar-for-dollarpenaltiesforextra-billingallowedwithinaprovince:nopaymentsmaybepermittedunderthehealthcareinsuranceplanoftheprovinceinrespectofinsuredhealthservicesthathavebeensubjecttoextra-billingbymedicalpractitionersordentists.7Asimilarprovisionexistsforuser-fees.SupplementingtheCHAlegislation,theMarleauletterof1995outlinesthefederalinterpretationoftheCHAthatfeeschargedbyprivatemedicalfacilitiesconstituteauserfeeifphysician-servicesportionofthecostsiscovereddirectlybytheprovincialhealthinsuranceplan.8

TherearetwomeansbywhichsuchmandatorypenaltiesmaybeassessedunderthesesectionsoftheAct.Therstistriggeredwhenprovincesself-reportextra-billinganduser-feesunderprovisionsspelledoutintheExtra-billingand User Charges Inormation Regulations putinforceundertheAct.9GiventheprovisionsoftheCHA,thefederalministerhasnodiscretioninimposingtransferreductionsonprovincesthatself-reportextra-billinganduser-fees.Inthesecondinstance,whereextra-billingandchargingofuser-feestakesplacebutisnotreportedassuchbytheprovince,thefederalMinistershall(whereinformationisnotprovidedinaccordancewiththeregulations)levypenaltiesinanamountthattheMinisterestimatestohavebeensocharged.10Insuchcases,itremainstheprerogativeofthefederalministertodeterminewhetherextra-billingandthechargingofuser-feesistakingplacealthoughdeductions,inanamountdeterminedbytheminister,aremandatoryifthisisfoundtobethecase.Todate,nopenaltieshavebeenleviedbasedonaministerialdeterminationthatextra-billingandthechargingofuser-feeshasoccurredandtransferreductionshaveonlytakenplacewhenextra-billinganduser-feeshavebeenself-reportedbyaprovince.11Takingthesevariousprovisionstogether,the CHAatthebroadestlevelstipulatestheprincipleswhichprovincesmustfollowinprovidingfnancial reimbursementundertheirpublichealthplansinordertobeeligibleforfullfederaltransfers.Thatis,thelegislationrelatesprimarilytothenancingofhealthservicesandnotdirectlytohowtheyareactuallyprovidedorbywhom.TheCHAdoesnotspeak,whatsoever,tothedeliveryofservicesandthusdrawsnodistinctionbetweenfundinganddelivery.Putmostsimply,iffundingarrangementsareCHA-compliant,thedeliveryisnecessarilyCHA-compliant.Thus,fundinganddeliveryshouldnotbeconsideredseparatelyintermsofCHA-complianceandfundingmustreceivecentralfocus.Moreover,intermsoffunding,itisimportanttorealizethelimitedscopeofCHAproscriptions.First,theCHAdoesnotrequirethatprovincesbantheprivatepurchaseofanytypeofhealthservice.Whatitdoeslimitaretheconditionsunderwhichprivately-purchasedservicesmaybesubsidizedthroughthepublicprovincialplan.Secondly,theCHAdoesnotrequirethatmedicalpractitionersoperatefullyinsideof(oroutsideof)thepublicsystembut,rather,placesspeciclimitsonbillingproceduresforinsured services.Ofcourse,allphysicians

5Canada Health Act, 1984,s.15.6HealthCanada,Canada Health Act Annual Report 2006-2007,6.7Canada Health Act, 1984,s.18.8MinisterofHealthandWelfare,Federal Policy on Private Clinics,6January1995.Accessedon15/05/08athttp://www.hc-sc.gc.ca/hcs-sss/medi-assur/interpretation/index_e.html.9Extra-billing and User Charges Information RegulationsAccessedon14/05/08athttp://laws.justice.gc.ca/en/ShowFullDoc/cr/SOR-86-259///en.10Canada Health Act, 1984,s.18.11TheonlyexceptionwasthecaseofBCinwhichtheprovincereportedextra-billinginagivenscalyearandthenfailedtoreportitinsubsequentyears.Inthiscase,estimatesofextra-billingweremadeforthenon-reportedyearsonthebasisofinformationprovidedbytheprovinceintheyearinwhichitreportedextra-billing.InformationfromtelephoneinterviewwithofcialinHealthCanada,CanadaHealth ActEnforcementBranch.

4


6/365

combineincomestreamsfrompublicandprivateincomessourcesthelatterprimarilyforservicesthatarenotinsuredunderthepublicplan.However,evenformedically-necessaryservices,theCHAmakesreferenceonlytothestatusofservices(i.e.eitherinsuredonnon-insured)andmakesnoreferencewhatsoevertothestatusof

practitioners.12Thirdly,asitonlygovernspublicreimbursementforhealthservices,theCHAdoesnotrequirethatprovincesprohibitprivateinsuranceforotherwisepublicly-insuredservices.However,asitrequiresfederaltransferreductionsforextra-billingandchargingofuser-feesforinsuredservices,theCHAimplicitlyplaceslimitsonthe

roomforthird-partyinsurancetosupplementpublicinsuranceforservicesthatarepublicly-coveredanddirectlybilledtotheplan.InadditiontothelimitsontherangeofpracticestowhichtheCHAapplies,itisalsocriticaltonotethat,giventhenatureofthelegislation,enforcementoftheCHAisprimarilyapoliticalratherthanlegalissue.First,despitetheexistenceofadisputeresolutionmechanism,13theinterpretationandenforcementoftheCHAremainsprimarilyaprerogativeofthefederalministerand,asoutlinedabove,thelegislationconfersconsiderablediscretionontheministerwithimportantareasremainingopentofederalinterpretation.14Secondly,thelegislationisnotjusticiableitisneitheragreedtobybothparties,legallybindingoneitherparty,nordoesitcreateasetofcitizenentitlementswhichmaybeclaimedthroughthecourts.15

Giventhis,itisnotprimarilytolegalinterpretationbut,rather,previousfederalinterpretationsoftheCHAaswellaspracticesallowedinotherprovincestowhichonemustturninattemptingtodiscernthelimitsoftheCHArequirements.Atthesametime,thehighlydiscretionarybasisofCHAenforcementimpliesthatthefederalgovernmentisnotboundbysuchprecedentsinfutureinterpretationsoftheCHA.However,itwouldundoubtedlybemoredifcultpoliticallyforthefederalgovernmenttolevytransferreductionsagainstaprovinceforpracticeswhichithasallowedinthepastorwhicharecurrentlyallowedunderprovinciallegislationinotherprovinces.

An Oeriew o Penalties Iposed Under the CHA

SomeindicationsoftheboundariesoftheCHAcanbediscernedfromanexaminationoftheenforcementoftheCHAtodate.Uponcomingintoforcein1984,theCHAallowedprovincesathree-yeargraceperiodunderwhich

transferreductionswouldberefundedtotheprovincesifthepracticesgeneratingreductionswerediscontinuedbyApril1987.Sevenprovinces(NewBrunswick,Qubec,Ontario,Manitoba,Saskatchewan,AlbertaandBritishColumbia)facedtransferreductionsduringthisthreeyearperiodwhichwererefundedasallCanadianprovincesweredeemedtobecomplyingwithprovisionsregardingextra-billinganduser-feesbyApril1987.16Nofurthertransferreductionswereleviedagainstanyprovinceuntil1994-95whenfederaltransferstoBritishColumbiawerereducedasaresultofprovincialreportingofextra-billinginthatprovince.Since1994,federaltransferreductions

12Thelegislationrequiresthatnopaymentsmaybepermittedunderthehealthcareinsuranceplanoftheprovinceinrespectofinsuredhealthservicesthathavebeensubjecttoextra-billingbymedicalpractitionersordentists.However,itmightalternativelyhaverequiredthatnopaymentsmaybepermittedunderthehealthcareinsuranceplanoftheprovincesinrespectofhealthservicesthathavebeenprovidedbymedical practitionersengaginginpracticeswherepublichealthinsuranceplanpaymentshavenotbeenacceptedaspaymentforservicesinfull.

13Thedisputeavoidanceandresolutionprocesswasagreedtobythefederalandprovincialministersofhealth(exceptQubec)inApril2002.Theagreementprovidesthatwheredisputeavoidanceisunsuccessful,eitherthefederalorprovincialministermayrefertheissuetoathird-partypaneltoundertakefact-ndingandprovideadviceandrecommendations.However,thefederalMinisterofHealthretainsnalauthoritytoenforcetheCHAandisonlyrequiredtotakethepanelsreportintoconsiderationinsodoing.Canada Health ActAnnual Report, 2006-2007,8andesp.AppendixC.14AstheCHAisfederallegislationratherthananintergovernmentalagreement,eveninthosecaseswhereapracticeisclearlywithinoroutsidetheparametersestablishedbytheCHA,thefederalgovernmentretainstheprerogativetounilaterallyamendthelegislation.15AstheReportoftheTaskForceontheFundingoftheHealthCareSystem(Qubec)notes:Fromthelegalstandpoint,theCanadaHealth Actdoesnotconferanyrightsonpersonsthattheycouldinvoketohavetheirprovinceadoptmeasuresintendedtogivethemaccesstohealthservices...(255)ThisconclusionisbasedonalegalstudycommissionedbytheTaskForce.SeePatrickMolinari,LinterpretationdelaLoicanadiennesurlasant:rperesetbalises.November2007.16HealthCanada,Canada Health Act Annual Report 2006-2007,10.


7/361

undertheCHAhavebecomemorecommonplaceandhavesetprecedentsforcurrentenforcementoftheCHA--especiallyinregardtouser-feeschargedbyprivateclinics.(SeeTable1.)

VirtuallyallofthefederaltransferreductionsundertheCHA(exceptreductionsforextra-billinginBritishColumbiafrom1992-1995)sincetheinitialgraceperiodhavebeenrelatedtonon-compliancewiththefederalpolicyonprivateclinicsasoutlinedintheMarleauletterwhichstipulatesthatfeeschargedbyaprivatefacilityforservices

forwhichthephysicianfeeispaidbytheprovincialpublicplanconstituteauserfeeandrequireamandatoryCHAreductioninfederaltransfers.Feeschargedbyfacilities(bothpublicandprivate)continuetobeacentralissueinCHAenforcement.Whilereportinghasnotyettakenplacefortheperiodfollowingscalyear2004-05,BritishColumbiain2006orderedpublichospitalstodiscontinuethepracticeofallowingthechargingoffeesforexpeditedaccesstoinsureddiagnosticservicesandQubectookactiontodiscourageprivateclinicsfromcharginguser-feesforinsuredservices.17

Tabl 1: Fral Trafr Rct r CHA, 1987-2008

PRovinCe PeRiod deduCTion issue

BritishColumbia 1992-1995 $2.025M Extra-BillingbyPhysicians

Alberta 1995-1996 $3.585M Non-compliancewithfederalpolicyonprivateclinics(userfees)

Newfoundland 1995-1997 $284,430 Non-compliancewithfederalpolicyonprivateclinics(userfees)

Manitoba 1995-1998 $2.355M Non-compliancewithfederalpolicyonprivateclinics(userfees)

NovaScotia 1995-2003 $372,135 Non-compliancewithfederalpolicyonprivate

clinics(userfees)BritishColumbia 2000-2005 $347,718 Non-compliancewith

federalpolicyonprivateclinics(userfees)

Newfoundland 2002-03 $4,610 Userfeeinpublichospital

NovaScotia 2004-05 $9,460 Extra-Billing*

ToTAL 1987-2008 $8,977M

Source:HealthCanada,Canada Health Act Annual Report, 2006-2007.*ReportedbyprovincebutnofurtherdetailsprovidedbyHealthCanada.

