a sustainable health system: what can be learnt from canada?
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A Sustainable Health System: What can be learnt from Canada?. Alan Shiell Professor and AHFMR Senior Health Scholar Markin Institute University of Calgary Institute of Public Policy Research Symposium Great Expectations: Towards a Sustainable Health System April 10 2006. - PowerPoint PPT PresentationTRANSCRIPT
A Sustainable Health System: A Sustainable Health System: What can be learnt from Canada?What can be learnt from Canada?
Alan ShiellAlan ShiellProfessor and AHFMR Senior Health ScholarProfessor and AHFMR Senior Health Scholar
Markin InstituteMarkin InstituteUniversity of CalgaryUniversity of Calgary
Institute of Public Policy Research SymposiumInstitute of Public Policy Research SymposiumGreat Expectations: Towards a Sustainable Health Great Expectations: Towards a Sustainable Health
SystemSystemApril 10 2006April 10 2006
Will George Zeliotis’s painful hip Will George Zeliotis’s painful hip
be the end of Medicare?be the end of Medicare?
IS MEDICARE SUSTAINABLE?IS MEDICARE SUSTAINABLE?
Canada’s publicly funded health care system, as it Canada’s publicly funded health care system, as it is currently organized and operated, is not fiscally is currently organized and operated, is not fiscally sustainable given current funding levels sustainable given current funding levels
(Kirby, (Kirby, 2002)2002)
Medicare … is as sustainable as Canadians want it Medicare … is as sustainable as Canadians want it to beto be (Romanow, (Romanow, 2002)2002)
TODAYTODAY
What do we mean by sustainability?What do we mean by sustainability?
What is the basis for claims that the system What is the basis for claims that the system is or is not sustainable?is or is not sustainable?
Sustainability is a choice that we can make. Sustainability is a choice that we can make. The greatest threat to the Medicare system is The greatest threat to the Medicare system is political reluctance to face up to that choicepolitical reluctance to face up to that choice
ON SUSTAINABILITYON SUSTAINABILITY
What is to be sustained?What is to be sustained?• The elements of MedicareThe elements of Medicare• The essence of MedicareThe essence of Medicare
What is meant by sustainability?What is meant by sustainability?• Affordability - EconomicAffordability - Economic• Acceptability - PoliticalAcceptability - Political
THE POLITICAL ECONOMY OF THE POLITICAL ECONOMY OF SUSTAINABILITYSUSTAINABILITY
The debate over health care … is less a pure The debate over health care … is less a pure macroeconomic issue than an exercise in the macroeconomic issue than an exercise in the political economy of sharing political economy of sharing
(Rheinhardt et al., (Rheinhardt et al., 2004)2004)
It is about It is about differing viewsdiffering views on the correctness of on the correctness of who pays, how much and for what benefitwho pays, how much and for what benefit
THE CANADIAN HEALTH CARE THE CANADIAN HEALTH CARE SYSTEMSYSTEM
• Not one, but 13 provincial single-payer systemsNot one, but 13 provincial single-payer systems
• Federal – Provincial cost sharing governed by Federal – Provincial cost sharing governed by the Canada Health Actthe Canada Health Act
The Five Pillars of MedicareThe Five Pillars of Medicare– Comprehensiveness ( all “medically necessary” Comprehensiveness ( all “medically necessary”
services)services)– UniversalityUniversality– Public administrationPublic administration– PortabilityPortability– AccessibilityAccessibility
THE CANADIAN HEALTH CARE THE CANADIAN HEALTH CARE SYSTEMSYSTEM
Funding:Funding:• Predominantly income taxPredominantly income tax• Some social insurance (Alberta, BC, Ontario)Some social insurance (Alberta, BC, Ontario)• Private insurancePrivate insurance• Direct out of pocket paymentsDirect out of pocket payments
CHA effectively prohibits extra billing and user feesCHA effectively prohibits extra billing and user fees
Provincial laws effectively ban parallel private Provincial laws effectively ban parallel private health carehealth care
THE CASE AGAINST ECONOMIC SUSTAINABILITY
0
500
1000
1500
2000
2500
3000
3500
4000
TOTAL HEALTH SPENDING (per capita) CIHI, 2006
