The Health of Canadians – The Federal Role
Interim Report
Volume One – The Story So Far
National Principles for Health Care and the Advent of the Canada Health Act
The fact that the delivery of health care is primarily an area of provincial jurisdiction does not mean that national principles are absent. The federal government has always attached a set of national principles or conditions to its health care contribution, whether cost-shared or block-funded.
2.1 The Origins of the Canada Health Act
Both the Hospital Insurance and Diagnostic Services Act of 1957 and the Medical Care Act of 1966 included four explicit conditions for provincial public health care insurance plans – namely universality, public administration, comprehensiveness and portability. They did not, however, contain specific provisions preventing provinces from demanding a financial contribution from patients. Moreover, since federal contributions under cost-sharing arrangements were proportional to provincial government expenditures, the provincial governments had nothing to gain from permitting direct patient charges; the revenue from such charges would in fact have resulted in a reduction in the federal contribution. This implicit reduction mechanism thus strongly deterred provinces from adopting any form of direct patient charges, such as extra-billing or user fees.
In 1977-78, when EPF replaced the shared-costs formula, the conditions attached to both federal acts on hospital services and medical care were retained. However, the implicit mechanism for reduced federal contributions was eliminated, since federal funding was no longer linked to provincial government expenditures. Michael Bliss, professor of history at the University of Toronto, told the Committee that the late 1970s and early 1980s period were marked by an attempt to control health care costs through constraints in the physicians’ fee schedule and in hospital budgets. Overall, this resulted in a proliferation of direct patient charges:
In the 1970s, the problem of paying for health insurance quickly became the most serious thing that ministries of health, both provincial and federal, had to face. Immediately, the question of how to contain health care costs came to the fore, and a whole cadre of experts and health care economists grew up to try to give advice to state insurers on how you could stop the escalation of costs. We remember the 1970s of stagflation, in which the overall costs of Canadian social programs began to be a terrible burden on governments. (…) they began to try to squeeze the providers of health care, the hospital system and the physicians in order to try to hold down costs.
The providers responded the way anyone else does when they are squeezed: They began to look for alternatives. The Medicare system of 1968 was a pluralist system that allowed for the freedom of providers to practise outside the system. You could opt out; you could extra bill. It was not surprising, then, in the 1970s, that, as the provincial governments began to squeeze the Medicare fee schedule, more and more practitioners opted out. By the end of the 1970s and early 1980s, a kind of re-privatization occurred in health care. Many people saw the public system as a penny-pinching system and they wanted to work in the private sector where there was more freedom, more protection of incomes, and more possibilities for innovation.
By the early 1980s, we were seeing across the country serious problems in our Medicare system. So many specialists had opted out that, in large parts of the country, it was impossible to have access to certain specialists under Medicare. That was particularly true in obstetrics and gynaecology. The issue of accessibility became very important. (31)
More precisely, extra-billing by physicians was authorized in New Brunswick, Ontario, Manitoba, Saskatchewan and Alberta. In addition, hospital user fees were levied in New Brunswick, Quebec, Alberta and British Columbia.
In 1980, the Health Services Review by Justice Hall reported that health care in Canada ranked among the best in the world, but warned that direct patient charges were posing a threat to the principle of free and universal access to health care throughout the country. In response to these concerns, Parliament unanimously passed the Canada Health Act in 1984. Abby Hoffman told the Committee that the new Act combined and updated the conditions set out in the two federal acts of 1957 and 1966 and it added accessibility as a fifth criterion. In addition, specific restrictions were added to deter any form of direct patient charges and to provide residents of all provinces with access to health care regardless of their ability to pay:
The government ended up tabling and obtaining unanimous passage of the Canada Health Act, to fix a problem, which derives, in my opinion, from EPF. Hon. Monique Bégin (16:3). |
There were several key points in the Canada Health Act worth noting, including the affirmation of universal insurance as the basis for medically necessary hospital and physician services, and the strengthening of the principles of portability, comprehensiveness, and public administration. A fifth criterion, accessibility, was added – that is, reasonable access to medically necessary insured services on uniform terms and conditions. Further, and perhaps most importantly, there was to be an effort to discourage user charges and extra billing. The Canada Health Act provided for mandatory dollar-for-dollar deductions from federal transfer payments to any province that permitted user charges or extra billing for insured services.(32)
According to Marc Lalonde, the Canada Health Act was adopted in response to the erosion of public health care insurance. Its was not intended as a means of increasing some of the federal visibility that was lost in this field with the advent of EPF block funding:
As to the 1984 Act, I do not think it had anything to do with reasserting our visibility. It had to do with a genuine concern that there was, through the back door, erosion of the basic elements of Medicare generally. Extra billing and additional fees for hospital care were creeping in right and left, and there was a necessity for the federal government to reassert the basic principles that were enshrined in the first legislation and to try to set up regimes that would provide for greater accountability in the way the provinces were using federal funds, in particular, for the public in general and for the federal government.
