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Is Canadian Health Care a Model for the United States?

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Is Canadian Health Care a Model for the United States? Gerard W. Boychuk, Ph.D. Author of National Health Insurance in the United States and Canada – PowerPoint PPT presentation

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Title: Is Canadian Health Care a Model for the United States?


1
Is Canadian Health Care a Model for the United
States? Gerard W. Boychuk, Ph.D. Author of
National Health Insurance in the United States
and Canada
2
Is Canadian Health Care a Model for the US?
  • the Canadian model?
  • should Canadian health care be a model?
  • could Canadian health care be a model?

3
Is Canadian Health Care a Model for the US?
  • the Canadian model?
  • should Canadian health care be a model?
  • could Canadian health care be a model?

4
What is the Canadian model?
  • Canada Health Act, 1984 (CHA)
  • health care as predominantly provincial
    jurisdiction
  • federal principles governing financial
    reimbursement for eligible health services by
    provincial health plans
  • does not apply to means of provision of services
    (which may be provided by for-profit providers)
  • physicians -- primarily private, for-profit
    practice on a fee-for-service basis
  • hospitals -- primarily private not-for-profits
    (e.g. not publicly-owned) on a global-funding
    basis
  • increasingly, private for-profit facilities
    offering surgical and diagnostic services on a
    fee-for-service basis
  • arguably a single-payer system not a
    single-provider system

5
What is the Canadian model?
  • universal availability of publicly-administered
    health insurance (on uniform terms and
    conditions) for access to all medically necessary
    hospital and physician services

6
What is the Canadian model?
  • universal availability of publicly-administered
    health insurance (on uniform terms and
    conditions) for access to all medically necessary
    hospital and physician services

7
What is the Canadian model?
  • universal availability of publicly-administered
    health insurance (on uniform terms and
    conditions) for access to all medically necessary
    hospital and physician services
  • single-public-payer (not exclusive-public payer
    system)

8
What is the Canadian model?
  • universal availability of publicly-administered
    health insurance (on uniform terms and
    conditions) for access to all medically necessary
    hospital and physician services
  • single-public-payer
  • public plan may charge premiums (various
    provinces)

9
What is the Canadian model?
  • universal availability of publicly-administered
    health insurance (on uniform terms and
    conditions) for access to all medically necessary
    hospital and physician services
  • single-public-payer
  • public plan may charge premiums (various
    provinces)
  • on uniform terms and conditions

10
What is the Canadian model?
  • universal availability of publicly-administered
    health insurance (on uniform terms and
    conditions) for access to all medically necessary
    hospital and physician services
  • single-public-payer
  • public plan may charge premiums (various
    provinces)
  • on uniform terms and conditions
  • mandatory community-rating -- cannot be
    experience-rated

11
What is the Canadian model?
  • universal availability of publicly-administered
    health insurance (on uniform terms and
    conditions) for access to all medically necessary
    hospital and physician services

12
What is the Canadian model?
  • universal availability of publicly-administered
    health insurance (on uniform terms and
    conditions) for access to all medically necessary
    hospital and physician services
  • no mandate that individuals carry public
    insurance coverage

13
What is the Canadian model?
  • universal availability of publicly-administered
    health insurance (on uniform terms and
    conditions) for access to all medically necessary
    hospital and physician services
  • no mandate that individuals carry public
    insurance coverage
  • individuals allowed to opt out of public coverage
    (various provinces)

14
What is the Canadian model?
  • universal availability of publicly-administered
    health insurance (on uniform terms and
    conditions) for access to all medically necessary
    hospital and physician services
  • no mandate that individuals carry public
    insurance coverage
  • individuals allowed to opt out of public coverage
    (various provinces)
  • cannot subsidize private coverage

15
What is the Canadian model?
  • universal availability of publicly-administered
    health insurance (on uniform terms and
    conditions) for access to all medically necessary
    hospital and physician services
  • no mandate that individuals carry public
    insurance coverage
  • individuals allowed to opt out of public coverage
    (various provinces)
  • cannot directly subsidize private coverage
  • eligibility for coverage cannot be categorical or
    income-tested

16
What is the Canadian model?
  • universal availability of publicly-administered
    health insurance (on uniform terms and
    conditions) for access to all medically necessary
    hospital and physician services

17
What is the Canadian model?
  • universal availability of publicly-administered
    health insurance (on uniform terms and
    conditions) for access to all medically necessary
    hospital and physician services
  • financial barriers at point of access must not
    impede or precludereasonable access to insured
    services
  • places limits on allowable extent of user fees
    (co-payments) and extra-billing (balance billing)

