Medicare (Canada)

The term medicare (in lowercase) (French: assurance-maladie) is the unofficial name for Canada's universal public health insurance system. Under the terms of the Canada Health Act, the provinces provide all residents with health insurance cards, which entitle the bearer to receive free medical care for almost all procedures. Patients are free to choose their own doctor, hospital, etc. Health institutions are either private and non-profit (such as university hospitals) or provincially run (such as Quebec's CLSC system). Doctors in private practice are entrepreneurs who bill the medicare system for their fees.

Services covered
Canada has always referred to their healthcare system as "healthcare". The term "medicare" was recently adopted and spoken by former Prime Minister Paul Martin during the previous election. Canada's healthcare system provides diagnostic, treatment and preventive services to every Canadian regardless of income level or station in life.

Each Province in Canada manages their own healthcare system. For example, each Province issues their own healthcare identification cards and negotiates with the Federal Government for money to cover their healthcare costs. Each province also provides their own Prescription Drug Benefit Plan, available to every Canadian regardless of income level. The prescription drug benefit is however adjusted for income, with a higher co-payment required for those with higher personal incomes. The prescription drug benefit is very comprehensive and rarely excludes a medication. Where there is a medication excluded, which is needed by a patient, the patient applies for coverage under the plan for that drug using a Section 8 form.

Dental care is not covered by any government insurance plans. Canadians rely on their employers, individual private insurance, or simply pay cash themselves for dental treatments.

The range of services for vision care coverage is widely varied amongst the Provinces. Generally, vision care is covered (cataract surgery, diabetic vision care, some laser eye surgeries required as a result of disease); the main exception is the standard vision test, which patients pay for if they have their eyes tested more than once within a two year period.

Naturopathic services are covered in some cases, but homeopathic services are generally not covered. Chiropractic is partially covered in some Provinces. Cosmetic procedures are not typically covered.

Opinions on medicare
Many Canadians highly value their medicare program. Polling data in the last few years have consistently cited it as the most important political issue in the minds of Canadian voters. Along with peacekeeping, the CBC ran a poll that found medicare to be one of the most defining characteristics of Canada. It has increasingly become a source of controversy in Canadian politics. Due to massive healthcare transfer payment cuts at the hands of recent Federal governments, and the resulting shortfalls in Provincial government budgets, combined with rising costs due to an aging population, quality of care provided has decreased through the past two decades.

Commonly referenced problems include: limited access to diagnostic equipment (such as MRIs and CT Scanners), lengthy wait times for surgeries and serious physician shortages, which are particularly prevalent for General Practitioners(GP)/Family Doctors. In some parts of the country waiting times to acquire a GP have been quoted at several years. As a result some right-wing political figures and think tanks have proposed removing barriers to the existence of a parallel private health care system. Though polling suggests support for such reforms has been increasing, it has yet to be adopted as official policy by any of the main federal political parties. There have been private clinics opened and operating in Canada, but they are few and far between. Canadians who pay for their own services at Private Clinics are not penalized or prevented from using the public healthcare system simultaneously.

Current concerns involved the need for the Federal Government to improve healthcare funding to the Provinces, after the massive cuts enforced on the system over the past 20 years. Prime Minister Paul Martin has already reduced wait times, increased the number of doctors and nurses, by giving the Provinces back the money they lost during Conservative Party Leadership. The improvement was noticeably remarkable in 2005.

Despite wait times and funding cuts, Canadians do receive a very high standard of care, on par with what a privately-insured US citizen would get. The Canadian system is much more affordable for certain items such as patented drugs and this difference in price has created a large prescription drug exporting industry in Canada. Older medicines that are off patent tend to be somewhat more expensive due to less competition as entry into the Canadian market suffers from government barriers. The Canadian governments spend a smaller amount per capita on health care as the United States governments, while almost every Canadian citizen is fully covered. In the United States there are large percentages of the population who are uncovered or only marginally covered, despite higher proportional spending along with large private investment. Even more are just a job loss away from not having coverage (although in most cases the employer must maintain health care with copayment of the patient for a period of time after employment in the United States.)

In recent years, waiting lists for some procedures and treatments were very long. However, there have been some wait-time improvements through 2005 and 2006.

Proposed reforms
Though most Canadian politicians and citizens acknowledge that there are some problems with the system, the proposed solutions often spark passionate debate. On one hand there are those who believe that the problem is simply one of under funding. They point to the rise of neo-conservative economic policies in Canada, and the associated reduction in welfare state expenditure (particularly in the provinces) from the 1980s onwards as the cause of degradation in the system. However, it is commonly estimated that costs associated with the medicare system have still been creeping upwards as a percent of total government expenditures. Again, many critics argue that neo-conservative governments merely made huge cuts to other programs as a reason for health care creeping to high percentages of government spending. The increasing costs are also directly linked to Canada's ageing population.

On the other hand, there are those who argue that the system in its current form is financially unsustainable. They suggest that the rising cost of medical technology, infrastructure and wages are partly to blame. Canada's proximity to the United States is also cited as a serious problem, on account of the infamous "Brain Drain" - a phenomenon which describes the migration of Canadian-trained doctors and nurses (as well as other professionals) to the United States, where private hospitals can pay much higher wages and income tax rates are lower.

There are other proposed reforms that come from the populist left and centre wings and also those with a special interest in health care. While right wing reforms often get more attention, there is a grass roots movement to try and keep medicare public in Canada and to avoid privatization. This is usually presented as a value that separates Canadians from Americans by mandating equality and fairness in health care.