If you must look for a rationale for the 1984 Act, I do not think you should look for it in terms of trying to recuperate some lost visibility that the federal government did not have or had lost. It was essentially that there was federal legislation that provided for fundamental principles to which the federal Parliament was unanimously attached. We were seeing erosion that, if not stopped at that time, might have led to a dismantling of the whole national system as we knew it.(33)
In essence, Mr. Lalonde reiterated that the main objective of Medicare was, as Tom Kent had said, to remove financial barriers to access to health care:
The aim of public policy was quite clearly and simply to (…) make sure that people could get care when it was needed without regard to other considerations.(34)
2.2 Definition/Interpretation of the National Principles and their Application
The Canada Health Act sets out five major criteria or "national principles" – universality, accessibility, comprehensiveness, portability and public administration. Table 2.1 provides details about each criterion.
TABLE 2.1
THE FIVE CRITERIA OF THE Canada HEALTH ACT
Public Administration: requires that the administration and operation of the health care insurance plan of a province be carried out on a non-profit basis by a public authority responsible to the provincial government. Comprehensiveness: requires that all medically necessary services provided by hospitals and doctors be covered under the provincial health care insurance plan. Universality: requires that all residents of a province be entitled to public health care insurance coverage. Accessibility: requires reasonable access unimpeded by financial or other barriers to medically necessary hospital and physician services for residents, and reasonable compensation for both physicians and hospitals. Portability: requires that coverage under public health care insurance be maintained when a resident moves or travels within Canada or travels outside the country (coverage outside Canada is restricted to the coverage the resident has in his/her own province). |
Source: Health Canada, Canada Health Act Annual Report – 1998-1999, Ottawa, 1999, pp. 2-3. This document is available on Health Canada’s Internet site at http://www.hc-sc.gc.ca/medicare/dwnloade.htm
During her testimony, Abby Hoffman provided a description of the health services to which the Canada Health Act applies and does not apply. She made a distinction among the five categories of health services:
- insured services;
- extended health care services;
- supplementary health care services;
- uninsured health services, and
- de-insured services.
Table 2.2 provides examples for each category of health care services and indicates whether or not they are governed by the five conditions of the Canada Health Act. Clearly, the federal legislation is very limited: it is centred on medically necessary services provided by hospitals and doctors.
TABLE 2.2
CATEGORIES OF HEALTH CARE SERVICES
Type of Services |
Examples |
Five criteria |
Provisions with respect to user charges and extra-billing |
Insured Services |
Medically necessary hospital and physician services, including some dental care when performed in a hospital | Apply |
Apply |
| Extended Health Care Services | Long term care, adult residential home, some ambulatory care | Do not apply |
Do not apply |
| Supplementary Health Care Services | Prescription drugs outside hospitals, chiropractic services, physiotherapy, dental services | Do not apply |
Do not apply |
Uninsured Services |
Cosmetic surgery, telephone advice by physicians | Do not apply |
Do not apply |
De-Insured Services |
Wart removal, extraction of wisdom teeth | Do not apply |
Do not apply |
Source: Abby Hoffman (13:11-12).