THE CASE FOR ECONOMIC SUSTAINABILITY
0.0
2.0
4.0
6.0
8.0
10.0
12.0
TOTAL HEALTH SPENDING: % GDP (CIHI, 2006)
THE CASE FOR ECONOMIC SUSTAINABILITY
0.0
2.0
4.0
6.0
8.0
10.0
12.0
TOTAL HEALTH SPENDING: % GDP (CIHI, 2006)
A SLIGHT COMPLICATION … RISING SHARE OF GDP
0.0
2.0
4.0
6.0
8.0
10.0
12.0
SOURCE: CIHI Health Expenditure Trends, 2006
WHERE WE’RE ATWHERE WE’RE AT
Medicare is economically sustainableMedicare is economically sustainable
Is it politically acceptable?Is it politically acceptable?– Political wolves knocking at the door (Evans)Political wolves knocking at the door (Evans)– The challenge from withinThe challenge from within
CHANGING HEALTH TECHNOLOGY AND CREEPING PRIVATISATION
0
20
40
60
80
100
Hospitals Physicians Drugs Other
SOURCE: CIHI Health Expenditure Trends, 2006
PROBLEMS ACCESSING PROBLEMS ACCESSING SERVICESSERVICES
AustraliAustraliaa
CanadaCanada UKUK USAUSA
Problems with waiting Problems with waiting timestimes
17%17% 24%24% 21%21% 14%14%
Difficulty seeing Difficulty seeing specialistspecialist
41%41% 53%53% 38%38% 39%39%
Long waits to be Long waits to be admitted to hospitaladmitted to hospital
19%19% 32%32% 21%21% 13%13%
Source: Commonwealth Fund, International Health Policy Survey, 2001
ACCESS PROBLEMS DUE TO COST1,2
AustraliAustraliaa
CanadaCanada UKUK USAUSA
Did not get medical Did not get medical serviceservice
16%16% 9%9% 4%4% 28%28%
Skipped test or Skipped test or treatmenttreatment
16%16% 10%10% 5%5% 26%26%
Failed to fill scriptFailed to fill script 23%23% 19%19% 10%10% 35%35%
Did not get dental Did not get dental serviceservice
44%44% 35%35% 21%21% 40%40%
(1) Among adults with a health problem(2) Source: Commonwealth Fund, International Health Policy Survey, 2001
Did not get a recommended test or Did not get a recommended test or treatment due to its cost – by treatment due to its cost – by
incomeincome
AustraliAustraliaa
CanadCanadaa
UKUK USAUSA
Above average Above average incomeincome
14%14% 4%4% 2%2% 14%14%
Below average Below average incomeincome
17%17% 9%9% 4%4% 36%36%
Source: Commonwealth Fund, International Health Policy Survey, 2001
THE REAL CHALLENGE: THE REAL CHALLENGE: CHASING AN INCONSISTENT TRIADCHASING AN INCONSISTENT TRIAD
Comprehensive coverageComprehensive coverage
Universal and equal access free at point of Universal and equal access free at point of carecare
High quality (timely, responsive, effective) High quality (timely, responsive, effective) carecare
Constrained by our willingness to payConstrained by our willingness to pay
SOURCE: Weale, BMJ 1998
THE CHALLENGE WITHINTHE CHALLENGE WITHIN
Changing health technology is leading to Changing health technology is leading to ‘creeping privatisation’, which is undermining ‘creeping privatisation’, which is undermining comprehensivenesscomprehensiveness
Problems with access are experienced more by Problems with access are experienced more by lower SES, which is contrary to universalitylower SES, which is contrary to universality
Political failure to address these will undermine Political failure to address these will undermine support for Medicare and its long term political support for Medicare and its long term political sustainabilitysustainability
Above average income
Below average income
Australia 24% 36%
Canada 19% 26%
UK 12% 16%
USA 26% 43%
Respondents who believe their health care system should be completely rebuilt
SOURCE: Commonwealth Fund, International Health Policy Survey 2001
Equity and Physician Visits: Probability of Consultation
Source: van Doorslaer et al, CMAJ, 2006
WHO rank Country Main Funding Source Spend per capita
1 France SI 2,077
2 Italy Tax 1,783
10 Japan SI 1,822
12 Portugal Tax 1,237
17 Netherlands SI/VI 2,070
18 UK Tax 1,461
20 Switzerland VI 2,794
23 Sweden Tax 1,746
25 Germany SI 2,424
30 Canada Tax 2,312
32 Australia Tax/VI 2,043
37 USA VI 4,178
FUNDING SOURCE AND WHO RANKING
SATISFACTION WITH HEALTH CARE SYSTEM
Very
SatisfiedFairly
SatisfiedTotal
SatisfiedMethod
of Funding
Denmark 54.2 35.8 90.0 Tax
Finland 15.1 71.3 86.4 Tax
Netherlands 14.2 58.6 72.8 SI/VI
Luxembourg 13.6 57.5 71.1 SI
Belgium 10.9 59.2 70.1 SI
Sweden 13.1 54.2 67.3 Tax
Germany 12.8 53.2 66.0 SI
France 10.0 55.1 65.1 SI
UK 7.6 40.5 48.1 Tax
Portugal 0.8 19.1 19.9 Tax
Italy 0.8 15.5 16.3 Tax