TheprecedentsforfederaltransferreductionsundertheCHAmakeclearthefederalcommitmenttotheprinciplesoutlinedintheMarleauletterof1995facilityfeeschargedforserviceswherethephysicianfeeiscoveredbytheprovincialhealthinsuranceplanareconsidereduser-feestriggeringadollar-for-dollarreductioninfederaltransfers.However,theissueofextra-billing(asopposedtouserfees)ismuchlessclearincertainrespectsasoutlinedbelow.Thesingleexistingprecedent(federaltransferreductionsforextra-billinginBritishColumbiafrom1992-1995)ismuchlessclearinitsimplicationsthanisthecaseforuserfeeschargedinprivatefacilities.

17HealthCanada,Canada Health Act Annual Report, 2006-2007,11.

6


8/367

Transer Reductions or Extra-Billing in British Columbia, 1992-1995Thecaseoftransferreductionsforextra-billinginBritishColumbiaintheperiodfrom1992to1995warrantsspecialattentionasitmarkedtherstpenaltiesleviedundertheCHAfollowingthe1984-87graceperiodforprovincestocomeintoCHAcomplianceandistheonlysignicantexampleoftransferreductionsmadeinrespectofextra-billing.18Thetechnicalmattersatissueinthisinstanceoftransferreductionsarequitecomplex.Furthermore,thecorrespondingpoliticalcontextinwhichthesetransferreductionsoccurredwasquitepeculiar

makingitdifculttodiscerntheenforcementprecedentsset.AsreportedintheCanada Health Act Annual Report,2006-07:

AsaresultofadisputebetweentheBritishColumbiaMedicalAssociationandtheBritishColumbiagovernmentovercompensation,severaldoctorsoptedoutoftheprovincialhealthinsuranceplanandbeganbillingtheirpatientsdirectly.Someofthesedoctorsbilledtheirpatientsatarategreaterthantheamountthepatientscouldrecoverfromtheprovincialhealthinsuranceplan.Thishigheramountconstitutedextra-billingundertheAct.Includingdeductionadjustmentsforprioryears,datingbacktoscalyear1992-1993,deductionsbeganinMay1994untilextra-billingbyphysicianswasbannedwhenchangestoBritishColumbiasMedicare Protection Act cameintoeffectinSeptember1995.Intotal,$2.025millionwasdeductedfromBritishColumbiascashcontributionforextra-billingthatoccurredintheprovincebetween

1992-1993and1995-1996.19

Technically,thebillingpracticesinquestionconstitutedextra-billingunderthe CHAnotbecausethefederalministerhadinvestigatedthepracticesandmadeadeterminationthatthiswasthecaseinfactbut,rather,becausetheBCMinisterofHealthhadinvestigatedthepractices,determinedthat(intheprovincialMinistersestimation)extra-billingwasoccurring,andreportedspecicamountstothefederalMinisterasextra-billing.Thus,thesepracticesconstitutedextra-billingundertheCHAbecausetheywerereportedbytheprovinceasextra-billingleavingthefederalMinisterwithnodiscretioninimposingtransferreductionsundertheextra-billingprovisionoftheCHA.LegislationwasbroughtinbytheBCgovernmenttobanextra-billingtowhichtheCHA Annual Reportattributesthecessationoffederaltransferreductions.20Thislegislationstipulatesthatmedicalpractitionersenrolledinthe

publichealthinsuranceplan(whetherbillingtheplandirectlyorelectingtobillpatientswhowouldthenseekreimbursementfromtheplan)couldnotchargeinexcessoftheprovincialratescheduleforinsuredservices.Furthermore,medicalpractitionersnotenrolledintheprovincialhealthinsuranceplancannotchargeinexcessoftheprovincialratescheduleiftheserviceisprovidedinahospitalorcontinuingcarefacility.21Thisrepresentedachangefromthe1992legislationwhichallowedphysiciansoperatingundertheplantoelecttobillpatientsdirectly(potentiallyatrateshigherthantheprovincialfeeschedule)withthelatterbeingallowedtomakeaclaimtotheprovincialhealthinsuranceplanforamountsuptotheprovincialfeeschedulerate.22Byvirtueofmakinganelectiontobillpatientsdirectly,practitionerswouldberequiredtobillallpatientsdirectlyforallservicesthusforfeitingtheirabilitytobilltheplandirectlyforanyservicesprovidedtoanypatient.

18Withtheexceptionofanominaltransferreductionof$9,460appliedagainstNovaScotiaforprovincially-reportedextra-billingcharges

in2004-05.19HealthCanada,Canada Health Act Annual Report 2006-2007,11-12.20BritishColumbiaLegislativeAssembly.Bill54(1995)AnActtoProtectMedicare.Accessedonline15/05/2008athttp://www.leg.bc.ca/1995/1st_read/gov54-1.htm.21BritishColumbiaLegislativeAssembly.Bill54(1995)AnActtoProtectMedicare,s.17.2(2).22BritishColumbiaLegislativeAssembly.Bill71(1992)MedicalandHealthCareServicesAct,esp.s.13(1)ands.13(9)(a)(ii).The1992legislationalsoprohibitedtheprovisionofthird-partyprivateinsuranceforpublicly-insuredservices.Sees.39(1).The1992leg-islationrepresentedasignicantchangefromthestatusquounderwhich,byvirtueoftheMedical Service Plan Act, 1981,directandextra-billingwerecompletelyprohibited:Nomedicalpractitionerparticipatingintheplanshall...seekcompensationbymeansofbalancebilling,extrabillingorextracharging,ordemandorreceiveanypaymentotherthanapaymentundertheagreementandplanattherateapplicableforthatservice...s.3(2).Byvirtueofthisprovision,medicalpractitionerswouldberequiredtobilleithercompletelyinsidetheprovincialplanorcompletelyoutsideofitand,inthelattercase,thelegislationmadenoprovisionfornancialcompensationtopatients.


9/369

Intermsofthepoliticalcontext,theNDPgovernmentinBritishColumbiawasopposedtoextra-billingandbelievedthatfederaltransferreductionsleviedagainsttheprovincewouldhelpincreasepoliticalpressureonprovincialphysicianstoendthepractice.23Asaresult,thegovernmentofBritishColumbiahadencouragedthefederalgovernmenttogoaheadwithitspunishment...24TheBCHealthMinisterPaulRamseystatedpublicly:Weagreewiththe[federal]ministerthatextra-billingisnotanacceptablepractice,andthefederalgovernmentiswithinitsrightsiftheychoosetocutourtransferpaymentsbecauseofit.25Infact,byreportingspecicamounts

ashavingbeenextra-billed,theprovincewentbeyondencouragingthefederalministertoapplytransferreductionsandactuallymadethereductionsmandatoryunderfederallegislation.Thatis,federaltransferreductionswereleviedbecausetheprovincialMinistermadeadeterminationthatspecicpracticeswerenon-compliantwithCHArequirementsthefederalMinisterdidnotformallymakesuchadetermination.ThismakesitdifculttousethisinstanceoffederaltransferreductionsasaprecedentforfederalenforcementofCHArestrictionsagainstextra-billing.Twoclearbasepointsemergefromacombinedreadingofthe CHAitselfanditsenforcementfollowingitsfulladoption:user-feesandextra-billingarenon-compliantandrequireamandatoryreductionoffederaltransfers.Practicesoutsideofthesetwoclearinstancesofnon-complianceremainopentointerpretationandsubjecttothepoliticsofCHA-enforcement.

Health Reor in Alberta (Bill 11) and the Politics o Federal CHA Enorceent

ThepoliticaldynamicsshapingthepoliticsofCHAenforcementarehighlightedbyfederal-provincialconictinearly2000overAlbertasBill11--whichnowastheAlberta Health Care Protection ActcomprisesacentralpillarofhealthfundingregulationinAlberta.Thefederal-provincialpoliticsaroundtheissueofBill11andCHA-complianceillustratethelimitedconstraintsonprovincesunderastrictreadingoftheprovisionsoftheCHA,thedegreeoflatitudeforfederalinterpretationoftheCHA,andthecomplexityofthepoliticsofCHAenforcement.

CompliancewiththeCHAwasacentralissueinthepoliticsofthereformlegislation.ThecentralpoliticalstrategyofopponentsofthelegislationwhentheAlbertagovernmentintroducedBill11inthelegislatureinearlyMarch

2000wastoarguethatitcontravenedtheCHA.Perhapsmostnotably,therewasextensivemediacoverageoflegalanalysis(commissionedbyCUPE)whichallegedthatthelegislationviolatedCHAcriteriaofcomprehensiveness,universality,accessibility,and,possibly,public-administration. 26Moreover,prominentcriticsofthelegislationsuchasSaskatchewanPremierRoyRomanowalsoarguedthatthelegislationviolatedtheCHA(andcontinuedtoarguethatthiswasthecaseevenafterthefederalgovernmentconcededthatthelegislationdidnotdoso.)Proponents,mostnotablyPremierKlein,maintainedconsistentlythattheAlbertagovernmentdidnotbelievethatthelegislationrepresentedaviolationoftheCHA.27ApparentlyanticipatingthatthefederalgovernmentwouldnotconcludethatthelegislationwasinviolationoftheCHA, theAlbertagovernment,onintroducingthebilltotheAlbertalegislativeassembly,forwardedacopytothefederalHealthMinisterAllanRockandformallyrequestedconrmationinregardtowhetherthelegislationrepresentedaviolationoftheCHA.28

23RossHoward,MarleautoPunishBCforFees,Globe and Mail,19May1994,A1.24Ibid.25RodMickleburgh,OttawaGetsToughOverBCExtra-Billing, Globe and Mail,23April1994,A1.26HeatherScofeld,LegalOpinionsRipKleinsHealthBill:AlbertasPlanWouldViolateCanadaHealthAct,Globe and Mail,14March2000,A1.27TimHarper,RockTakesMedicareFighttoAlberta, Toronto Star,10March2000,NE06.28JillMahoney,OttawaTakingItsTimeonHealth-CareBill,KleinSays, Globe and Mail,21March2000,A5; DeanBennett,HealthCareDebateBecomingUgly, Toronto Star,14March2000,NE07;TimHarper,RockSaysHeWillGoDirectlytoAlbertans,TorontoStar,17March2000,NE07.


10/3610

ThefederalgovernmentwasextremelycarefultoavoidconrmingpubliclywhetherthelegislationwasconsideredtobeinviolationwiththeCHAorCHA-compliant.InthefaceofquestionsregardingCHA-compliance,thefederalMinistersrstresponsewasthatthefederalgovernmentwasintheprocessofreviewingthelegislationasintroducedintheAlbertalegislaturebutthatfederallegalopinionswerenotyetavailable.29ThefederalHealthMinisterwouldlaterarguethatthefederalgovernmentwouldnotconsiderthedraftlegislationasitwouldbesubjecttoamendmentsbutwouldwaitfornallegislationbeforemakingadeterminationonCHA-compliance.30

PrimeMinisterChrtienthenannouncedthatthefederalgovernmentwouldonlymakeadeterminationafterboththenallegislationandassociateregulationswereannounced.31Finally,thefederalgovernmentannounceditwouldonlymonitortheoperationofthelegislationandassociatedregulationsinpracticetodetermineifviolationsoftheCHAwereoccurring.32

DespiteitsunwillingnesstomakeadeterminationinregardtoCHA-compliance,thefederalgovernmentdidclearlystateitsoppositiontothebill.33Whilebroadlyopposedtothephilosophicalunderpinningsofthelegislation,thefederalHealthMinisteroutlinedtwomajorconcernsinregardtothespecicproposalsmadebyAlberta:rst,concernsinrespectofadd-onfeesforenhancedcareand,second,concernsinrespectofprivateclinicsbeingallowedtokeeppatientsovernight.34AsthefederalHealthMinisterwouldargue,Topermitfor-protfacilitiestosellenhancedservicesincombinationwithinsuredserviceswouldcreateacircumstancethatrepresentsaserious

concerninrelationtotheprincipleofaccessibility. 35Themainfederalconcerninthisregardwasthatallowingfeesforenhancedserviceswhenprovidedincombinationwithinsuredservicesmayleadtoquickeraccesstopublicly-fundedservicesforthosepatientsableandwillingtopaytheassociatedprivatefees.36ItwasthisaspectofBill11whichthefederalministerwarnedmight,butdidnotconclusively,constituteaviolationoftheCHA.