The application of the Act is so restricted that provinces are not required to insure health promotion/prevention services or non-hospital based services of health care practitioners such as chiropractors, physiotherapists or psychologists. The national principles do not apply to extended health care services – nursing homes, adult residential care, home care and ambulatory health care. Although some provinces do insure some of these additional services, Canadians do not have universal and equal access to them.
Moreover, the Canada Health Act applies to a shrinking number of services because fewer services are provided now in hospitals. Thanks to new technologies, health services can be provided on an out-patient basis or at home. Hospital stays are shorter and pharmaceutical products sometimes enable us to avoid surgery altogether. When services and prescription drugs are provided outside the hospital, however, they are outside the ambit of the Canada Health Act. As a result, these services are not necessarily provided at no cost to patients, nor are they necessarily provided in accordance with the principles of accessibility, comprehensiveness and universality.
Over the years, provinces have expanded the array of services that are eligible for public coverage, either fully or partially. This includes, for example, dental care, vision care and prescription drugs to selected population groups in some provinces, as well as some community care and some home care. These services, once again, do not fall under the Canada Health Act. As a result, the range of publicly funded health services varies greatly from province to province. The Committee was told that our health care system, as defined broadly, is becoming less and less uniform:
It is good that provinces have chosen to extend the array of chosen services. The difficulty is that they have not done so uniformly, and we have ended up with fragmentation and something of a patchwork across the country. (35)
While the Canada Health Act has managed to obtain consistent public coverage for hospital and physician services across the country, it is clear that its limited focus has led to a lack of uniformity in public coverage for the much broader range of health care services which, one suspects, Canadians would like to receive under their publicly funded health care system.
2.3 Enforcement Penalties under the Canada Health Act
Provinces must comply with the five conditions of the Canada Health Act in order to qualify for the entire federal cash contribution. If these conditions are not met, section 15(1)(a) of the Act stipulates that a penalty may be applied to the cash value of federal transfers. The Governor in Council sets the amount of this financial penalty depending on the "gravity" of the default. Sections 18 to 21 of the Act, which set out penalties for extra-billing and user charges, stipulate that the federal government may withhold one dollar of cash transfer for every dollar collected through direct patient charges.
Between 1984-85 and 1991-92, penalties for a failure to comply with the Canada Health Act were applied to the portion of EPF cash transfers earmarked for health care. Then, from 1991-92 to 1995-96, financial penalties were extended to cover other transfer payments because of the federal government’s continuing restriction on the growth of EPF transfers and its specific impact on cash transfers: it was estimated that the health care portion of the EPF cash transfers to some provinces would have reached zero by the year 2000. Without the cash transfer, the federal government would not have had the power to enforce the conditions of the Canada Health Act. The additional withholdings or deductions were not stipulated in the Act, but were specifically set out in the Federal-Provincial Fiscal Arrangements Act (paragraphs 23.2(1), 23.2(2) and 23.2(3)). Since 1996-97, penalties under the Canada Health Act have applied to the cash portion of the CHST.
Information provided by Health Canada(36) indicates that, on three occasions, the federal government resorted to financial penalties and reduced its contributions to some provinces that were authorizing extra-billing or imposing user charges. First, it deducted over $246,732,000 from EPF cash transfers to all the provinces from 1984-85 to 1986-87. However, it also complied with section 20(6) of the Act, under which a province was able to recover these funds if it terminated all forms of direct patient charges in the three years after the Act came into force, that is, before 1 April 1987. Since all provinces complied with the Act within that timeframe, the amounts withheld were all reimbursed.
Second, from 1992-93 to 1995-96, the federal government withheld some $2,025,000 in EPF cash transfers to British Columbia because a number of physicians in that province had opted out of the province’s health care insurance plan and resorted to extra-billing.
