CANADA’S HEALTH CARE SYSTEM Bartoshyk, Patrick 1

Canada’s Health Care System

IssueCanada, with its National Health Insurance Model, is one of the few countries in the world with a

universal publicly funded, not-for-profit health system, where care is provided on the basis of need as opposed to ability to pay.1 Since the implementation of this model under the Canada Health Act in 1984, outcomes have been monitored with purpose to ascertain improvements that will optimize access to high quality care.2 3 Why then, is there increasing skepticism and public outcry surrounding fair, timely, and equitable access to care?

BackgroundThe challenges currently faced within Canada’s health care system have evolved with the country’s

changing population and health circumstances. Faced with an aging, baby boomer population and a sicker, younger population susceptible to chronic disease, wait times for medical assessment, diagnostics, and essential treatment have become unreasonably long.4 5 6 The problem is compounded by health care specialist shortages,7 rising salaries for physicians (i.e., annual average salary of $328,000 in 2012) and unionized employees,8 and technological advances in medical care and treatment.9 Each of these factors impacts financial sustainability and places overwhelming resource demand on a health care system with principle based on equal treatment for all, regardless of whether or not individuals take responsibility for their health.

Current StatusAlthough responsibility for Canada’s health care system is shared by the federal government and a set of

overarching principles that align with the Canada Health Act, administration and funding of health care falls primarily under the umbrella of each province or territory.10 While revenue is generated largely through taxes (i.e., personal; corporate; and, in some provinces, sales) and some monetary donations, health care premiums are, in fact, cost-imposed for services that are deemed essential in some provinces (e.g., British Columbia) and required only for non-essential extended services in others (e.g., Alberta).11 Furthermore, since essential services are not defined by the Canada Health Act,12 each province or territory can interpret these on their own accord and this has created inequitable access to health care across the country. For example, while essential services are free in some provinces (e.g., Alberta), those who can afford and choose to pay higher premiums are given access to supplementary services and subsequently, a higher standard of health care.13 However, increased demand on available resources means that access is not necessarily provided in a timely manner to any given individual or population, regardless of financial status. This is despite total health care spending of over $207 billion in Canada each year.14

Key ConsiderationsThe epidemiology of Canadians and the subsequent impact on health care resources are of particular

relevance when examining the current state of the health care system. Chronic diseases that include cancer, heart disease, stroke, lung disease, and diabetes are among the top six leading causes of death in Canada,15 with evidence of escalating rates from childhood though adulthood.16 For example, hypertension and diabetes are approaching epidemic proportions in children, and this is because seventy per cent are sedentary and their consumption of fast food (high sugar, high fat, high sodium, high portion) is out of control.17 Despite the proven benefits of healthy lifestyle strategies (i.e., exercise, stopping smoking, healthy eating habits, and weight management) the number of obese Canadian adults has doubled in the past twenty-five years.18 In 2010, the federal, provincial, and territorial managers sanctioned a Declaration on Prevention and Promotion with focus on reducing the prevalence of childhood obesity and promoting healthy weight.19 However, the impact has yet to be observed.

The second issue relates to an imbalance between supply (i.e., assessment, diagnoses, and treatment) and demand. For example, sick people are waiting longer than ever before for such procedures as MRI, CT scan, or biopsy; people with cancer are lining up to begin life-prolonging treatment; and people with malignant tumors or debilitating bone diseases sometimes wait months for essential surgery.20 21 Moreover, while the federal government provides funding for special and high needs populations (i.e., Aboriginal people, veterans and serving members of the Canadian Forces; inmates in federal penitentiaries, refugee claimants) it is the responsibility of each province and territory to provide access to service.22 Therefore, provinces and territories with higher federally-funded populations may be at a disadvantage since these people, many who are exempt

CANADA’S HEALTH CARE SYSTEM Bartoshyk, Patrick 2

from paying tax (i.e., live on a reserve or unemployed), place high demands on available resources which the federal government does not necessarily support or accrue the cost for.23

The last concern is the discrepancy between those who can afford and those who cannot, and the fact that each province or territory sets the cost of premiums based on different definitions of services that are essential to health.24 Examples of this are demonstrated in the differences between the way health care is administrated between two neighboring provinces, Alberta (AB) and British Columbia (BC). According to the 2013 Fraser Institute Provincial Healthcare Index, in terms of per capita health care spending amongst the ten provinces, AB ranks second and BC ranks ninth.25 The reasons for this become evident when scrutinizing their respective programs.