Since the early 1990s Ontario, as with other provinces, has worked at trying to reduce health care costs. Some examples of ways that costs were reduced or could be reduced follow. None of these systems are forced on patients at the moment, but they attempt help to make the system more financially sustainable. This makes them substantially different from Health Maintenance Organizations (commonly referred to as HMOs in the US) and other somewhat similar looking attempts by the United States to reduce health care costs, which appear to have reduced the average patient's access to medical care. Therefore they have been better accepted by the public.

User premiums
Currently in Ontario, people with a high enough income must pay an annual health care premium. It can range from $300-$900, depending on one's annual income. This payment is charged for those having salary above CN$20,000. Funding for medicare in Ontario also comes from a dedicated Employer Health Tax (EHT) that ranges from 0.98%-1.95% of employer profit over $200,000. Premiums also exist in British Columbia, Quebec, and Alberta ($44 a month or $88 per family), though as Alberta approaches debt-free status, there has been talk of removing them.

Medical clinics
Proposals to reduce costs have been varied. There is a movement in Ontario to try and expand 24-hour drop-in medical clinic networks. This would mean that if someone were ill, no matter what the time of day, they would be able to see a doctor at a clinic. As many evening hospital visits are because there is no available medical service for problems that cannot wait until morning, it is likely that this would reduce costs considerably.

Many Family Doctor Practices have created their own clinics, offering 24 hour service for their patients if needed. Each Doctor in the Practice takes a turn at being "on call" on an ever rotating basis. Patients who have family doctors belonging to these practices are even able to have a doctor come to their home in extreme situations. There is no additional charge for these services as they are billed to the Province, the same as an office visit.

Some major Canadian cities have restructured their Emergency services between different hospitals. For example, in London, Ontario, there are several hospitals. The hospitals worked together to streamline services. One hospital provides full emergency room care. Another sees patients who have broken limbs, minor injuries. Yet another sees patients suffering cold, flu, etc. They have divided up the care adequately so that everyone is well served and critical cases are served first and foremost.

Alternatives to fee-for-service
There is also a movement to try and move the system away from bill for service. The Ontario government in the early 1990's helped develop many community health care centres which provide both medical and social support. The emphasis is on medical care but the over-all approach is holistic. Collective kitchens, Internet access, anti-poverty groups and groups to help people quit smoking are common and funded in various ways. While funding has decreased for these centres, and they have had to cut back, they have been quite cost effective. They are often located in low income areas. If it is possible to reduce illness before it reaches a hospital a lot of money can be saved, although it is often hard to estimate how much and thus it is easier to cut these programs. Many of these centres are filled to capacity in terms of general doctors, and there are often fairly long waiting lists, although drop in health care is provided, often for those who have no other doctor. The centres also make use of nurse practitioners, who reduce the workload on the doctors and increase efficiency.

Midwives
Ontario and Quebec have also recently licensed midwives, providing another option for childbirth. While midwifery cannot always take the place of a doctor, it can still reduce costs. If the mother wishes it and the birth appears uncomplicated, a hospital need not be involved. However, hospitals are now introducing birthing areas which contain their own suite, often with a hot tub (which is good for relieving pain without medication). These births often cost much less than the traditional manner of birth but are close to hospital facilities in case the need emerges. There have been occasional problems but overall the system has worked quite effectively.

Privatization
In recent years some on the political right-wing have called for an increased role for the private sector in the delivery of hospital medicare services. Currently, privately owned and operated hospitals that allow patients to pay out-of-pocket for services cannot obtain public funding in Canada, as they contravene the "equal accessibility" tenets of the Canada Health Act.

A recent Canadian court decision has ruled that a Quebec law, which outlaws private health insurance, contravened the Quebec Charter of Rights guaranteeing the right to security of the person. In June 2005, the Supreme Court of Canada overturned a Quebec law preventing people from buying private health insurance to pay for medical services available through the publicly funded system. While the ruling applies only to the province of Quebec, it is believed by some that it could fundamentally change the way health care is delivered across the country. See: Chaoulli v. Quebec (Attorney General).

The ruling may be read here:

In November 2005, the Quebec government announced that it would be allowing residents to purchase private medical insurance to comply with the Supreme Court Chaoulli decision.

Private Insurance covering that which is not covered by Medicare, such as dental care and eye care has been available for many years and is provided by many employers as a benefit. Blue Cross, Green Shield and Manulife are all well known providers in Canada of this type of insurance.

Barriers to foreign trained practitioners
Currently, Doctors arriving in Canada from other countries must meet Canadian Health Practitioner standards. Canada's health education system is above average in the world, so there is concern that doctors from other countries are not trained or educated to meet Canadian standards.

Doctors who want to practice in Canada must meet the same educational and medical qualifications as Canadian trained doctors, prior to practicing in Canada.

Provincial insurance plans
Though the Canada Health Act provides national guidelines for healthcare, the provinces have exclusive jurisdiction over health under the constitution and are free to ignore these guidelines. The counterbalance to this is that the federal government requires provinces to adhere to their guidelines in order to receive federal funding for healthcare. All provinces currently abide by the Canada Health Act in order to receive this funding, however Alberta has often mused about ignoring the Act should their planned health reforms require them to do so.

The federal government has no direct role in the delivery of medicine in the provinces so each province has its own independent public health insurance program. Under the Canada Health Act, each province must provide services to members of plans in other provinces.