HEALTH POLICY IN CANADA Evette Bisard, BSN, RN Jamie McGuire, BSN, RN Neeta Monteiro, BSN, RN Wright State University April 23, 2012

Canada Geographically larger than the United States Smaller in population Settled by the French and English 1867 Provincial and territorial boundaries, government model a result of the British North America (BNA) Act BNA Act relinquished responsibility for governance of health and education to the provinces and territories Universal coverage for medically necessary health care services provided on the basis of need, rather than the ability to pay

History of Canadian Health Care System Canadian Constitution Constitutional Act, 1867 Provinces responsible for maintaining and managing Hospitals, asylums, charities and charitable institutions Federal Government Tax, borrow, spend, without infringing on provincial powers

History of Canadian Health Care System (cont.) 1867-1919 Department of Agriculture 1919 Creation of Department of Health Pre-World War II Canadian health care Privately funded Privately delivered

History of Canadian Health Care System (cont.) Introduced province-wide, universal hospital care plan 1947 – Saskatchewan 1950 – British Columbia and Alberta 1957 – Hospital Insurance Diagnostic Services Act Provided for publicly administered universal coverage for a specific set of services, uniform conditions and terms 4 years later – all provinces and territories

History of Canadian Health Care System (cont.) 1962 – Saskatchewan Universal provincial medical insurance plan to provide physicians’ services to all its residents 1966 – Medical Care Act 1972 - All provinces and territories had universal physician services insurance

History of Canadian Health Care System (cont.) 1977 – Federal Provincial Fiscal Arrangements and Established Programs Financing Act Block fund – money provided from one level of government to another for an identified purpose More flexibility 1984 – Canada Health Act Federal legislation – established criteria on portability, accessibility, universality, comprehensiveness and public administration 1995-1997 – Canada Health and Social Transfer (CHST)

History of Canadian Health Care System (cont.) 2000 – 2003 Accord on Health Care Renewal Agreement reached by federal, provincial and territorial government leaders that committed governments to work toward targeted reforms Accelerated primary health care renewal Information technology (EHR, telehealth) Home care services Drugs Enhanced access to diagnostic and medical equipment Better accountability from governments Increased cash transfers in support of health

History of Canadian Health Care System (cont.) 2004 – CHST now split Canada Health Transfer for Health Canada Social Transfer for post-secondary education, social services and social assistance 10 Year Plan to Strengthen Care Supported by federal governments increased health care cash transfers 2007 – Patient Wait Times Guarantee Offers alternative care options Starting in one priority clinical area by 2010 Undertaking pilot projects to test guarantees and inform of their implementation

Comparing to US Health History Prior to 1800 – medicine in US was “family affair”, midwifery (women), home remedies 1765 University of Pennsylvania – 1st medical college Mid-1800’s – hospitals, first built by city governments to treat the poor began to treat the not-so-poor. Patients who could pay were treated in private rooms 1846 American Medical Association 1865 – post Civil War, hospitals became either public or private, nursing became professionalized with the establishment of training schools for nurses 1899 American Hospital Association founded, employers began offering benefits, including paid medical care. National health insurance, such as provided by many European nations, became associated with socialism and the concept became unpopular in the United States, opening the door for private health insurance to cover the rising cost of medical care End of 1920’s – 1st large medical insurance company was established, Blue Cross 1930’s – Doctors paid by fee-for-service, new insurance plans – Blue Cross and Blue Shield. During this time, a medical plan started by Henry J. Kaiser for his employees featured pre-paid program. Paved the way for Health Maintenance Organizations (HMO’s) 1940’s – establishment of the Centers for Disease Control and Prevention 1960’s – initiation of social programs to aid the medical care of the aged (Medicare) and the poor (Medicaid) 2000’s – The Medicare Prescription Drug Improvement and Modernization Act of 2003; the Affordable Care Act was signed into law, putting in place comprehensive U.S. health insurance reforms

Health Care Service Delivery Canada has a universal health care system. Canada’s publicly funded health care system is best described as an interlocking set of ten provincial and three territorial health insurance plans. Known to Canadians as “Medicare”, which provides universal coverage for medically necessary health care services provided on the basis of need, rather than the ability to pay.