Finally, since 1995-96, the federal government has imposed financial penalties on provinces that permit private clinics to demand facility fees from patients for medically required services, having determined that such facility fees constitute user charges. These penalties have applied to four provinces. By the time the deductions from transfers to Alberta ended in July 1996, a total of $3,585,000 had been deducted from that province (see Table 2.3). Similarly, a total of $323,000 had been deducted from Newfoundland, which started complying with the Act in January 1998. The penalties imposed on Manitoba ($2,056,000 in total) were discontinued as of 1 February 1999. Nova Scotia has still not complied with the Canada Health Act and is being penalized in the amount of $4,780 per month (a total of $247,750 was deducted from transfers to Nova Scotia between October 1996 and January 2000 inclusively).
The Hon. Monique Bégin, the former federal health minister who introduced the Canada Health Act, noted that, until now, no discretionary penalty for failure to comply with the five national principles of the Act has ever been applied, despite some complaints regarding portability, comprehensiveness and accessibility.
TABLE 2.3
DEDUCTIONS BY PROVINCE UNDER THE CANADA HEALTH ACT
(In Thousands of Dollars)
1992-93 |
1993-94 |
1994-95 |
1995-96 |
1996-97 |
1997-98 |
1998-99 |
1999-00* |
|
Newfoundland |
46 |
96 |
128 |
53 |
||||
Prince Edward Island |
||||||||
Nova Scotia |
32 |
72 |
57 |
39 |
47,8 |
|||
New Brunswick |
||||||||
Quebec |
||||||||
Ontario |
||||||||
Manitoba |
269 |
588 |
587 |
612 |
||||
Saskatchewan |
||||||||
Alberta |
2,319 |
1,266 |
||||||
British Columbia |
83 |
1,223 |
676 |
43 |
||||
Total Canada |
83 |
1,223 |
676 |
2,709 |
2,022 |
772 |
704 |
47,8 |
* Up to January 2000.
Source: Health Canada, Deductions by Province Since Passage of the Canada Health Act,
Information binder prepared for the Committee, Section 8, 10 February 2000.
2.4 Is the Canada Health Act Still Relevant?
A few witnesses discussed the relevancy of the Canada Health Act. Some of them were of the view that the Act should remain intact. For example, the Hon. Marc Lalonde stated:
Many people blame the Canada Health Act for something it was not trying to do. The Act does not introduce rigidity. The five criteria existed before. The Canada Health Act introduces clearer definitions through regulations, or otherwise, to ensure that these rules mean something. In that sense perhaps there is some rigidity. I have no qualms whatsoever about saying that the federal Parliament should maintain the five criteria that were enacted by Parliament in the past. In my view, those criteria remain as valid as they ever were. (37)
The Hon. Monique Bégin indicated that the Act is very important for Canadians and should not be reopened:
The Canada Health Act has taken on a life of its own. It has now reached the status of an icon. Because of that, I personally think that no politician can reopen the Canada Health Act, even to improve it, because it will destabilize people too much. (38)
She suggested, however, that new legislation similar to the Canada Health Act be established to govern the use of new federal transfers. The new Act could include additional conditions, such as accountability and sustainability.
By contrast, others argued that the Act should be reviewed. For example, the Hon. Claude Castonguay indicated that the new prescription drug insurance plan initiated by the Quebec government in 1996 would not qualify for federal funding under the Canada Health Act because it is made up of a mixture of public and private components. While all citizens are covered, beneficiaries are required to pay a premium and a portion of the cost of their drugs.
In this section, the Committee wishes to outline its thoughts about the national principles underlying Canada’s health care system and its questions about these principles.
As mentioned earlier, Tom Kent indicated that the original policy objective of public hospital and medical care insurance was to ensure that all Canadians, regardless of their personal financial circumstances or where they lived in Canada, would have access to all medically necessary services. We believe that this objective explains four of the principles of the Canada Health Act:
- The principle of universality, which means that health care services are to be available to all Canadians;
- The principle of portability, which means that all Canadians are covered, even when they move from one province to another;
- The principle of comprehensiveness, which is meant to guarantee that all medically necessary services are covered by public health care insurance;
- The principle of accessibility, which means that barriers to the provision of health care, such as user charges, are discouraged, so that services are available to all Canadians regardless of their income.