Through the AB Health Care Insurance Plan, the provincial government provides residents with free, full coverage access to medical services that are deemed necessary by a physician.26 Other health-related services are included, although limited in coverage and somewhat inconsistent in relation to their importance on overall health. For example, good oral health that includes routine dental care (i.e., cleaning, fillings, wisdom tooth extraction), proven to positively impact cardiovascular health, is not covered.27 28 Yet, some types of dental surgery are fully funded.29 Moreover, to address health care needs that are deemed non-essential but advantageous, AB Health offers additional non-mandatory benefit coverage through Alberta Blue Cross, a premium-based plan which, although free for individuals over age 65, comes at a monthly age-dependent cost with ability to choose from three different plans.30 Plan A is the most basic, Plan B extends coverage, and Plan C provides maximum coverage for health, dental, vision, drug, and out-of-country travel.31 An individual in the age range of 21 to 34 would pay a monthly premium of $53, $70, or $84 for Plan A, B, or C, respectively.32 In cases where taxable income is very low and premiums are unaffordable, Albertans can apply for premium subsidy (e.g., an individual with a taxable income of less than $20,970 can save up to 45% off the regular cost of a premium).33 This means that most Albertans are eligible for a premium-based plan, albeit not necessarily the best plan. Ironically, naturopathic medicine, with its important focus on holistic care and disease prevention, is only included in the most expensive Plan C.34 In principle then, the plan that most effectively mitigates the costs associated with chronic disease, is also the most expensive.

British Columbia employs a significantly different and less flexible method of distributing and managing health care resources. Unlike AB, the BC Medical Services Plan (MSP) is mandatory with monthly premium rates based on net income.35 Only individuals with an annual net income of greater than $22,000 pay a premium, with incremental income-based payments that range between $12.80 and $72 per month.36 The MSP covers only services deemed essential which differ from those defined in AB.37 For example, routine eye exams are not covered for individuals between the age of 18 and 65 in BC whereas, in AB, annual eye exams are considered essential for all ages.38 39 Although the BC MSP is not directly affiliated with a premium-based plan like AB, BC residents still have the option to purchase extended coverage from private insurance agencies such as Pacific Blue Cross.40 The cost is comparable to what Albertans pay for Alberta Blue Cross with one significant difference: in AB, the premium-based plan is free for people over age 65 but in BC, seniors pay the highest premiums.41 42 The differences in health care administration between AB and BC are thus enormous and this is further demonstrated when comparing value for money amongst all ten provinces. Alberta’s health care system ranks the highest in both cost and value while BC ranks the lowest.43

Conclusion and RecommendationAccording to studies in public health, there is no health care system in the world that does not present

with challenges.44 Canada is no exception and despite ongoing reforms to the system, health care administrators are faced with an onslaught of problems and a broken model. The medical needs of a sicker, larger, and older population have fundamentally been compromised by a scarcity of human, technical, and financial resources. This is complicated by costs associated with varying definitions and allocations of essential services. As the nature and direction of health care continue to evolve, it is imperative that government officials, health care administrators, and the public at large work together to: a) stimulate a healthier, more engaged, and educated population; b) embed clear global definitions for essential services in the Canada Health Act; and c) employ premium rates that are consistent across the country. While tangible first steps have been demonstrated by such initiatives as the 2010 Declaration on Prevention and Promotion, uncompromising proactive strategies are essential to mitigate the epidemic of chronic disease if it is the desire of Canadians to maintain a not-for-profit health care system that is accessible, equitable, and sustainable.

CANADA’S HEALTH CARE SYSTEM Bartoshyk, Patrick 3

References

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