18
What is the Canadian model?
  • universal availability of publicly-administered
    health insurance (on uniform terms and
    conditions) for access to all medically necessary
    hospital and physician services
  • financial barriers at point of access must not
    impede or precludereasonable access to insured
    services
  • limited required coverage of services within
    province

19
What is the Canadian model?
  • universal availability of publicly-administered
    health insurance (on uniform terms and
    conditions) for access to all medically necessary
    hospital and physician services
  • financial barriers at point of access must not
    impede or precludereasonable access to insured
    services
  • limited required coverage of services within
    province
  • narrow but deep -- e.g. not comprehensive
  • not covered
  • pharmaceuticals
  • home care
  • long-term care
  • dental care

20
What is the Canadian model?
  • regulation of private purchase of health services
    and private health insurance?
  • limits on how public payment can be combined with
    private payment for privately-purchased health
    services
  • payment from public plan must be accepted by
    provider as payment in full if services are to be
    billed directly to the public plan (or province
    faces federal penalties)
  • physicians can opt-out of public plan e.g.
    forfeit ability to bill public plan directly
  • bill patients at rates above provincial fee
    schedule
  • patient reimbursed from public plan up to
    provincial rate schedule
  • patient allowed to carry third-party, private
    insurance for the difference

21
What is the Canadian model?
  • does not preclude competition between publicly
    and privately funded services or competition
    between public and private insurance

22
What is the Canadian model?
  • does not preclude competition between publicly
    and privately funded services or competition
    between public and private insurance
  • does not mandate a single-payer system
  • allows for a single-payer dominant system

23
What is the Canadian model?
  • does not preclude competition between publicly
    and privately funded services or competition
    between public and private insurance
  • does not mandate a single-payer system
  • allows for a single-payer dominant system
  • sets the terms of competition
  • different degrees of tax-funded subsidization of
    public insurance versus private payment/private
    insurance

24
What is the Canadian model?
  • does not preclude competition between publicly
    and privately funded services or competition
    between public and private insurance
  • does not mandate a single-payer system
  • allows for a single-payer dominant system
  • sets the terms of competition
  • different degrees of tax-funded subsidization of
    public insurance versus private payment/private
    insurance
  • public insurance insulated from adverse selection
  • individuals may opt out of provincial insurance
    premiums/coverage
  • cannot opt out of provincial taxes!

25
Is Canadian Health Care a Model for the US?
  • the Canadian model?
  • should Canadian health care be a model?
  • could Canadian health care be a model?

26
Is Canadian Health Care a Model for the US?
  • the Canadian model?
  • should Canadian health care be a model?
  • could Canadian health care be a model?

27
Should Canadian Healthcare be a Model for the US?
  • performance
  • objective criteria
  • optimizing among competing goals
  • quality (e.g. physician perceptions)
  • access (e.g. unmet health care needs)
  • effectiveness (e.g. survival rates, avoidable
    events)
  • cost and cost control (over time)

28
Total Health Expenditures, of GDP, Canada,
1992-2008
29
Should Canadian Healthcare be a Model for the US?
  • performance
  • objective criteria
  • optimizing among competing goals
  • quality (e.g. physician perceptions)
  • access (e.g. unmet health care needs)
  • effectiveness (e.g. survival rates, avoidable
    events)
  • cost and cost control (over time)

30
Should Canadian Healthcare be a Model for the US?
  • performance
  • objective criteria
  • subjective (public) perceptions
  • quality and general satisfaction
  • caveats
  • insurance status
  • sicker adults
  • indirect evidence of public perceptions
  • fundamental reform of the Canadian health funding
    system is not on the political agenda

31
Should Canadian Healthcare be a Model for the US?
  • performance
  • objective criteria
  • subjective (public) perceptions

32
Should Canadian Healthcare be a Model for the US?
  • performance
  • objective criteria
  • subjective (public) perceptions
  • similar problems

33
Should Canadian Healthcare be a Model for the US?
  • performance
  • objective criteria
  • subjective (public) perceptions
  • similar problems
  • esp. fee for service vs. capitation
  • cost-shifting

34
Should Canadian Healthcare be a Model for the US?
  • performance
  • normative implications of different models

35
Is Canadian Health Care a Model for the US?
  • the Canadian model?
  • should Canadian health care be a model?
  • could Canadian health care be a model?

36
Is Canadian Health Care a Model for the US?
  • the Canadian model?
  • should Canadian health care be a model?
  • could Canadian health care be a model?