The above four principles all focus on individual Canadians – they are patient-centred. This is consistent with the patient-oriented approach in the original public policy objective of Canadian Medicare. However, what began over thirty five years ago as a patient-centred national health care system has become a more narrow national system that is centred more around the delivery mechanism (hospitals and doctors) than around the patient’s entire health care needs. This distinction, even though it is critical to the development of future public policy, is not made in the vast majority of public commentary on the current system.
Moreover, the final principle of the Canada Health Act – the principle of public administration – is of a completely different character. It does not focus on the patient but is rather the means of achieving the ends to which the other four principles are directed. In our view, this distinction between ends and means explains much of the current debate about the Canada Health Act and Canada’s health care system. People who agree completely on the desired ends of a public policy can nevertheless disagree strongly on the means of achieving those ends.
The recent debate over Alberta’s Bill 11 is a clear example of this. This legislation allows private, for-profit, health care facilities to compete against publicly funded hospitals for the provision of selected minor surgical services. It is the view of the Alberta government that contracting out to these facilities can improve access, reduce waiting times/lists and increase efficiency by reducing the demand on the existing publicly-funded hospitals. Opponents of the new legislation believe that these goals could be better achieved by increasing the level of funding of public hospitals.
In Phase Three of our study, the Committee will examine the means by which other countries have tried to achieve the ends of comprehensive and universally accessible coverage for health care. This exercise will be useful in enhancing our understanding of Canada’s health care system and in evaluating options for building a long-term sustainable system.
The principles of comprehensiveness and accessibility are intertwined. Indeed, they go to the very core of the critically important issue of what services are covered by public health care insurance as "medically necessary" and how these services should be paid for. This, in turn, leads to the debate over affordability and sustainability.
Determining what services ought to be considered "medically necessary" is a difficult task. Most Canadians would agree that life-saving cardiac procedures are medically necessary. Most Canadians would also agree that most cases of cosmetic surgery do not meet the criterion of medical necessity. The difficulty comes with those services that lie between these two extremes. For example, virtually everyone would consider life-sustaining medication as "medically necessary", even if the medication is not taken in a hospital and therefore not subject to public coverage pursuant to the "medical necessity test" contained in the Canada Health Act. However, this does not change the harsh reality that many Canadians are struggling to find the money to pay for their "medically necessary" prescriptions every month.
Obviously, the more services we include in the definition of "medically necessary", the more costly the health care system is. Yet clearly, as more medically necessary products and services are produced and delivered outside the traditional hospital setting, a broadening of the definition of the concept of medical necessity is essential if Canada is to remain true to the spirit of the Canada Health Act. But broadening this definition raises the question of how these services should be paid for, and how excessive costs can be prevented.
For example, would modest user fees be an effective way to reduce unnecessary use of the health care system, as some people have proposed? Or would user fees have a disproportionately negative impact on low-income patients, preventing them from seeking out services when they truly need them ( a violation of the principle of accessibility)? Alternatively, should higher income Canadians pay a portion of the health care costs they are responsible for generating, through, for example, some form of income tax surcharge?
Tom Kent told the Committee that this was in fact the original vision of Medicare the Liberal party adopted:
To look at the history, when the Liberal rally, in 1961, so firmly committed the Liberal Party to health care, it was with a provision. It was that the costs that an individual thereby incurred through the tax system, would indeed become a charge through the tax system directly to the individual. The value of the services that you obtained from public health insurance would become a part of your statement for income tax purposes, within limits, and so on, so that it would never be overwhelming in any one year for any individual or family, and it would mean that people who paid little or no tax would pay nothing for their health care, but people who had relatively large incomes, had a significant tax, would pay something.(39)
If this funding method were ever to be used, the question arises as to whether individual Canadians should be able to purchase private insurance to cover the potential cost to them?