Thefederalgovernmentalsoevincedconcerninregardtoovernightstays.Underthisproposal,surgicalfacilitieswouldbeabletobillthepublicinsurancesystemforthesurgerybutpotentiallychargepatientsmoreforhotelarrangementsforpost-operativecare.37Suchpracticeswerealreadyallowedbyfor-protclinicsfordaysurgeryaswellaspublicfacilitiesforaccommodationbeyondsemi-privateaccommodation(astheCHArequirescoverageofaccommodationandmealsonlyatthestandardwardlevel.)ThefederalministerdidnotarguethatthisprovisionwouldviolatetheCHAbut,rather,that[t]heAlbertagovernmenthasnowproposedaroleforprivate,for-prot

facilitiesthatgoesbeyondwhatisalreadyinplaceinotherprovincesinCanada.38ThefederalministersargumentinthisregardillustratesacentralpointinthepoliticsoffederalCHAenforcement:theimportanceplacedbythefederalgovernmentonpracticesexistinginotherprovincesinmakingdeterminationsinregardtotheacceptabilityofprovincialreforms.

29Scofeld,LegalOpinionsRipKleinsHealthBill.30Harper,RockSaysHeWillGoDirectlyToAlbertans;Mahoney,OttawaTakingItsTime.31TimHarper,AlbertaPremierWillBeThreatenedwithSanctionsoverHealthBill, Toronto Star,22March2000,NE01.32HealthScofeld,OttawaCantStopAlbertasHealthBill,Globe and Mail,12May2000,A1;RockVowstoStandGuardonAl-bertasHealthChanges,Winnipeg Free Press,12May2000,B6.33Mahoney,OttawaTakingItsTime.34CanadaWire,AlbertaOversteppingBounds:Rock,Winnipeg Free Press,9April2000,A6.35Ibid.36Ibid.37ThispracticewasalreadyallowedinAlbertafordaysurgery.38Ibid.


11/3611

AllthreemajorplayerstheAlbertaPremier,thefederalHealthMinister,andthePrimeMinisterrecognizedtheimportanceoflegislationinotherprovinces.PremierKleinconsistentlyclaimedthatthebillincludedonlyprovisionsthatwereinplaceinotherprovincesand,assuch,respectedtheCHA.39Inapparentresponse,PrimeMinisterChrtienstatedthathewouldrequestprovincialhealthministersreviewthebilltocompareitwithhealthprogramsinotherprovincesaproposaltowhichPremierKleinagreed.40ThisproposalbythePrimeMinisterillustratestwocentralaspectsofCHAenforcement.First,ithighlightsthedegreeoflatitudeininterpretingthe

CHA.WhiletheCHAclearlyoutlinesparticularpracticesthatrequirefederaltransferreductions,thereisalsoawiderangeofpracticesonwhichthelegislationisnotclearandrequiressignicantinterpretation.Secondly,inturningtoprovincialhealthministersinmakingthisdetermination,thePrimeMinisterimplicitlyrecognizedtherealpolitikofCHAenforcementitispoliticallymuchmoredifcultforthefederalgovernmenttochallengepracticescurrentlyallowedunderprovinciallegislationinotherprovincesthanwouldotherwisebethecase.Thefederalgovernment,however,eventuallyabandonedthistack.

DespitethefactthattheAlbertagovernmentdidnotmakeanyoftheamendmentspubliclyrequestedbythefederalhealthminister,thefederalgovernmentwouldultimatelyconcedethatthelegislationdidnotviolatetheCHA.FederalofcialsconcedeprivatelythatthebillaswrittenisinkeepingwiththeprinciplesofpublichealthcareanddonotbelievethatitviolatestheCHA.41PremierKlein,whennallyinformedindirectlyontheday

ofthenallegislativereadingofthebillthatfederalgovernmentsourcesreportedthatBill11didnotviolatetheCHA,responded,Itsnicetoknow,butitdoesntcomeasmuchofasurprise. 42ItwasnotsurprisingtothedegreethatnothinginlegislationconstitutedaclearviolationoftheCHA.AstheissueofCHA-compliancewasthenpushedintothegreyerareaoffederalinterpretationofthediscretionarycriteriaoftheCHAregardingpracticesalreadyallowedbylegislationinotherprovinces,thelikelihoodoffederalpenaltiesdiminished.

TheenforcementoftheCHAwashighlypoliticallychargedwithclaimsandcounter-claimsofCHA-compliancebeingacentralpoliticalweaponinthearsenalsofbothproponentsandopponentsofthelegislationwiththefederalgovernmentincludedinthelattercamp:.thefederalgovernmenthasbeencarefulnottocomeoutandstatedirectlythatthebilldoesnotviolatetheCanadaHealthAct.Ottawadidnotwanttolendsupportto[the]campaigntowinpublicsupport.43Clearly,therewerenoprovisionsintheAlbertalegislationthatconstituted

aclearviolationoftheCHAmakingthepoliticsofoppositiontothelegislationmuchmorecomplexthanwouldhaveotherwisebeenthecasegiventhattheprimarypoliticalstrategyofopponentswastoclaimthatthelegislationwasnotCHA-compliant.Atthesametime,thelegislationincludedprovisionsthatthefederalminister,underhisdiscretiontointerpretthefederallegislation,couldhaveclaimedconstitutedaviolationoftheCHAdemonstratingthatitisnotonlyastrictlegalisticinterpretationoftheCHAthatdeterminesthepoliticsofCHAenforcement.Inthefaceofalackofpoliticalwilltomakesuchaninterpretation(shapedinpartbytheexistenceoflegislationallowingsimilarpracticesinotherprovinces),astrictlegalisticinterpretationoftheCHAallowedsignicantlatitudefortheAlbertagovernmenttoimplementreforms.TherevisionswhichtheAlbertagovernmentdidmaketothereformpackagewereinresponsetopoliticaldynamicswithintheprovinceratherthanpressuresgeneratedbyfederalgovernmentorconstraintsposedbytheCHA.44

39AdrianWyld,OtherProvincesHaveSimilarLaws:Klein,Toronto Star,24March2000,NE01.PremierKleinpubliclymadespecicreferencetolegislationinBC,Saskatchewan,ManitobaandOntarioandarguedpubliclythatallfourhadlegislativeprovisionsimilartotheproposedlegislationinAlberta.40Ibid.;OttawaFinallyinPositiontoFightKleinonHealth,Toronto Star,14April2000,NE06.41KeytoAlbertaBillisHowItsUsed,Globe and Mail,10May2000,A2.42JamesCudmore,KleinsBill11SettoPassFinalHurdle,National Post,10May2000,A8.43KeytoAlbertaBillisHowItsUsed,Globe and Mail,10May2000,A2.44CanadaWire,ExtendedOvernightStaysatPrivateClinicsOK,saysKlein,Winnipeg Free Press,8April2000,A2.


12/3612

Current Regulation in Alberta and CHA Copliance

AlbertagoeswellbeyondtherequirementsoftheCHAinitsregulationofprivateprovision,fundingandinsuranceforhealthservicesunderboththeHealth Care Protection Act (HCPA)andtheAlberta Health Care Insurance Act(AHCIA).45First,AlbertagoesbeyondtherequirementsoftheCHAinitsprohibitionoftheprovisionofcertainmedicalservicesoutsidethepublichealthsystemastheCHAdoesnotrequirethatprovincesbantheprivatepurchaseofanytypeofhealthservice.Albertaprohibitsprivatefacilitiesprovidingemergencycarerequiringmedically-supervisedstaysofmorethantwelvehours46aswellasrestrictingphysiciansfromperformingmajor

surgicalservicesexceptinapublichospital.47ItisthislegislatedpublicmonopolythatledBrianDay,thePresidentoftheCMAandfounderofCambieSurgicalServicesinBritishColumbia,topubliclyassert:Alberta,ofalltheprovincesinCanada,isthemosthostiletowardsprivateclinics.WecouldntfunctioninAlberta.48Secondly,theprovincerequiresthatphysiciansoperateeithercompletelyinsidethepublicsystemoropt-outofpublicpaymentcompletely.Provinciallegislationrequiresthatphysicianscompletelyforfeitallclaimstoanypubliccompensationiftheywishtobillpatientsabovetheprovincially-determinedfeescheduleforanyservice.49Asoutlinedabove,theCHA,inrelationtoextra-billing,onlyreferstopublicly-insuredserviceswhichreceivedirectpaymentundertheprovincialhealthplananddoesnotmakeanymentionwhatsoevertomedicalpractitioners.50Thirdly,Albertahasablanketbanontheprovisionofprivateinsuranceforotherwisepublicly-insuredhealthservicesundertheAlberta Health Care Insurance Act(AHCIA).51Asoutlinedabove,nosuchrequirementisexplicitorimpliedintheCHA.UndertheHealth Insurance Premiums Act,residentsmayoptoutoftheAlbertaHealthCareInsurancePlanand,asaresult,notbeliableforprovincialhealthinsuranceplanpremiums.52However,theAHCIAprohibitstheprovisionofthird-partyinsurancetoopted-outresidentswhomustbearthefullnancialriskofforegoingparticipationinthepublichealthinsuranceplan.

Alberta in Coparatie Cross-Proincial Perspectie

Anexaminationofthemeansbywhichprovincesplacelimitsonprivatefundingofpublicly-insuredmedicalserviceshighlightsthewiderangeofoptionsareavailabletoprovincesundertheCHA.Provincesvarysignicantlyintheapproachestheytake,noprovinceallowsprivatefundingtothefulldegreeallowedundertheCHA,andregulationinAlbertatendstobemorestringentthaninanumberofotherprovincesandclearlymorestringentthanrequiredbytheCHA.

45Alberta Health Care Insurance Act,R.S.A.2000,c.A-20.Accessedonlineon16/05/2008athttp://www.canlii.org/ab/laws/sta/a-20/20060718/whole.html.Health Care Protection Act,R.S.A.2000,c.H-1.Accessedonlineon16/05/2008athttp://www.canlii.org/ab/laws/sta/h-1/20060718/whole.html.46Health Care Protection Act,R.S.A.2000,Part1,S.1andPart5,S.29(m).47Health Care Protection Act,R.S.A.2000,Part1,S.2(2).ThedenitionofmajorsurgeryisdeterminedbytheCollegeofPhysiciansandSurgeonsofAlberta.SeeCollegeofPhysiciansandSurgeonsofAlberta,2006.48MichelleLang,TheQuickeningPulseofPrivateHealthCare,Edmonton Journal,18September2005,E6.49Alberta Health Care Insurance Act,R.S.A.2000,Part1,S.9(1)andHealth Care Protection Act,R.S.A.2000,Part1,4(b).Fees

maybecollectedforenhancedmedicalservices;however,purchaseofenhancedservicescannotberequiredinordertoaccesstheinsuredservices.HealthCareProtectionAct,R.S.A.2000,Part1,S.5(1and2).50Therewerenoopted-outphysiciansinAlbertaasofMarch31,2007.HealthCanada,Canada Health Act Annual Report, 2006-2007,149.51AlbertaHealthCareInsuranceAct,R.S.A.2000,Part1,S.26(2,4)ThisistheissuethatwasraisedintheChaoullicaseinwhichtheSupremeCourtofCanadafoundthatQubecsbanonprivateinsurancesimilartothebanonprivateinsuranceinAlbertaconstitutedaviolationoftheQubecCharterofHumanRightsandFreedomsalthoughtheCourtwassplit(withonejusticeabstaining)astowhetherthebanconstitutedaviolationoftheCanadianCharterofRightsandFreedoms.TherulinghadlittledirectapplicabilitytotheCHAitselfasthelatterdoesnotrequireabanonprivateinsuranceforpubliclyinsuredservices.Chaoulliv.Quebec(AttorneyGeneral),[2005]1S.C.R.791,2005SCC35.52Health Insurance Premiums Act,ChapterH-6,S.25(1).Accessedonlineon16/05/2008athttp://www.qp.gov.ab.ca/Documents/acts/H06.CFM.