37
  • Nowtell me something interesting, David.
  • Hillary Rodham Clinton to David
    Himmelstein, 1993

38
Is Canadian Health Care a Model for the US?
  • the Canadian model?
  • should Canadian health care be a model?
  • could Canadian health care be a model?
  • feasibility of reforms that would move the US
    system closer toward the Canadian model in the
    long-term

39
Political Feasibility of the Canadian Model
  • inception of health care in Canada
  • occurred in political culture and institutional
    context no more favourable to public insurance
    than US
  • displaced existing private benefits
  • which paved the way for public benefits

40
Political Feasibility of the Canadian Model
  • inception of health care in Canada
  • occurred in political culture and institutional
    context no more favourable to public insurance
    than US
  • displaced existing private benefits
  • positive feedback -- created its own
    self-sustaining dynamic

41
Political Feasibility of the Canadian Model
  • inception of health care in Canada
  • occurred in political culture and institutional
    context no more favorable to public insurance
    than US
  • displaced existing private benefits
  • positive feedback -- created its own
    self-sustaining dynamic
  • public predisposition toward/against public
    insurance is not immutable

42
Political Feasibility of the Canadian Model
  • inception of health care in Canada
  • occurred in political culture and institutional
    context no more favorable to public insurance
    than US
  • displaced existing private benefits
  • positive feedback -- created its own
    self-sustaining dynamic
  • public predisposition toward/against public
    insurance is not immutable
  • impressive resilience of the public insurance
    element of the Canadian system

43
Public Expenditures as Proportion of Total Health
Expenditures, Canada, 1996-2008
44
Political Feasibility of the Canadian Model
  • inception of health care in Canada
  • occurred in political culture and institutional
    context no more favorable to public insurance
    than US
  • displaced existing private benefits
  • positive feedback -- created its own
    self-sustaining dynamic
  • public predisposition toward/against public
    insurance is not immutable
  • impressive resilience of the public insurance
    element of the Canadian system

45
Political Feasibility of the Canadian Model
  • inception of health care in Canada
  • occurred in political culture and institutional
    context no more favourable to public insurance
    than US
  • displaced existing private benefits
  • positive feedback -- created its own
    self-sustaining dynamic
  • length of time for system implementation

46
Political Feasibility of the Canadian Model
  • inception of health care in Canada
  • occurred in political culture and institutional
    context no more favourable to public insurance
    than US
  • displaced existing private benefits
  • positive feedback -- created its own
    self-sustaining dynamic
  • length of time for system implementation
  • comprehensive universal public health insurance
    proposed in 1942
  • national hospital insurance 1958
  • national physician care insurance 1968-1971
  • CHA 1984 (effective 1987)
  • system remains incomplete by standards of 1945
    blueprint

47
Political Feasibility of the Canadian Model
  • inception of health care in Canada
  • occurred in political culture and institutional
    context no more favourable to public insurance
    than US
  • displaced existing private benefits
  • positive feedback -- created its own
    self-sustaining dynamic
  • length of time for system implementation

48
Gerard W. Boychuk National Health Insurance in
the United States and Canada (Georgetown
University Press, 2008)
49
Health Care and Hockey
  • proposing universal public health insurance in US
    is tantamount to selling the US a product that
    is about as American as hockey. (Birch, 1993)
  • National Hockey League
  • new NHL franchises since 1993
  • US 6
  • Canada -2
  • US (2008) 24/30 NHL franchises
  • Stanley Cup winning franchises
  • 1978-1992
  • Canadian 9/15
  • US 6/15
  • 1993-2008
  • Canadian 0/14
  • US 14/14

50
Gerard W. Boychuk National Health Insurance in
the United States and Canada (Georgetown
University Press, 2008)
51
(No Transcript)
52
Political Feasibility of the Canadian Model
  • politics of health care in the US
  • gaining perspective on resistance
  • reform period 1945-1965

53
(No Transcript)
54
Is Canadian Health Care a Model for the US?
  • the Canadian model?
  • should Canadian health care be a model?
  • health care performance in Canada and the US
  • could Canadian health care be a model?
  • feasibility of the Canadian model

55
Is Canadian Health Care a Model for the US?
  • the Canadian model?
  • should Canadian health care be a model?
  • health care performance in Canada and the US
  • could Canadian health care be a model?
  • feasibility of the Canadian model

56
What is the Canadian model?
  • regulation of private purchase/provision of
    health services and private health insurance?
  • private purchase of health services by
    individuals allowed (various provinces)
  • physicians allowed to opt out of public plan and
    provide services privately
  • except Ontario since 2004
  • private third-party insurance for health services
    allowed even for services that are otherwise
    publicly-insured (various provinces)

57
(No Transcript)
58
Political Feasibility of the Canadian Model
  • inception of health care in Canada
  • occurred in political culture and institutional
    context no more favourable to public insurance
    than US
  • displaced existing private benefits
  • positive feedback -- created its own
    self-sustaining dynamic
  • length of time for system implementation
  • driven by powerful dynamics related to the
    politics of territorial integration
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