A major problem with health care insurance is that conventional economic principles do not fully apply. Because most bills are picked up by insurance, people pay little attention to the cost of health care. In addition, they have no way to assess the quality of the health services they receive. Beyond that, for most people, good health is priceless; they want to have access to the best available medical technologies and procedures at whatever cost. This creates a conundrum for politicians. On the one hand, their constituents will not accept the rationing of their health services. On the other hand, neither the politicians nor their constituents want to pay the higher taxes required for unlimited health care.
The question of precisely what services should be covered by government and what services should be paid for by individuals out of their own funds, either partially or fully, directly or through private insurance, is one that requires full discussion. Though these crucial questions are difficult ones, and just asking them arouses anxiety in some Canadians, they must be the focus of serious public debate. The Committee, through its subsequent reports of this study, hopes to provide a forum for this debate.
It is no longer possible for Canadians to gloss over the issues of what services are to be covered by their public health care insurance plan, and how the plan should be paid for, by simply referring to the laudable principles of comprehensiveness and accessibility in the Canada Health Act. These terms, even though they represent very important principles to all Canadians, are no longer sufficient to enable the government, and all Canadians, to avoid confronting the difficult practical decisions that must be made with respect to our health care system. In future parts of its study, the Committee will outline options for addressing these issues, and for examining the opinions and expectations of Canadians about their health care system.
Public Expectations about Health Care
For many Canadians, our health care system is a defining feature of the country and a symbol of our societal values. They cherish their public health care insurance plan for what it is, and for the values it represents: shared risk, compassion, fairness and common responsibility. However, an increasing number of Canadians are concerned that the health care system will not retain these qualities in the future. Many believe that health care in Canada is not as good now as it was in the past, because of government cuts in health care spending, longer waiting lists for doctors and procedures, and the number of doctors and nurses leaving to work in the United States. These views reflect an understanding that health care costs will continue to grow, especially for prescription drugs and new medical technologies, for instance.
The universality of the system is certainly linked to strong Canadian values like egalitarianism and generosity… Our health care system is a powerful symbol of our societal values. Chris Baker ,V-P, |
Knowing more about public values and attitudes is a vital component that can help ensure the development of policy options that are consistent with the views of Canadians. In this perspective, the Committee invited Canadian pollsters to provide more information on historical and current public attitudes towards, and expectations of, the health care system. We acknowledge that different surveys and polls often ask different questions and use different survey methods and that, as a result, findings may not be directly comparable. It is interesting to note, however, that we found great consistency and similar long-term trends in the polling data presented to the Committee.
3.1 Health Care is an Important Public Policy Concern
Canadians’ faith in their health care system has declined significantly during the past decade. A survey by Goldfarb Consultants found that 45% of Canadians felt in 1989 that the health care system was working well, compared with only 14% in 1999 (see Graph 3.1). Similarly, the Environics survey suggests that the level of satisfaction with the Canadian health care system has decreased dramatically during the 1990s. In fact, there is a growing consensus that there is a problem with our health care system.
With respect to public policy, data from the Goldfarb survey indicate that Canadians are becoming more and more concerned with health care (see Graph 3.2). In the early 1990s, Canadians were predominantly concerned with government spending, the debt and taxes. While taxation remained a major public policy concern in 1999, health care was perceived as one of the most important problems facing Canada. There were, however, demographic differences on this issue. For example, in 1999, women were more concerned about health care, while men were more concerned about taxes. Similarly, older Canadians were more concerned about the state of the health care system than younger ones.
It is not that taxation and debt have completely disappeared from the agenda, they are still in the public’s mind, but health is grabbing a larger share of that concern. Dr. Scott Evans, |
3.2 Canadians Are Concerned About Quality, Access and Universality
According to the Environics survey, quality appears to be the most important health care concern. About 70% of Canadians were very concerned about quality in 1999 (see Graph 3.3). Health care costs and the maintenance of a publicly funded health care system were both seen as very important, but secondary (with 64%). Some 51% of Canadians were very concerned about the integration of community and hospital services. During the hearings, it was noted that concerns about cost and the publicly funded system have decreased since 1994, but the concerns about quality have remained persistently high.(40)
Furthermore, Chris Baker explained that there is a strong link between quality and accessibility in the mind of Canadians (see Graph 3.4). In his view, they would strongly resist any measures that could restrict access to health care.(41)
Access and availability remain the top areas of concern, and any move to restrict that would be strongly resisted by Canadians. Chris Baker, V-P, Environics Research Group ( 9 :33). |
The 1999 Goldfarb survey asked about the most desirable use of the federal budgetary surplus. While cuts to personal income tax were important to Canadians, reinvesting in health care was just as high a priority (Graph 3.5). Universality remains a core value for Canadians. In fact, support for universal health care insurance coverage for all regardless of economic status increased from 81% to 84% between 1991 and 1999 (Graph 3.6).