13/3613

Opted Out Physicians53

Provinceshavearangeofoptionswhichallowthemtoeffectivelylimitthescopeofprivatefundingofpublicly-insuredservicesincludingregulatingprivateinsurance,regulatingbillingpractices,andregulatingfees.InallprovincesexceptOntario,physicianshavetherighttooptoutofthepublicplanwhich,inessence,impliesthattheyforfeittheirabilitytobillthepublicplandirectly.54(SeeFigure1andTable2.)OutsideofnotallowingphysicianstooptoutasisnowthepracticeinOntario,themoststringentmethodofrestrictingprivate-fundingof

insuredservicesprovidedbynon-participatingphysiciansistolimitthefeestheymaylegallychargetothelevelsstipulatedintheprovincialrateschedulethusgreatlyreducingtheincentivetooperateoutsidethepublicplan.

Fgr 1: Rglat f Prat Fg fr Pblcly-ir Mcal src, opt-ot Phyca

SourcesforFigures1and2:ColleenM.FloodandTomArchibald,TheIllegalityofPrivateHealthCareinCanada,Canadian Medical Association Journal164,6(20March2005):825-30.SupplementedfromCHAAnnualReport,2004-5.Notes:Provincesappearinshadowwhereamorestringentexistingregulationmakessubsequentlimitationson

privateinsurancecoveragesuperuous.SKandNBpubliccoveragedenied;PEIandMBprivateinsuranceprohibited.

53Becauseprovinciallegislationgenerallytreatsnon-participatingphysiciansdifferentlythanparticipatingphysicianscombinedwiththewidevariationamongprovincesinregardtoboth,itishelpfultodifferentiatebetweenprovincialregulationofprivate-fundingofinsuredservicesprovidedbyopted-outandopted-inphysicians.Thepaperusesopted-in/opted-outandparticipating/non-participatinginter-changeably.54Opting-outofthepublicplanisnolongergenerallyallowedinOntarioeffectiveSeptember2004asaresultofthecomingintoeffectoftheCommitment to the Future of Medicare Act, 2004.


14/3614

Tabl 2: Prcal Rglat f Prat icm src, by stat f Phyca, 2001

Phyca stat Rglat BC AB sK MB onA QB nB ns Pei nF

opt ot ProhibitsOptingOut N N N N Y N N N N N

LimitsonFees N N N Y n/a N N Y N N

BanonPrivateInsurance Y Y N Y n/a Y N N Y N

PublicCoverageDenied Y Y Y N* n/a Y Y N* N* N

opt i DirectPatientBillingProhibited N* N Y* Y Y Y N Y N Y

LimitsonFees Y Y Y Y Y Y N Y N Y

BanonPrivateInsurance Y Y N Y Y Y N N Y N

PublicCoverageDenied*** Y Y

BasicsourceforprovincialregulationofprivatehealthinsuranceisColleenM.FloodandTomArchibald,TheIllegalityofPrivateHealthCareinCanada,Canadian Medical Association Journal164,6(20March2005):825-30.SupplementedfromCHAAnnualReport,2004-5.

APriortotheJune2004passageoftheCommitment to the Future o Medicare Act, 2004,Ontarioallowedphysiciansto

optoutalthoughitlimitedtheirfeestolevelsetunderthepublicplanandbannedprivateinsurancecoverageforsuchservicesalthoughpatientscouldapplyforcompensationdirectlyfromtheplan.UndertheCommitment to the Future oMedicare Act, 2004,physiciansarenolongerabletooptoutandbillpatientsdirectly.*Source:CHAAnnualReport,2006-7.**RequiredbyCHA.

InManitobaandNovaScotia,provincialregulationslimitthefeesofopted-outphysicianstolevelsspeciedintheprovincialfeeschedule.Servicesprovidedbyopted-outphysiciansarecoveredbypublicinsurance(reimbursedtothepatient)but,becausefeesarealsocapped,thereissimplynoroomfortheprivatenancingofpublicly-insuredservicesprovidedbyopted-outphysicians.

Theremainingprovincesuseavarietyofmeanstolimitthepotentialfortheprivatefundingofpublicly-insuredservices.Threeprovinces(Alberta,BritishColumbiaandQubec)denypubliccoverageforservicesprovidedbyopted-outphysicianswhile,atthesametime,implementingalegalban(partialinthecaseofQubec)ontheprovisionofprivate,third-partyinsuranceforthoseservices.55Thus,patientsareabletoreceiveservicesoutsidetheplanatratesdeterminedsolelybythephysicianalthoughthepatientmustabsorbthefullcostofthoseservices.SaskatchewanandNewBrunswickalsodenypubliccompensationforservicesprovidedbyopted-outphysiciansalthoughtheydonotprohibitprivateinsurancecoverageforthoseservices.

BothPEIandNewfoundlandallowforpubliccompensationofpatients(uptotheprovincialfeeschedule)forservicesprovidedbyopted-outphysiciansbilledatunrestrictedrates.WhilePEIallowspubliccompensationforservicesprovidedbyopted-outphysicians,itprohibitsprivateinsurance.Thus,thepatientmust

bearthefullcostofchargesaboveratesspeciedintheprovincialfeeschedule.InNewfoundland,opted-outphysiciansareabletosettheirownfees,patientsarecompensatedbytheprovinceforcostsuptotheprovincialfeeschedule,andprivatethird-partyinsurersareallowedtoinsureforthedifference.56

55QubecmaintainsonlyapartialbanfollowingchangestoallowprivateinsuranceforspeciedservicesinordertocomplywiththeChaoullidecision.AsitwasbasedontheQubecCharterofHumanRightsandFreedoms,thedecisionhasnoforceoreffectoutsideoftheProvinceofQubec.56In2005,nophysiciansinNewfoundlandhadopted-outoftheNewfoundlandmedicalcareprogram.http://www.hc-sc.gc.ca/hcs-sss/medi-assur/pt-plans/nl_e.html#f1


15/3615

Opted In PhysiciansThepotentialforprivatefundingofpublicly-insuredservicesprovidedbyphysiciansparticipatinginthepublichealthinsuranceplaniscloselyrelatedtotheirabilitytocombinebothprivateandpublicincomestreams(discussedmorefullybelow.)Inorderforphysiciansparticipatinginthepublicplantohaveaccesstobothpublicandprivateincomestreamsforservicescoveredunderpublicplans,theyrequiretheabilitytobillpatientsdirectly.Ifopted-inphysiciansbillpatients(oratleastsomepatients)directlyforservices,thepatientpaysthebillandthenmustreceive

compensationfromthepublicplan,absorbthecostdirectly,orreceivecompensationfromathird-partyindemnityinsuranceplan.Inanycase,thebillingphysicianmaynotevenbeawareofthepartywhichultimatelybearstheburdenofthepayment.

Currently,thepracticeofparticipatingphysiciansbillingpatientsdirectlyisallowedonlyinAlberta,BritishColumbia,NewBrunswickandPEI.(SeeFigure2.)Inallotherprovinces,physicianswhooptintothepublicplanarenotabletobillpatientsdirectlyand,therefore,havenomeansbywhichtocollectprivatepaymentforpublicly-insuredservices.Inthesefourprovinceswhichallowdirectbillingofpatientsbyphysiciansparticipatinginthepublicplan,AlbertaandBritishColumbiadonotallowbillingatrateswhicharehigherthanthepublicfeescheduleand,inturn,thereisnoincentiveforpatientstoinsureforthoseservices.

Fgr 2: Rglat f Prat Fg fr Pblcly-ir Mcal src, opt-i Phyca

ThesituationissomewhatdifferentinNewBrunswickandPEIwhereparticipatingphysicianscanbillpatientsdirectlyatratesabovethosestipulatedbytheprovincialfeeschedule;however,inbothoftheseprovinces,payment

fromthepublicplanisforfeitedforagivenserviceifthephysicianbillsabovetheprovincialfeeschedule.Thus,physiciansareabletobillboththepublicplanandbillprivately,however,inthelattercase,theprivatepayermustabsorbtheentirecostoftheservice.InPEI,theprovincebansthird-partyinsuranceforpublicly-insuredservices,sothepatientmustabsorbtheentirecostoftheservicedirectly.InNewBrunswick,thereisnobanonthird-partyinsurancesoparticipatingdoctorsareallowedtobillpatientsdirectlyforfeesabovethepublicfeeschedulewhichmaybe,inturn,coveredbythird-partyinsurancebutarenoteligibleforpublicreimbursement.


16/3616

Fgr 3: Rglat f Prat Fg fr Pblcly-ir Mcal src, opt-i a opt-otPhyca

Figure3combinestheregulationofnon-participatingandparticipatingphysiciansandhighlightsatleasttwoaspectsofprovincialregulationofprivatefundingforpublicly-insuredservices.First,thereiswidevariationamongprovincesintheirapproachtosuchregulationandlittleclusteringofprovincesonagivenapproachalthoughprovincesdiffermoresignicantlyintheirtreatmentofopted-outphysiciansthanintheirtreatmentofopted-inphysicians.Secondly,noprovinceallowsforprivatefundingtothefullextentallowedundertheCHA.

The Public-Private DivideAcriticalissueintheregulationofprivatefundingisthedegreetowhichthesesystemsenforceasharpdistinctionbetweenprivateandpublicincomestreamsforserviceproviderswithprovidersopting-intothepublicplansreceivingincomeonlyfrompublicsourcesforinsuredservicesandprovidersopting-outreceivingincomeonlyfromprivatesourcesforotherwisepublicly-insuredservices.Emphasizingtheimageryofsuchasharpdistinction,Flood

andChoudhryassertthat[i]n all provinces,physicianscanoptoutofthepublicsystemandoperatewhollyintheprivatesectorbut they cannot work in both.57

Incontrasttothisclaimthatinallprovincesphysiciansareprohibitedfromworkinginboththepublicandprivatesystems,therearetwosetsofcircumstancesinwhichphysicianscanbesaidtobeallowedtoworkbothinthepublicandprivatesystems:rst,wherephysicianservicesarebilleddirectlytopatientsatunrestrictedratesandreceivepublicsubsidizationand,second,wherephysicians(whetheroptedinoroptedout)areabletoreceivepublicpaymentforsomeservices(atratesrestrictedtotheprovincialfeeschedule)andprivatepaymentforother

57FloodandChoudhry,2002:15.FloodandArchibaldnotethat,withtheexceptionofNewfoundland,physiciansmustoptinoroutofthepublicplanandthusareeffectivelypreventedfromworkinginboththepublicandprivatesectors.FloodandArchibald,829.

POTENTIAL FOR PRIVATE FUNDING OF PUBLICLY-INSURED

SERVICES SERVICES Opted In & Opted Out Physicians

Low High

Low

High

Opted-In

Opted-OutOntario

Newfoundland

Manitoba/Nova Scotia

BC/AlbertaQuebec

Saskatchewan PEl New Brunswick

max allowedunder CHA


17/3617

services.TherstsetofcircumstancesoccursinNewfoundlandwherenon-participatingphysiciansmaydirectbillatratesabovetheprovincialfeeschedulewithpatientsthenbeingreimbursed(uptotheprovincialfeeschedule)bytheprovince.