Social Organization The organization ‘Canada’s Health Care System’ is largely determined by the Canadian Constitution. Roles and responsibilities for delivering health and social services are divided between the federal, and provincial and territorial governments. Publicly funded health care is financed with general revenue raised through federal, provincial and territorial taxation.

The Federal Government The federal government’s role in health care: * Setting and administering national principles for the system under the Canada Health Act * Financial support to the provinces and territories * Delivery of primary and supplementary services * Health protection and regulation, consumer safety, and disease surveillance and prevention. The Canada Health Act * Objective is to protect, promote and restore the physical & mental well-being of residents of Canada and to facilitate reasonable access to health services without financial barriers

The Canada Health Act The Canada Health Act * Objective is to protect, promote and restore the physical & mental well-being of Canadians * Facilitate reasonable access to health services without financial barriers *Establishes criteria and conditions for health insurance plans that must be met by provinces and territories to receive federal funds. *Discourages extra-billing and user fee.

The Provincial and Territorial Government The provinces and territories administer and deliver most of Canada’s health care services. Administer health insurance plans that meet principles set by the Canada Health Act. (Public administration, comprehensiveness, universality, accessibility, portability). Covers medically necessary services. Plan and fund care in hospitals and other health care facilities by doctors and other health professionals Planning and implementation of health promotion Negotiation of fee schedules with health professionals.

Health Care Service Delivery A health card is issued by the provincial ministry of health to each individual who enrolls in the program and everyone receives the same level of care. Depending on the province dental and vision may not be covered but are often insured by employers through private companies (private insurance). Cosmetic surgeries are generally not covered. These can be paid out-of-pocket or through private insurance. Family physicians are chosen by individuals in their province. If specialist care is needed the physician can make a referral.

Health Care Service Delivery What Happens First (Primary Health Care Services) What Happens Next (Secondary Services) Additional (Supplementary) Services Trends/Changes in Health Care

Health Care Service Delivery Primary Health Care Services First point of contact Serves a dual function 1. Provides first-contact health care services 2. Coordinates services to ensure continuity of care and more specialized service such as referral to specialists, nurse practitioners, and palliative and end-of-life care. Most doctors work in independent or group practices, and are not employed by the government. Doctors are paid through fee-for-service that is negotiated between provincial and territorial government.

Secondary Service After primary contact a patient may be referred for specialized care at a hospital, at a long-term care facility or in the community. Hospitals are operated by boards of trustees, voluntary organizations or regional authorities established by provincial/territorial government. Hospital reimbursement is mainly by global funding. Home care and long term care facilities services are paid for by the provinces and territories; room and board cost for long term care is paid by the individual. Palliative care is delivered in hospitals, long-term care facilities, hospices, community and at home.

Supplementary Services The provinces and territories provide coverage to certain people (seniors, children and low income residents) for services that are not generally covered by the publicly funded health care system. Supplementary health benefits include prescription drugs outside hospitals, dental care, vision care, medical equipment and appliances (prosthesis, wheelchairs, etc.), and the services of other health professionals such as physiotherapists. The level of coverage varies across the country. Those who do not qualify for supplementary benefits pay for these services through out-of pocket payments or through private insurance plans. Many Canadians, either through their employers or on their own, are covered by private health insurance and the level of coverage provided varies according to the plan purchased.

Trends/Changes in Health Care Challenges in the health care delivery due to *Changes in the way services are delivered *Financial constraints *Aging of the baby boom generation *High cost of new technology There is a greater emphasis on public health and health promotion. Medical advances have led to more procedures being done on an out-patient basis, and to a rise in the number of day surgeries. Decentralizing decision making to the regional or local board level to control cost and improve delivery. Service delivery change- that is reliance on hospitals and doctors to alternative care delivery in clinics, primary health care centers, community health centers and home care.

Challenges in Health Care Wait Times Reduction * Training and hiring more health care professionals * Clearing backlogs of patients requiring treatment * Building capacity for regional centers of excellence * Expanding ambulatory and community care programs * Developing and implementing tools to better manage wait times. Patient Safety: Avoiding medical errors or adverse events to improve patient safety and quality of care.

Changes in Health Care Primary care: Due to the changes in care delivery there is more focus on increasing the number of primary health care centers, primary health teams, promoting health, preventing illness and injury and managing chronic diseases; increasing coordination and integration of comprehensive health services; and improving the work environments of primary health care providers. eHealth: Electronic health records and telehealth- improve access to services, patient safety, quality of care, and productivity.