When asked about spending priorities in health care, Canadians show a strong preference for "bricks and mortar" infrastructure and research activities. Community-based activities are considered secondary, and activities that are seen as remote from front-line care are assigned the lowest priority for new health care funding.
Some 78% of Canadians believe that maintaining hospital beds is a high priority, followed by funding research for women’s diseases, and medical technology. Population health initiatives, while providing benefits over the long term, cannot match the immediacy of new hospital beds or high-tech diagnostic or therapeutic equipment in the public perception. Baker explainedthis as follows:
I believe this is because there is a certain immediacy to anxiety about our health care system… Hospital beds and high-tech equipment will deliver immediate benefits, whereas community-based initiatives, population health initiatives, are seen as more long term. Canadians, because of their level of anxiety, focus on those activities that will deliver benefits immediately rather than down the road.(42)
Abby Hoffman from Health Canada expressed similar views:
(…) when people feel that the care and treatment side is vulnerable, they are somewhat resistant, quite understandably, to seeing more energy, and possibly more resources, being devoted to health prevention and promotion, public health, population health, those kinds of activities.(43)
Graham Scott, a former deputy minister of health in the province of Ontario, cautioned that while short term solutions may help ease the anxiety of Canadians about their health care system, long term solutions could bring more benefits down the road. He provided the following example:
If you spend $100 million to upgrade the OHIP system in Ontario, in the short term that does not cure one patient. However, if you announce that you are expanding the emergency wings in six community hospitals in southwestern Ontario, that is worth many seats. That is where the trade-off is.(44)
In his view, "it will take a fair amount of political courage at the federal and provincial levels" to invest in those areas that can bring the most benefits in the long term.
3.4 Health Care is a Federal/Provincial Partnership
Both the Environics and Goldfarb surveys indicate that Canadians expect both levels of government to do their part to reinvest in health care. Both surveys also suggest that Canadians give low marks to both the federal and provincial governments on their handling of health care issues. Furthermore, Canadians are impatient with blame-laying, they are more interested in positive results and intergovernmental cooperation. For example, as Dr. Scott Evans pointed out:
There is declining satisfaction with the system and critical assessments of all government performance in this area. There is a strong desire for governments to stop competing on the issue of health care and start cooperating. Chris Baker, V-P, |
Canadians are also becoming impatient with the bickering between the two levels of government. When asked about their understanding of federal-provincial relations, they cannot seem to understand why there is such unwillingness or inability to reach agreement on what needs to be done. There is a sense of losing patience with what governments are doing.(45)
3.5 Support for the Principles of the Canada Health Act is High
A review of polls, surveys and reports from the past ten years undertaken by the Conference Board of Canada shows that support for the principles of the Canada Health Act has remained high throughout the past decade. The highest supported principles have been universality and accessibility, while public administration has received the lowest support (see Table 3.1).
table 3.1
the principles of the Canada health act are "very
important"
(percentage)
1991 |
1994 |
1995 |
1999 |
|
| Universality | 93 |
85 |
89 |
89 |
| Accessibility | 85 |
77 |
82 |
81 |
| Portability | 89 |
78 |
81 |
79 |
| Comprehensiveness | 88 |
73 |
80 |
80 |
| Public Administration | 76 |
63 |
64 |
59 |
Source: Conference Board of Canada, Canadians’ Values and Attitudes on Canada’s Health Care System: A Synthesis of Survey Results, 6 October 2000, p. 11.
