1. 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

2. Will George Zeliotiss painful hip be the end of Medicare?

4. IS MEDICARE SUSTAINABLE? Canadas publicly funded health care system, as it is currently organized and operated, is not fiscally sustainable given current funding levels (Kirby, 2002) Medicare … is as sustainable as Canadians want it to be (Romanow, 2002)

6. TODAY What do we mean by sustainability? What do we mean by sustainability? What is the basis for claims that the system is or is not sustainable? What is the basis for claims that the system is or is not sustainable? Sustainability is a choice that we can make. The greatest threat to the Medicare system is political reluctance to face up to that choice Sustainability is a choice that we can make. The greatest threat to the Medicare system is political reluctance to face up to that choice

7. ON SUSTAINABILITY What is to be sustained? The elements of MedicareThe elements of Medicare The essence of MedicareThe essence of Medicare What is meant by sustainability? Affordability - EconomicAffordability - Economic Acceptability - PoliticalAcceptability - Political

8. THE POLITICAL ECONOMY OF SUSTAINABILITY The debate over health care … is less a pure macroeconomic issue than an exercise in the political economy of sharing (Rheinhardt et al., 2004) (Rheinhardt et al., 2004) It is about differing views on the correctness of who pays, how much and for what benefit

9. THE CANADIAN HEALTH CARE SYSTEM Not one, but 13 provincial single-payer systemsNot one, but 13 provincial single-payer systems Federal – Provincial cost sharing governed by the Canada Health ActFederal – Provincial cost sharing governed by the Canada Health Act The Five Pillars of Medicare –Comprehensiveness ( all medically necessary services) –Universality –Public administration –Portability –Accessibility

10. THE CANADIAN HEALTH CARE SYSTEM 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 fees Provincial laws effectively ban parallel private health care

11. THE CASE AGAINST ECONOMIC SUSTAINABILITY TOTAL HEALTH SPENDING (per capita) CIHI, 2006

13. THE CASE FOR ECONOMIC SUSTAINABILITY TOTAL HEALTH SPENDING: % GDP (CIHI, 2006)

14. THE CASE FOR ECONOMIC SUSTAINABILITY TOTAL HEALTH SPENDING: % GDP (CIHI, 2006)

15. A SLIGHT COMPLICATION … RISING SHARE OF GDP SOURCE: CIHI Health Expenditure Trends, 2006

17. WHERE WERE AT Medicare is economically sustainable Medicare is economically sustainable Is it politically acceptable? Is it politically acceptable? –Political wolves knocking at the door (Evans) –The challenge from within

18. CHANGING HEALTH TECHNOLOGY AND CREEPING PRIVATISATION SOURCE: CIHI Health Expenditure Trends, 2006

19. PROBLEMS ACCESSING SERVICES AustraliaCanadaUKUSA Problems with waiting times 17%24%21%14% Difficulty seeing specialist 41%53%38%39% Long waits to be admitted to hospital 19%32%21%13% Source: Commonwealth Fund, International Health Policy Survey, 2001

20. ACCESS PROBLEMS DUE TO COST 1,2 AustraliaCanadaUKUSA Did not get medical service 16%9%4%28% Skipped test or treatment 16%10%5%26% Failed to fill script 23%19%10%35% Did not get dental service 44%35%21%40% (1) Among adults with a health problem (2) Source: Commonwealth Fund, International Health Policy Survey, 2001

21. Did not get a recommended test or treatment due to its cost – by income AustraliaCanadaUKUSA Above average income 14%4%2%14% Below average income 17%9%4%36% Source: Commonwealth Fund, International Health Policy Survey, 2001

22. THE REAL CHALLENGE: CHASING AN INCONSISTENT TRIAD Comprehensive coverage Comprehensive coverage Universal and equal access free at point of care Universal and equal access free at point of care High quality (timely, responsive, effective) care High quality (timely, responsive, effective) care Constrained by our willingness to pay Constrained by our willingness to pay SOURCE: Weale, BMJ 1998

23. DEALING WITH THE INCONSISTENCY Medicare – promotes universality at the expense of quality Medicare – promotes universality at the expense of quality Parallel private insurance – promotes quality at the expense of universality Parallel private insurance – promotes quality at the expense of universality Restricting Medicare to core services – promotes quality at the expense of comprehensiveness Restricting Medicare to core services – promotes quality at the expense of comprehensiveness Social insurance – does nothing to address the problem Social insurance – does nothing to address the problem

24. THE CHALLENGE WITHIN Changing health technology is leading to creeping privatisation, which is undermining comprehensiveness Changing health technology is leading to creeping privatisation, which is undermining comprehensiveness Problems with access are experienced more by lower SES, which is contrary to universality Problems with access are experienced more by lower SES, which is contrary to universality Political failure to address these will undermine support for Medicare and its long term political sustainability Political failure to address these will undermine support for Medicare and its long term political sustainability

26. Above average income Below average income Australia24%36% Canada19%26% UK12%16% USA26%43% Respondents who believe their health care system should be completely rebuilt SOURCE: Commonwealth Fund, International Health Policy Survey 2001

27. Equity and Physician Visits: Probability of Consultation Source: van Doorslaer et al, CMAJ, 2006

28. WHO rankCountryMain Funding SourceSpend per capita 1FranceSI2,077 2ItalyTax1,783 10JapanSI1,822 12PortugalTax1,237 17NetherlandsSI/VI2,070 18UKTax1,461 20SwitzerlandVI2,794 23SwedenTax1,746 25GermanySI2,424 30CanadaTax2,312 32AustraliaTax/VI2,043 37USAVI4,178 FUNDING SOURCE AND WHO RANKING

29. SATISFACTION WITH HEALTH CARE SYSTEM Very Satisfied Fairly Satisfied Total Satisfied Method of Funding Denmark54.235.890.0Tax Finland15.171.386.4Tax Netherlands14.258.672.8SI/VI Luxembourg13.657.571.1SI Belgium10.959.270.1SI Sweden13.154.267.3Tax Germany12.853.266.0SI France10.055.165.1SI UK7.640.548.1Tax Portugal0.819.119.9Tax Italy0.815.516.3Tax