Thesecondsetofcircumstancesobtainsforopted-inphysiciansinbothNewBrunswickandPEIwhomaybillpatientsdirectlyatratesabovetheprovincialfeescheduleforsomeservices(thoughwithnoprovincial

compensationbeingprovidedforthoseservices)whilealsobillingtheprovincialplandirectlyforotherservices.InNewBrunswick,patientsareallowedtocarryprivateinsuranceforsuchinstanceswhile,inPEI,privateinsurancecoverageisprohibited.InPEI,opted-outphysiciansmayalsoprovideservicesforwhichpatientsarereimbursedbythepublicplan(iftheyarenotbilledatratesabovetheprovincialfeeschedule)whilealsobillingforservices(iftheyarebilledatratesabovetheprovincialfeeschedule)whicharenoteligibleforpublicbenetpayments.

Ineachoftheseinstances,physiciansareallowedtocombinebothpublicandprivateincomestreamsforpublicly-insuredservicesand,thuseffectively,areallowedtoworkinboththepublicandprivatesystem.Thesesetsofcircumstancesagainemphasizecentralpointsmadeearlier.Firstly,the CHAregulationsfocusonthestatusofservicesandnotonthestatusofserviceproviders.Secondly,provincesvarysignicantlyinhowtheyregulatethemixingofpublicandprivateincomestreamsforpublicly-insuredservices.Thirdly,provincesalsovarysignicantly

intheirregulationofprivateinsuranceregulationthatisneitherspeciedinorrequiredbytheCHA.

DiscussionTakingexistingpracticesintheCanadianprovincesasthestartingpoint,themaximumallowanceforprivatefunding,provisionofservices,andprivateinsurancegivenexistingprovincialpracticesisasfollows:

norestrictionsontheprivatepurchaseofhealthserviceswherefullyprivatelyfunded;norestrictionsontheprovisionofprivateinsuranceforhealthservices(restrictionsonlyonpublicreimbursementforhealthservices);allowingnon-participatingphysicianstobillprivatelyatunrestrictedrateswithpatientsbeingreimbursed

(uptothepublicrateschedule)whileallowingpatientstoinsureforthedifference;allowingparticipatingphysicianstobillthepublicplandirectlyforsomeservices(atrateslimitedtotheprovincialfeeschedule)andbillsomepatientsdirectlyforservicesatunrestrictedrates(withoutpubliccompensation)withthepatientbeingabletoinsureforthelatter.

Allofthesepracticesarecurrentlyallowedbylegislationinvariousprovincialjurisdictions.TotheextentthatexistingprovinciallegislationispresumedtobeCHAcompliant,thecombinationofthefourpracticesabovecouldalsobepresumedtobeCHAcompliant.Asnotedabove,thereisnothingthatbindsthefederalgovernmenttoacceptthesepracticesas CHA-compliant;however,itwouldbemuchmoredifcultpoliticallytolevypenaltiesagainstthesepracticeswhicharecurrentlyallowedunderprovinciallegislationinotherprovinces.

Otherpractices(foraninventoryofalternatives,seeTable3)maybeconsideredCHAcompliantbasedonfederalinterpretationstodateofCHArequirementsmostnotably,theinterpretationofuserfeesasoutlinedintheMarleauletter.TheMarleauletterclearlyoutlinesthatfacilityfeesarenotCHAcompliantincaseswherethephysicianfeeiscoveredundertheprovincialplan.Theconverseofthisinterpretationisthat,ifthephysicianfeeisnotpaidundertheprovincialplan,anyassociatedfacilityfeeisnot,bydenition,auserfeecontrarytotheCHA.Inthecaseofparticipatingphysiciansbillingpatientsdirectlyaccordingtothemethodoutlinedabove,thechargingoffacilityfeesbyeitherprivateorpublicfacilitiesforthoseserviceswouldnotconstituteauserfeeincontraventionoftheCHA.


18/3618

Tabl 3: Prat Fg src a CHA Cmplac

Mcham Prc Allw/

i u

CHA Cmplac nt

C-Paymt* None NotCHAcompliant

extra-Bllg** None NotCHAcompliant

Pblc irac Prmm Ontario,BritishColumbia

CHAcompliant -failuretopaypremiummustnotrestrictaccesstopublicly-insuredservices

Prat irac Saskatchewan,NewBrunswick,NovaScotia,Newfoundland

CHAcompliant -CHAdoesnotrequireregulationofprivateinsurance

Allwg Phyca t Bll Bth

Pblcly a PratlyNewBrunswick,PrinceEdwardIsland,Newfoundland

CHAcompliant -PEIandNewfoundlandallowpublicreimbursementforunrestrictedfeeschargedbyopted-outphysicians

Faclty F (ur F) *** CHAcompliantunder

speciccircumstances

-facilityfeesareCHA

compliant(chargedbyprivateorpublicfacilities)ifphysicianfeeisnotcoveredbypublicplan

ehac src F **** CHAcompliantunderspeciccircumstances

-enhancementmustnotbemedically-necessaryandmustrelatetoqualityofservice(mustnotallowquickeraccess)

Aal Rgtrat F BritishColumbia CHAcompliantunderspeciccircumstances

-failuretopayaccessfeemustnotrestrictaccesstopublicly-insuredservices

MsA Crrr None CHAcompliantunderspeciccircumstances

-failuretopaychargesmustnotrestrictaccesstopublicly-insuredservices

*Co-paymentherereferstoafeechargedtothepatientbythepublicinsuranceplanforservicesthatarebilleddirectlytotheplan.**Extra-billingherereferstoafeechargedtothepatientbythephysicianforservicesthatarebilleddirectlytotheplan.***Physicianfeesatratesabovepublicschedulearebillable(butnotpubliclycovered)inNewBrunswickandPEI(opted-inphysicians)andBritishColumbia,Alberta,Saskatchewan,Qubec,NewBrunswick,PEIandNewfoundland(opted-outphysicians).Inthesecase,facilityfeesmaybebeingchargedbutthereisnorequiremen

thattheybepubliclyreported.Iamnotawareofinstancesofpublicfacilitieschargingfacilityfeesforserviceswherethephysicianfeeisnotcoveredbythepublicplan.****Unknown.However,thisisacommonpracticeandfeesforenhancedservicequalityareprobablyineffectinallprovinces.

Whilethiswouldcertainlyalsobethecaseinregardtonon-participatingphysiciansiftherewerenopubliccompensationforsuchservices,itmayalsobethecasewithregardtonon-participatingphysiciansbillingpatientsdirectlyatunrestrictedrateswherepatientsarereimbursedforcostsuptotheprovincialfeeschedule(asiscurrentlyallowedinNewfoundland.)


19/3619

Giventhisinterpretation,aprovincewhichallowedthechargingoffacilityfeeswherethephysicianfeeisnotcoveredbypublicinsurance,wouldnothavetoreportthesefeesasuserfeesundertheCHAreportingrequirements.Shouldthefederalgovernmentchoosetointerpretsuchfeesasprohibiteduserfees,itwouldbefreetodosounderministerialdiscretion(eitherunderprovisionsrelatingtothereportingofuserfeesorthegeneralaccessibilitycriterion)althoughthefederalgovernmenthasneveryetexercisedtheseprovisions.Certainly,thepoliticsofdoingsowouldbemuchmorecomplexthanisthecaseforpracticeswheretheprovinceisboundto

reportthechargingoffeesandthefederalministerisobligatedtoimposefederaltransferreductions.

Anadditionalissuethathaspercolatedontothepoliticalagendaisthechargingofannualregistrationfeesbyprivatefacilitieswhichthenofferamixofuninsuredandinsuredservices.SuchfeescontravenetheCHAonlyifnon-paymentoftheannualregistrationfeeblocksorreducespatientaccesstopubliclyinsuredservices.InBritishColumbia,theMedicalServicesCommissionauditedoneVancouverclinicchargingannualregistrationfeestodeterminewhetheritspracticeswereCHAcompliantanddeterminedthattheclinicwasoperatingwithinprovincialandfederallawsbecausetherewasnoevidenceofextrabillingorenhancedservicesrelatedtothefees.58

Theissueisnotwhetherallpatientsintheclinicreceivinginsuredserviceshavepaidtheannualregistrationfee.Aprivateclinicspatientlistmaybecomelled(amatterdeterminedbythephysician)withpatientswhoarepayingtheregistrationfeewithouttheclinicactuallydenyingcaretoprospectivepatientsunwillingtopaytheannual

registrationfee.59

Thecentralissueinregardtoannualregistrationfeesiswhethernon-payingpatientsareexpresslydeniedaccesstoinsuredservices.TwosituationsaremostlikelytoestablishCHAnon-compliance:rst,wheretwopatientswithidenticalhealthneedsattempttoreceiveinsuredservicesfromaprivateclinicwiththeclinicrefusingtoprovideservicestothepatientwhodidnotpaytheannualregistrationwhilesimultaneouslyagreeingtoprovideinsuredservicestothepatientwhoagreedtopaythefeeand,secondly,wherearegisteredpatientdiscontinuespaymentoftheannualregistrationfeeandsubsequentlyisremovedfromthepatientlistand,asaresult,deniedaccesstoinsuredservices.However,intheabsenceofsuchpractices,annualregistrationfeesappeartobeotherwiseCHA-compliantsubjecttothecaveatthatthefederalgovernmentcouldalwaysunilaterallyissueaninterpretationoftheCHAtothecontraryshoulditchoosetoacceptthepoliticaltrade-offsandchallengesinherentindoingso.

Therearebasicbutimportantconclusionsthatowfromthisanalysis:itwillbepoliticallymoredifcultforthefederalgovernmenttoimplementtransferreductionsforaccessfeeswhen,asinBC,theyarenotreportedasextra-billingbytheprovinceandwhentheyareallowedinotherprovinces(wheretheywereinvestigatedandfoundtobeCHAcompliant)thanifneitheroftheseconditionsweretoobtain.Similarly,itispoliticallymoredifcultforopponentsofsuchfeestoopposethemiftheyareCHAcompliantthaniftheyarenot.

PROPOSED PROvINCIAL REFORmS AND THE CHA

ThefollowingsectionexaminesproposedreformsinbothAlbertaandQubecintermsoftheircompliancewiththeCHA.Albertahashadtwomajorreportsoverthepastsevenyearsoutliningmajornewdirectionsforhealthcare

reformthemajorelementsofwhicharesummarizedinTable3.WhileneitherreportusesrhetoricchallengingtheCHA,bothreportsrecommendedagainstsignicantchangesthatcouldbemadeundertheCHAwhile,atthesametime,includingreformsthatwouldviolatetheCHA.Inbothcases,theCHAdidnotconstitutethemainconstraintonreformasthegovernmentchosenottoproceedwithevenwiththeelementsofreformthatwereCHA-compliant.

58MichelleLang,$3,000-a-yearWillGetYouPrivilegedCare,Calgary Herald,16April2008,A1.59MichelleLang,PrivateClinicWillingtoTreatPatientsforFree,Calgary Herald,18April2008,B5.