Despite this strong support, many Canadians believe that, with the exception of universality, the health care system is not fully living up to the national principles of Medicare. According to the Conference Board, these views "are not entirely surprising, given that many health services that Canadians rely on fall outside the scope of the Canada Health Act (…)."(46)
3.6 Decreasing Support for User Charges and Private Initiatives
Surveys show an increasing resistance to financial measures that would limit access to health care. According to Goldfarb Consultants, support for patient charges to visit a doctor, which was on the rise between 1989 to 1992, has been on decline since then (see Graph 3.7). Similarly, the Environics survey indicates that only a minority of Canadians (31%) believe that private clinics are a good way to reduce waiting lists. In addition, there is increasing concern that the introduction of privately-run facilities will erode the publicly-funded health care system (Graph 3.8).
In its 2000 survey review, the Conference Board of Canada suggests that support for various privatization options is higher when they are presented a a means for preserving Medicare either through making the system more efficient or ensuring equal access to high quality services. For example, with respect to user charges, it states that "support for user fees is often conditional – support is highest if user fees are presented as a method to improve system efficiency while not prohibiting people from accessing needed services(47)." Similarly, with regard to private facilities, the Board’s report indicates: "Public support is stronger for people purchasing private services in the event that the public system is unable to provide the necessary services than for allowing people to purchase services for the purposes of receiving faster or better service."(48)
The reason for the decline in public confidence to the Canadian health care system remains open to debate. According to Dr. Scott Evans:
Certainly much of the financial restructuring in the health care system, and the response of the media and the various advocacy groups to that, have all contributed to this general sense of declining faith.(49)
Similarly, Dr. John S. Millar, V-P of Research and Analysis at the Canadian Institute for Health Information (CIHI) indicated:
(…) changes in funding and the reductions in funding have clearly created a lot of stresses in the system. (…) One of those is that public confidence has been eroded significantly. We certainly have very well documented in this report that there has been less access to some services, such as emergency rooms and some specialist services and procedures. As a consequence of that and as a result of media attention to it, public confidence has dropped quite considerably.(50)
While reductions in government spending are often pointed as an important factor in declining public support for Medicare, it remains unclear whether or not recent increases in federal CHST transfers through the enactment of Bill C-32 (2000) and Bill C-35 (2000) will be enough to enhance Canadians’ confidence in the publicly funded health care system. Moreover, the Committee was told that the lack of confidence in the system should not be confused with the actual performance of the health care system. In fact, when patients are questioned about the health care they have received, they are generally satisfied:
(…), when you ask people who have actually been the recipients of care, they express very high levels of satisfaction. That reflects the fact that the provider groups, that is, doctors and nurses, despite all the stresses, have been struggling to continue to perform to a high level. The performance measures we have show that there are good outcomes. It is an interesting dichotomy, which shows up time and time again when these types of surveys are done. (51)
Sholom Glouberman, Director of the Health Network, Canadian Policy Research Networks, suggested that the major issue therefore is to develop strategies that will enhance public confidence in Canada’s health care system:
There is a bit of confusion between the actual performance of the health care system and people’s lack of confidence in it. The response to people’s lack of confidence in the health care system is often to add more resources to the system. That does not tackle the problem, because the problem is about confidence. The question is: What strategies can be used to increase confidence in the health care system? Part of it is information. Another part is an assurance that the health care system will be there when people need it. That has been a big part of the struggle.(52)
This is one of the current challenges in our health care system:
I believe that this is an interesting and volatile period with respect to public opinion. There is an opportunity to make great gains on the legitimacy of different kinds of approaches to health care that will be able to restore a sense of faith and confidence in the system.(53)
Public opinion and public expectations are vital to the examination of Canada’s health care system. In Phase Two of its study, the Committee will look at the issue of rising expectations, as they may have a significant impact on future government decisions, particularly as regards what health services to cover and who should be eligible for publicly funded health care, as well as how the money to pay for these services should be raised.