20/3620

Premiers Advisory Council on Health The Mazankowski ReportInDecember2001,thePremiersAdvisoryCouncilonHealthmaderecommendationsinawiderangeofareasincludinghealthnancing.DespiterecommendingfurtherstudyofanoptionthatwouldclearlycontravenetheCHAwhiledismissinganotheroptionthatwouldclearlynotcontravenetheCHA(onthebasisthatitwould),theReportconcludesthatWebelieveourrecommendationsareconsistentwiththespiritandintentoftheCanadaHealthAct.(72)

SeveraloftheReportsrecommendationsproposedsignicantchangeswithintheparametersoftheCHA.First,theReportarguedthatPhysiciansshouldbeabletoworkinpublic,privateornot-for-protsystemsandretaintheirprivilegesatpublichospitals.(51)Asoutlinedabove,theCHAonlymakesreferencetothestatusofhealthservicesandnotthestatusofhealthcareproviders.TheReportalsorecommended,pursuanttofurtherstudy,variablehealthcarepremiumswhichwouldvarybasedbothonincomeaswellashealthserviceusage.(61)Premiums,regardlessofwhethertheyvaryaccordingtohealthserviceusage,donotcontravenetheCHAunlessnon-paymentofpremiumsresultsinthedenialofaccesstopublichealthservices.(SeeTable3.)TheReportalsoconsideredprivateinsurance.60TheReportdidnotrecommendexpandingprivateinsuranceforpubliclyfundedservicesbut,rather,concludedthat...thisapproachwould clearly contravenetheCanadaHealthAct.(56,italicsadded)However,thereisnothingintheReportsdescriptionofprivateinsurancewhichiscontrarytothe

CHA(whichhasnoprovisionsrelatingtoprivateinsurance)andprivateinsurance,asdescribedintheReport,isallowedunderprovinciallegislationinveotherCanadianprovinces.

Instead,theReportrecommendsthefurtherstudyofmedicalsavingsaccounts--asoneoftworeforms(alongwithvariablepremiums)havingthemostpositivefeatures.(61)TheReport,however,notesthat...ifpeoplearerequiredtopayforsomeservicesoncetheirmedicalsavingsaccountisexhausted,thismaycontravenetheCanadaHealthAct.(58)However,ifindividualshavetopayformedicallynecessaryservices(aboveacertaintotalspendinglimit)inordertoreceivethoseservices,thiswouldclearlycontravenetheCHA.(SeeTable3.)

RatherthanmovingaheadonthoseaspectsofthereportwhichcouldbeimplementedwithoutcontraveningtheCHAincludingallowingphysicianstomixpublicandprivateincomestreamsforpubliclyinsuredservicesand

removingtheprovincesbanonprivateinsurance,therecommendationsofthereportwouldlanguishinfaceofopposition,inpart,topossibleviolationsoftheCHAthussettingthestageforanothersetofreformproposals.

Albertas Health Policy FrameworkReleasedinFebruary2006,AlbertasHealth Policy Frameworkproposedtennewdirectionsforreformoftheexistinghealthcaresystem.Whilebeingcouchedinverycarefullanguage,theAlbertaproposalscontainedelements(typicallydesignatedfordiscussion)that,ifadopted,wouldviolatetheCHA:requiringco-payments(e.g.userfees)fornon-emergencyacutecareorallowingpublicfacilitiestochargeforexpeditedaccesstoserviceswherethephysicianfeeisbilleddirectlyundertheprovincialplan.Atthesametime,manyelementsoftheAlbertaproposalswhichappeartoberelativelyradicalshiftsinpolicysuchasallowingthird-partyprivateinsuranceforservicesprovidedbybothopted-outandopted-inphysicians,allowingbothopted-outandopted-inphysicianstocombine

bothpublicandprivateincomessources,andencouragingpublicfacilitiestochargefacilityfeesforprivately-fundedservicesarewithintheboundsoftheCHAandcurrently,inanumberofcases,areallowedinotherCanadianprovinces.6Alberta,Getting On with Better Health Care: Health Policy Framework,August2006.Accessedonlineon16/05/2008athttp://www.health.alberta.ca/key/health-care-renewal.html.

Ofthoserecommendationsmostgermanetotheissueofprivatefundingandprivatehealthinsurance,several

60IntheReport,asystemallowingprivateinsuranceisdenedasfollows:Peoplewouldbeabletochoosetogetbothinsuredandnon-insuredhealthserviceataprivatefacility.Theycouldpayfortheseservicesdirectlyorthroughsomeformofprivateorsupplementaryinsurance.Thepublicsystemwouldcontinuetoprovidethefullrangeofinsuredhealthservices.(56)


21/3621

proposalswouldentailasignicantshiftincurrentpracticebutwouldnotposeachallengetotheCHA.Thereport(Direction5)suggestsreshapingtheroleofhospitalsand,althoughvague,makesreferencetothepossibilityofdeliveringmoreservicesthroughprivatesurgicalfacilities.(13)Whileessentialhealthserviceswouldstillbepubliclyfunded,Direction6,emphasizeslimitingpublicly-fundedhealthservicesbyexcludinghealthserviceswhicharediscretionary,arenotofprovenbenet,orareexperimentalinnature(14)andleavingthoseservicestobenancedeitherbypatientsdirectlyorthroughthird-partyinsurance.Thelatterwouldincreasethescopeof

privatefundingandthepotentialforprivateinsurancebutisnotaviolationoftheCHA.

Thereport(Direction7)commitsthegovernmenttoexaminingalternativestothesingle-payerpublicinsurancesystemincludingco-paymentsandprivateinsuranceoptions--whilenotingtheneedtoconsiderhowtoimplementsafeguardstoprotectthepublicsystemandhowtoprovidebenetstothoseunabletoaffordprivateinsurance.(14)Co-payments,feeschargedtothepatientbythepublicinsuranceplanforservicesthatarebilleddirectlytotheplan,fornon-emergencybutmedically-necessaryserviceswouldclearlycontravenetheCHA.(SeeTable3.)Thatsaid,thereportiscarefullycouchedandonlycommitstheAlbertagovernmenttoexamininghowvariousalternativefundingmechanismswouldworkinthisprovince.(14)

Inregardtoprivateinsurance,theprovincialgovernmenthadannouncedin2005thatitwouldbeginaprocessof

studyingthepossibilityofopeningupthehealthcaresystemtoprivateinsurance.Ratherthansimplyremovinglegislativebansontheprovisionofprivateinsurance,theAlbertagovernmentpubliclycalledforrequestsforproposalstoundertakeanactuarialreviewofprovidingprivatehealthinsuranceforpublicly-providedhealthservices.Implicitintheproposalwasahighlydirectiveapproachtoopeningupthehealthcaresystemtomarketforcesincludingapprovingasingleprivateinsurertoprovidesuchinsurance.Whilethisinitiativestalled,the2006reportrevisitstheroleofprivateinsurance.Whilemuchofthe2006proposalfocusesonserviceareaswhicharecurrentlyoutsideuniversalpublichealthinsurancecoverage(e.g.prescriptiondrugs,dentalservices,etc.),theproposalalsomakesreferencetothepossibilityofintroducingthird-partyprivateinsurancefornon-emergencyacutecare.Intermsofallowingthird-partyinsurancefornon-emergencyacutecare,theCHAhasnorestrictionsagainstAlbertaliftingitscurrentbanand,asoutlinedabove,fourprovinceshavenosuchban.

Theproposals(Direction9)alsorecommendallowinghealthcareproviderstobothbillpubliclyforsomeproceduresandbillprivatelyforothersincontrasttothecurrentlegislationwhichrequiresthataprovidermustcompletelyoptoutofthepublicsystemcompletelyinordertoundertakeanyprivatebillingforinsuredservices.Certainly,allowingphysicianstobillsomeoftheservicestheyperformpubliclyandothersprivatelywouldremovelegislativebarrierstothegrowthofprivatelyfundedservices.Asoutlinedabove,themixingofpublicandprivateincomesourcesisallowedforopted-outphysiciansinPEI(whereindividualservicesareeitherpaidpubliclyinfullorprivatelyinfull)andNewfoundland(wherepaymentforindividualservicescancombinepartialpublicremunerationwithpartialprivateremuneration)whilemixingofpublicandprivateincomessources(thoughnotfoindividualservices)isallowedforopted-inphysiciansinbothPEIandNewBrunswick.

Thissectionofthereportalsodiscussesallowingbothpublicandprivateproviderstoofferenhancedservices

andexpeditedaccesstoalimitedrangeofnon-emergencyservicesatanappropriatecharge.(16)Whetherchargedbyapublicly-fundedhospitaloraprivately-ownedclinic,suchchargeswouldbeaviolationoftheCHAiftheassociatedphysicianserviceswerepaidforunderthepublicinsuranceplan.However,thiswouldnotbethecaseforchargesbyprivateorpublicfacilitieswheretheassociatedphysicianfeesarenotpaidpublicly.Itmayalsonotbethecaseiftheservicesweretobeprovidedbyanon-participatingphysicianwherethepatientwouldthenbeeligibletobereimbursedwithpublicfunds(uptotheprovincialrateschedule)asiscurrentlyallowedinPEIandNewfoundland.


22/3622

FollowingapublicconsultationprocesssubsequenttothereleaseoftheHealth Policy Framework,AlbertareleasedarevisedversionoftherecommendationsinAugust2006.61TherevisedreportdoesnotincludetheproposalsundertheheadingsofDirection7andDirection9intheFebruaryreport(pleaseseeabove).Theremainingrecommendationsarenotdirectlyrelatedtotheissueofpublicandprivatefundingofhealthservicesand,asnancialreimbursementforhealthservicesisthemainfocusoftheCHA,donotimplicateissueswhichfallunderthepurviewoftheCHA.

Qubec Health Reorms -- The Castonguay Report ProposalsMorerecently,theCastonguayReport,madepublicinFebruary2008,proposesanadditionalrangeofreformalternatives.ThereportclearlycreatestheperceptionthattheproposedchangestotheQubechealthsystemwouldcontravenetheCanada Health ActandreinforcestheperceptionofadichotomybetweenminoradjustmentswhichrespecttheCHAandradicalreformthatchallengetheCHA.Certainly,thisperceptionwasevidentinmediacoverageofthereport:SomeofMr.CastonguayskeyrecommendationsalsowouldleadtoaconfrontationwithOttawa,sincetheygosquarelyagainsttheCanada Health Act.(Gagnon,2008)ThisperceptionisnotsurprisingconsideringthattheTaskForcestatesbluntly:ThefederalgovernmentmusteasetherequirementscontainedintheCanada Health Act.(Qubec,2008a:5)TheTaskForceconcludesthatTheCanadaHealthAct...hampersprogressindeningthepublichealthsystemsoftheprovinces.Furthermore,...soonerorlater,theCanada

HealthActwillhavetobeadaptedtocurrentrealities.(Qubec,2008a:23)Therearetwoaspectstothereport:thosethatdealdirectlywiththeCHAand,secondly,thesubstantiveproposalsforhealthservicefundingandprovisionwhichhaveimplicationsforCHAcompliance.

TheTaskForcewasmandatedto...formulat[e]recommendationsonthebestmeanstoensureadequatehealthcarefundingand,insodoing,tostudychangesthatcouldbesuggestedsothatthenecessaryadjustmentsaremadetotheCanada Health Act.(2008b:1,italicsadded)Thechapterofthereportwhichdetailsthisstudyisascantvepagesand,ultimately,nospecicrecommendationsaremadeinregardtotheCHAwiththeexceptionofthecalloutlinedabovetoeaseCHArequirements.TheReportterselynotes:Since1984,theprovincialhealthcaresystemshavebeencloselygovernedbytherandominterpretationofthevecriteriaofthefederalAct.62(2008b:255)However,theReportdoesnotacknowledgethatnoprovincehaseverbeenpenalizedundertheve

criteriaoutlinedintheCHA.63TheTaskForcereportishighlycriticaloftheimprecisionoftheCHA:...thereisnolongeranyonewhocansayforsure,withoutconsultingalawyer,exactlywhatservicesarereallyinsured,withinwhattimeperiod,bywhoandinwhatcircumstancestheymustbeproduced.(2008b:257)ThisclearlymissesthepointoftheReportsownlegalanalysis.64TheCHAisnotlegallyenforceable,itisnotacontractbetweentwoparties,anditdoesnotconferrightsoncitizenswhichcanbeinvokedtoforceprovincestoprovidehealthservicesinanyparticularway.Thecriticalpointisthat CHAenforcementisprimarilyapoliticalnotlegalissue.

61Alberta,Getting On with Better Health Care: Health Policy Framework,August2006.Accessedonlineon16/05/2008athttp://www.health.alberta.ca/key/health-care-renewal.html.62TheTaskForceconcludesthatithasbeenviathevecriteriathatthefederalgovernment...seizedthisopportunitytointroducetightcontrol...overtheprovincialhospitalizationandmedicalcareplansandtheiroperation.(2008b:253)63Nevertheless,thiscriticismoftheCHAisnotsurprisinggiventhat,astheTaskForcenotes,theCHA...iscontestedbytheQubecgovernment[.](Qubec,2008a:23)64TheTaskForcecommissionedalegalstudyinregardtotheCHAwhichconcludedthatFromthelegalstandpoint,theCanada HealthActdoesnotconferanyrightsonpersonsthattheycouldinvoketohavetheirprovinceadoptmeasuresintendedtogivethemaccesstohealthservicesthatwouldbeincompliancewiththeCanadianlegislation.(2008b:255)ThecentralimplicationofthisinterpretationisthattheCHAisnon-binding.


23/3623

Infact,thereisverylittlescopeforpotentialconictbetweentheCastonguayrecommendationsandCHAlegislativerequirements.Thereportrecommendsallowingphysicianstoengageinmixedmedicalpractice(allowingphysicianstopracticesimultaneouslybothwiththepublicandprivatesystems.)Asoutlinedabove,thispracticeiscurrentlyallowedinotherCanadianprovinces.Thereportalsorecommendsthatthegovernmentreviewthescopeofservicescoveredunderthepublicsystem.TheReportiscarefultoframeitsproposalsforqualitativelimitsontheprovisionofhealthcarebydeningmedicallynecessaryinawaythatwouldensure

thatthecriteriaofcomprehensivenesswouldcontinuetobemetasallmedicallynecessaryhealthserviceswouldcontinuetobeinsured.TheTaskForcerecommendsatax-baseddeductiblechargeforuseofhealthservices.AstheReportargues,thetaxdeductibleapproachdiffersfromuserfeesinonecriticalway:theuserfeeisadirectobstacletoaccesstocare,becauseitiscollectedatthesametimeasthecareisclaimed...whilethetaxdeductibleisnotcollectedatthetimetheserviceisusednor,presumably,wouldfailuretopaythetaxdeductibleresultinineligibilitytoreceivepublichealthservicesinthefuture.(226)Assuch,itwouldnotinfringetheCHAbanonuserfees.Finally,theReportrecommendsthathealthclinics...wouldbeentitledtocollectanannualcontributionfromregisteredpatients.(2008b,237)Asdiscussedabove,suchfeesdonotconstituteanancialbarriertoaccessifpaymentofthefeeisnotrequiredtoaccessinsuredservices.65

TheReportnotesanumberofhypotheticalexamplesofwaysinwhichtheCHAcouldpotentiallyblockhealth

systeminnovation.(2008b:255-6)TheTaskForcenotesthattheQubecgovernmentishesitanttolimitaccesstocare:Inthepast,theGouvernementduQubecactuallyusedthesepowers,particularlytolimittheageatwhichvisionexaminationsanddentalcarearecovered.Butithesitatestodosowhenmedicalandhospitalcareareinvolved,particularlyoutoffearthatthefederalgovernmentwillrelyontheCanada Health Acttopenalizetheprovincesnancially.(2008b:59)However,theTaskForcegivesnoexamplesofanywaysinwhichtheCHAconstrainsanyrecommendationsforactiontheTaskForcewouldhaveotherwisemade.

InresponsetoitsdirectmandatetosuggestchangestotheCHAnecessarytoimplementitsrecommendationsonthebestmeanstoensureadequatehealthcarefunding,theReportdoesnotmakeasinglerecommendation.Thecentralmessageofthis,inlightoftheconcreterecommendationsoftheReport,isthatsignicanthealthfundingreformcanoccurundertheauspicesoftheCHA.66Theimportantquestionwhichremainsiswhethersuchreforms

arejudgedtobepoliticallyfeasible.

PUBLIC OPINION ON PRIvATE HEALTH FUNDING AND INSURANCE

WhilepublicopinioninAlbertaisoftenseenasgenerallysupportiveofmarket-basedsolutionstopolicyproblems,publicopinionpollingstronglysuggeststhatAlbertansare,infact,lessreceptivetoprivatefundingandinsurancealternativesinthehealtheldthanCanadiansonaverage.67Thispatternofpublicsupportmirrorscross-provincialpatternsintherelativestringencyofregulationofprivatehealthfundingandinsurancerelativeasoutlinedabove.

65TherecommendedfeeinQubecwouldbe$100annuallyanditmaybearguedthatthisdoesnotposeanunreasonablebarriertoaccess.66Somewhatsurprisingly,theTaskForceconcludes:TheTaskForceisconvincedthattheorientationsproposedinitsreportnotonlyrespectthespiritofthevecriteriaoftheCanada Health Act,butwouldhavetheeffectofimprovingaccessandthequalityofcare.(2008b:257)67Thisconclusionisconsistentacrossawidenumberofpollsdonerecently(since2005)byanumberofCanadianpollingrmsinclud-ingEnvironics,Compas,PollaraandIpsos-Reid.


24/3624

Public Support or the CHA and Its Central Principles

OverallpublicopinioninCanadaisrelativelyevenlydividedbetweensupportforstrongenforcementoftheCHAversussupportforallowinggreaterprovinciallatitudeintheprovisionofhealthservices.(SeeFigure4.)Similarly,Albertansarerelativelyevenlydividedonthequestion.Certainly,AlbertadoesnotexhibitexceptionalsupportforallowinggreaterprovinciallatitudeinhealthcareasdoesQubec.EvenoftheEnglishCanadianprovinces,AlbertaisnotthemostsupportiveofgreaterprovinciallatitudeanoptionwhichreceivesmoresupportinBritish

Columbia.

Fgr 4: spprt fr strg CHA efrcmt, 2006

Source:Ipsos-Reid,Canadian Federation o Nurses Associations,2006.

NorisAlbertapublicopinionexceptionalinregardtoallowingextra-billinganduserfees.InFigure5,thersttwocolumnsforeachprovincereportthenetsupport(percentageofrespondentsinfavourminusthepercentageofrespondentsopposing)forallowingpaymentsforquickeraccessandpaymentsforserviceenhancements.IncomparisonwithBC,OntarioandQubecwherenetopinionwasinfavourofallowingpaymentforquickeraccess,netopinioninAlbertawasopposedmorestrongly,infact,thanthenationalaverageaswellasotherprovinces/regionswiththeexceptionofAtlanticCanada.Whilenetopinionacrossallregionsisinfavourofallowingpaymentsforserviceenhancements,thisoptionreceivestheleastsupportinAlberta.

-30

-20

-10

0

10

20

30

40

50

60

70

Percent(%

)

BC Alberta SK/MB Ontario Quebec Atlantic Canada

PREFERENCES FOR STRONG CHA ENFORCEMENT VS.

GREATER PROVINCIAL LATITTUDE, 2006

Strong CHA Enforcement

Greater Provincial Latitude

Net CHA Support


25/3625

Fgr 5: spprt fr Payg fr Qckr Acc a/r src ehacmt, 2005, 2006

Source:SupportforPayforQuickerAccessandPayforServiceEnhancementsPollara, Health Care in Canada,2005;netagreeandnetstronglyagreewithpayforenhanced/quickerservices--Ipsos-Reid,Canadian MedicalAssociation Survey,2006.Notes:Thesecondsetofquestions(Ipsos-Reid)asksrespondentsiftheystronglyagree/agree/disagree/stronglydisagreethatthebesthealthcaresystemwouldbeoneinwhichgovernmentpaysonlyforemergencyoressentialcarewithanoptionforpatientpaymentforenhancedorquickerservices.Netagreereportsthetotalpercentageofagree/stronglyagreeresponsesminusthetotalpercentageofdisagree/stronglydisagree.Netstronglyagreereportsthepercentofstronglyagreeresponsesminusthepercentageofstronglydisagreeresponses.

InFigure5,thethirdandfourthcolumnforeachprovincereportagreementwiththestatementthatthebesthealthcaresystemwouldbeoneinwhichthegovernmentpaysforemergencyandessentialmedicalcarewhilepatientswouldhavetheoptiontopayforenhancedorquickerservices.OverallsupportissimilaramongAlbertanandCanadianrespondentsmoregenerallywithopinionbeingmarginallyinfavour.However,examiningonlyrespondentswithstrongopinionsinfavouroragainst,Albertaisamongtheprovinces/regions(alongwithBritishColumbiaandAtlanticCanada)wherethismodelreceivesthemostopposition.

Public Support or Priate Purchase and Insurance o Serices

Asarguedabove,AlbertagoesbeyondtherequirementsoftheCHAinbanningtheprivateprovision/purchaseofcertainhealthservicesaswellasinbanningprivateinsuranceforallpublicly-insuredservices.Thereisstrong

publicsupportinAlbertafortheseregulationsandAlbertaisnotexceptionalinthisregard.

-30

-20

-10

0

10

20

30

40

NetSupport(%o

fRespondents)

BC/Terri Alberta SK/MB Ontario Quebec Atlantic CDA

SUPPORT FOR EXTRA-BILLING/USER FEES, 2005-6

Pay for Quicker Access

Pay for Service Enhancements

Net Agree -- Pay for Enhanced/Quicker Services

Net Strongly Agree -- Pay for Enhanced/Quicker Services


26/3626

Fgr 6: spprt fr Patt Payg/irg, 2005, 2006

Source:NetAgreePatientPay/Insure,NetStronglyAgreePatientPay/InsureandNetSupportParallelPrivatevs.StatusQuofromIpsos-Reid,Canadian Medical Association Survey,August2006;NetAgreeInsureNon-EmergencyandNetStronglyAgreeInsureNon-EmergencyfromPollara,Health Care in Canada, 2005.

InFigure6,thersttwocolumnsforeachprovincereportresponsestothequestionofwhetherrespondentssupportallowingpatientstopayforand/orinsureforserviceswhenthepublicsystemdoesnotprovidetimelyaccesstothoseservices.Ofallprovinces,oppositionamongallrespondentsishighestinAlberta.Whenexaminingonlythosewithstrongopinions,oppositioninAlbertaremainssignicantlyabovelevelsinCanadain

generalalthoughlowerthaninAtlanticCanadaandBritishColumbia.Thenexttwocolumnsforeachprovincereportagreementwiththestatementthatpatientsshouldbeallowedtoinsureand/orpayfornon-emergencyservicesoutsideofthepublicsystem.Thebalanceofpublicopinionamongallrespondentsacrossallprovinces/regionsisfavourablewithopinioninAlberta(26%netinfavour)beingonlyslightlymorefavourablethanthenationalaverage(22%netinfavour.)However,examiningonlyrespondentswithstrongopinionsinfavourandagainst,opinioninAlbertaisthemostresistantexceptfortheAtlanticprovinces.Asimilarpatternemergesinregardtosupportforaparallelprivatesystemversusthestatusquo.68Comparingnetlevelsofsupportforaparallelprivatesystemversusthestatusquo,AlbertarespondentswereslightlylessopposedonbalancethanCanadianrespondentsmoregenerallybutmoreresistantthanrespondentsinBC,Saskatchewan,

ManitobaandQubec.Respondentswereaskedwhichofsixoptionstheywouldmoststronglysupportifmoremoneywasneededtoimprovethehealthcaresystem.Albertans,alongwithrespondentsfromallprovinces,weremoststronglysupportiveofmovingmoneyfromotherpolicyareastohealthcare(31%).Ofthethreemainalternativestoincreasingpublicfunding(eitherthroughbudgetaryshiftsorincreasedtaxesasreportedinFigure7),Albertanrespondentswererelativelyequallysplitamongallowingprivateinsurance(13%),requiringpatientstopayaportionofthecosts[user

68Respondentswereaskedabouttheirsupportforfouroptions.Themedicareplusprivateparallelsystemscenariowouldincludeapublicsystemprovidinguniversalcoverageofservicesbutallowingindividualstheoptionofpurchasingprivateinsuranceforallservices(withtaxincentivestopromoteaccess)andallowingphysiciansdeliverservicesinbothsystems.Ipsos-Reid,2006:6.

-40

-30

-20

-10

0

10

20

30

40

NetSupport(%o

fRespondents)

BC/Terri. Alberta SK/MB Ontario Quebec Atlantic Canada

SUPPORT FOR PATIENT PAY/INSURE FOR SERVICES, 2005-6

Net Agree -- Patient Pay/Insure Net Strongly Agree -- Patient Pay/Insure

Net Agree -- Insure Non-Emergency Net Strongly Agree -- Insure Non-Emergency

Net Support -- Parallel Private vs. Status Quo


27/3627

fees](11%)andallowingoff-hoursaccessforprivatepayingpatients(12%).Inallthreecases,levelsofprovincialsupportcloselymatchedthenationalaveragealthoughsupportforoff-hoursaccessforprivatepayingpatientswassomewhathigherinAlbertathaninCanadaasawhole(9%).However,fornoneoftheseoptionswasAlbertapublicopinionthemostsupportiveofallprovinces.

Fgr 7: spprt fr opt fr Halth Fg Rfrm, 2007

0

5

10

15

20

25

%S

upport

BC AB SK/MB ON QB Atl. Canada

OPTIONS FOR HEALTH FUNDING REFORM, 2007

Private Insurance

User Fees

Private Pay Access

Source:Pollara,Health Care in Canada,2007.[Question19.]Notes:Respondentswereaskedtoidentifyoneofsixoptionsinresponsetothefollowingquestion:Ifmoremoney

wasneededtoimprovethehealthcaresystem,whichofthefollowingoptionswouldyoumoststronglysupport?Thesixoptionswereasfollows:movingmoneyfromothernon-healthcare,havingprivateinsurancecoverportionofcost,increasingtaxesanddirectingittothehealthcaresystem,requiringpatientstopayportionofcosts,offhoursaccessforprivatepayingpatients,andoffhoursaccessforpatientsfromothercountries.

Overall,thepublicopiniondatadiscussedabovesuggestthatpublicopinioninAlbertaisnotexceptionalinitsresistancetoallowingpatientstopayorinsureforservicesbutitdoesappeartolieonthemoreresistantendofthecross-provincialspectrum.Notsurprisingly,thesepatternsofpublicsupportaremirroredintherelativestringencyoftheregulationofprivatepaymentandinsuranceofhealthservicesinAlberta.

Eplaining Public Opinion in AlbertaThisraisestheobviousquestionastowhyAlbertapublicopinionislessfavourabletoprivatefunding/privateinsurancethanpublicopinioninotherprovinces.Thenextsectionconsidersthreepossibleexplanations:levelsofpublicspendingonhealthservices,publicperceptionsregardingthequalityofpublichealthservicesinAlberta,and,nally,publicperceptionsregardingtheimpactsofprivatefundingonthequalityofhealthservices.

Levels o Public Spending on Health ServicesPerhapsthemostobviousexplanationforresistancetoreformwouldbethatthesystemisrelativelywell-funded.HealthcareexpendituresinAlberta(inrealdollarspercapita)wereatthenationalaverageintheearly1990s.(SeeFigure8.)However,followingcutbacksinAlberta,provincialexpendituresfellsignicantlybelowthenational


28/3628

average.Intheperiodfrom1996to2005,healthcareexpendituresgrewatafasterrateinAlbertathannationallywithAlbertasurpassingthenationalaveragepercapitaexpenditureafter2000.

Fgr 8: Pblc Halth Car exptr Albrta a Caaa, Ctat $ pr capta, 1990-2005

PROVINCIAL HEALTH CARE EXPENDITURES

Alberta and Canada, 1990-2006

0

500

1,000

1,500

2,000

2,500

3,000

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Constan

t(1997)$percapita

Alberta All Provinces

Source:CanadaInstitutesforHealthInformation,StatisticsCanada.TableB.4.7.

Thus,by2006,whileprovincialgovernmenthealthexpenditurespercapitainAlbertawerecomparabletoexpendituresinSaskatchewan,Manitoba,andNewfoundland,theywerethehighestofallprovincesandjustunder10%higherthantheaverageforallprovinces.(SeeFigure9.)Perhapsmorestrikingly,therateofgrowthinprovincialhealthcareexpenditureshasbeenhighestinAlbertabyaconsiderablemarginoverthesixyearperiodfrom2000to2006.(SeeFigure10.)ExpenditureincreasesinAlbertafrom2004to2005werenearlydoublethenationalaverage.ExpendituregrowthinAlbertafrom2005to2006moderatedbutwasstillabovethenationalaverage.


29/3629

Fgr 9: Pblc Halth Car exptr Albrta a Caaa, 1990-2005

Source:CanadaInstitutesforHealthInformation,StatisticsCanada.TableB.4.2.Note:TheseexpendituresareincurrentdollarspercapitaandarenotcomparablewithexpendituredatareportedinFigure8.

Fgr 10: Chag Prcal Halth Car exptr, All Prc, ral (ctat) llar pr capta,2000-2006

Source:CanadaInstitutesforHealthInformation,StatisticsCanada.TableB.4.2.Constantdollarsascalculatedbyauthor.

0

500

1,000

1,500

2,000

2,500

3,000

3,500

Current$percapita

BC AB SK MB ON QB NB NS PEI NF CDA

Public Sector Health Expenditures, 2006

0

1

2

3

4

5

6

7

8

9

10

Current$percapita

BC AB SK MB ON QB NB NS PEI NF CDA

ANNUAL CHANGE IN HEALTH EXPENDITURES

Per Capita, 2000-20062000-2006

2004-2005

2005-6


30/3630

Public Perceptions o the Quality o Public Health ServicesThecomparativelyhighlevelsofexpenditureandexpendituregrowthinAlbertamayhaveasignicantimpactonthelimitedpublicdemandforreform.Mostsimply,thelimitedappetiteforreforminAlbertamaybetheresultofhigherlevelsofsatisfactionwiththequalityofhealthservicesprovidedinthisprovincewiththelatterbeingafunctionofcomparativelyhighlevelsofpublicexpenditureandexpendituregrowth.Whiletheredoesappeartobeageneralrelationshipacrossprovincesbetweenoveralllevelsofhealthfundingandperceptionsofqualityandlevels

ofpersonalsatisfactionwithhealthservices,theevidenceofAlbertaexceptionalismintermsofpublicsatisfactionwiththehealthsystemismixed.

Tabl 4: Ttal Halth exptr (pr capta), Pblc Halth exptr a % f Ttal, a Chag Prcal Halth xptr, 2000-2006

Ttal exptr

($ pr capta) 2007

% Pblc (prcal)

2007

Aal Arag % Chag Pblc (prcal)

exptr (ral $ pr capta)

2007 2007 2000-2006

BC 4713 71.5 2.0

AB 5390 74 6.4

SK/MB 5218 77.8 4.7

ON 4975 67.2 3.9

QB 4371 71.7 2.5

Atlantic 4946 76.6 4.8

Source:CanadaInstitutesforHealthInformation,TableB.1.2(totalexpenditure),TableB.4.3(provincialgovernmentexpenditureasproportionoftotalexpenditure),andTableB.1.4(provincialgovernmenthealthexpenditure)withconstantdollarscalculatedbyauthor.

Notes:Regionaltotals(SK/MBandAtlantic)arepopulation-weightedaveragesascalculatedbyauthor.Thepublicopiniondatausedinthecorrelationswerenotavailableonadisaggregatedbasisfortheseregions.

Intheircomparativeexaminationacross26nations(primarilyNorthAmericanandEuropean),Tuohy,FloodandStabilendthatboththelevelofpublicfundingandthepublicshareoftotalhealthspendingaresignicantlycorrelatedwithaggregatelevelsofsatisfactionwiththesystemasawhole.69Thecorrelationofvariousmeasuresofexpenditure(includingtotalhealthexpenditures,publicexpendituresasapercentoftotalhealthexpenditures,andchangeinprovincialhealthexpendituresasreportedinTable4)withbothperceptionsofthequalityofavailablehealthservicesaswellasperceptionsofpersonalexperienceswiththehealthsysteminTables5and6.

69CarolynHughesTuohy,ColleenM.FloodandMarkStabile,HowDoesPrivateFinanceAffectPublicHealthCareSystems?MarshalingtheEvidencefromOECDNations,Journal of Health Politics, Policy and Law,29,3(June2004):388.


31/3631

Tabl 5: exptr Mar a Prcpt f Qalty f Aalabl Halth src

% oRespondents

Rprt Car -- Qalty f Aalabl Halth src

A B C F A+B C+F(A+B)-(C+F)

BC 25 38 32 5 63 37 26

AB 16 46 27 11 62 38 24

SK/MB 29 35 18 18 64 36 28

ON 22 42 26 10 64 36 28

QB 14 45 32 8 59 40 19

Atlantic 35 27 30 7 62 37 25

Ttal 2007* 0.05 -0.01 -0.46 0.36 0.39 -0.33 0.37

Chag 2000-6* 0.01 0.00 -0.25 0.25 0.06 -0.06 0.06

% Pblc 2007* 0.27 -0.33 -0.16 0.20 0.00 -0.01 0.00

*rhosquared

Source:PublicopiniondatafromIpsos-Reid,Canadian Medical Association 2007 Report Card Study.Informationregardingonlineavailabilityathttp://www.ipsos-na.com/news/pressrelease.cfm?id=3604.Notes:Expendituremeasures(rows7-9)correspondwiththethreemeasurespresentedinTable4.

Tabl 6: exptr Mar a Prcpt f Pral exprc Accg Halth src

% oRespondents

Rprt Car -- Pral exprc Accg Halth src

A B C F A+B C+F(A+B)-(C+F)

BC 34 34 25 7 68 32 36

AB28 46 17 7 74 24 50

SK/MB 30 39 19 13 69 32 37

ON 35 36 18 10 71 28 43

QB 29 37 22 11 66 33 33

Atlantic 33 37 20 6 70 26 44

Ttal 2007* -0.04 0.49 -0.56 -0.01 0.75 -0.43 0.58

Chag 2000-6* -0.17 0.72 -0.76 -0.03 0.74 -0.66 0.73

% Pblc 2007* -0.22 0.12 -0.01 0.00 0.00 -0.01 0.00

*rhosquared

Source:SeeTable5.Notes:SeeTable5.

AsillustratedinTable5,thereisnocorrelationbetweenthethreeaggregatedmeasuresofperceptionsofqualityandeitherchangeovertimeinprovincialhealthexpendituresorpublicexpendituresasaproportionoftotalexpenditures.However,therelationshipbetweentheseaggregatemeasuresofperceptionsofqualityofavailablehealthservicesandtotalhealthexpendituresaremoderateandintheexpecteddirection(withhigherlevelsofspendingbeingpositivelycorrelatedwithpositiveperceptionsofhealthservicesandinverselyrelatedwiththeoverallnegativeperceptionsofhealthservices.)


32/3632

WhileTable6illustratesthatthereisnorelationshipbetweenperceptionsofpersonalexpe