Comparing with the US Health care in the US is provided by many separate legal entities.  Health care facilities are largely owned and operated by the private sector. Private and employer sponsored insurance is the primary source of insurance in the US covering more than 60% of Americans. (lose job  lose health insurance). Canadian Health care is not affected by job status. < 9% purchase individual health insurance The government accounts for nearly 46% (Medicare, Medicaid, TRICARE the Children's Health Insurance Program, and the VA. 16.7% of the population were uninsured in 2009. More money per person is spent on health care in the USA than in any other nation in the world.

Health Care Funding Canada's health care system is a group of socialized health insurance plans that provides coverage to all Canadian citizens. It is publicly funded and administered on a provincial or territorial basis, within guidelines set by the federal government. * Funded at both the provincial and federal levels * Financing of health care is provided via taxation both from personal and corporate income taxes * Additional funds from other financial sources like sales tax and lottery proceeds are also used by some provinces

Health Care Funding Continued While the health care system in Canada covers basic services, including primary care physicians and hospitals, there are many services that are not covered. These include things like dental services, optometrists, and prescription medications. Alberta, British Columbia, and Ontario also charge health premiums to supplement health funding, but such premiums are not required for health coverage as per the Canada Health Act. At a federal level, funds are allocated to provinces and territories via the Canadian Health and Social Transfer (CHST). Transfer payments are made as a combination of tax transfers and cash contributions.

Health Expenditure by Funding Source, Canada, 2010

Where Does all the Money Go?

Health Care and the Economy Canada's health care has a large impact on the Canadian economy. Here are a few facts and figures about the economy and health care: * Health care expenditures in Canada topped $100 billion in 2001. * Approximately 9.5% of Canada's gross domestic product is spent on health care. In comparison, the United States spends close to 14% of its GDP on health care. * Individually, Canadians spend about $3300 per capita on health care. * At a provincial level, funding is between one-third and one-half of what provinces spend on social programs. * About three-quarters of all funding comes from public sources, with the remainder from private sources such as businesses and private insurance.

Government Spending Health Research and Promotion In 2010, the Government of Canada provided an estimated $6.7 billion for health research, health promotion and health protection, and for health services to populations excluded from the CHA, First Nations and Inuit, veterans, persons detained for immigration purposes, and refugees and refugee claimants. Specifically, to advance the development of research, the Government of Canada funds organizations like the Canadian Institutes of Health Research (CIHR). Finally, as a leader in health care renewal, the Government of Canada funds independent organizations that support health-related knowledge development and dissemination, such as CIHI, the Health Council of Canada, the Mental Health Commission of Canada, the Canadian Patient Safety Institute, and the Canadian Agency for Drugs and Technologies in Health.

Prioritize Government Funding The Government of Canada makes direct investments to address health care priorities. For example, in support of governments' shared commitments to reduce wait times, as set out in the 2004 10-Year Plan to Strengthen Health Care, the federal government is providing provinces and territories with $5.5 billion over ten years (from 2004-05 to 2013-14) through the Wait Times Reduction Fund. Complementing this investment, the federal government also provided jurisdictions with $612 million (from 2007-08 to 2009-10) through the Patient Wait Times Guarantee Trust, as part of over $1 billion in new funding to support the development of guarantees in select areas. Similarly, Budget 2009 provided $500 million in additional funding to Canada Health Infoway to encourage greater use of electronic health records.

Reported Out of Pocket Prescription Spending By percentage of after-tax income

U.S. Healthcare Financing The U.S. government uses money generated from taxes to reimburse providers who take care of patients enrolled in Medicare, Medicaid, SCHIP or VA. There is also a tax subsidy of employer-based insurance. The government accounts for nearly 46 percent of the total health spending in the country. Businesses that provide employer-based insurance pay all or most of the premium and employees pay the remainder. Patients pay a direct co-payment to the provider, and cost-sharing provisions vary by type of insurance. Self-employed or those who purchase private insurance on their own must pay premiums themselves.

Life Expectancy in Canada

Leading Causes of Death in Canada Cardiovascular diseases (CVD) are the most significant cause of death in Canada, accounting for about one third of all deaths They include, among others, acute myocardial infarction (AMI) and stroke Mortality rates for AMI and stroke have been declining for decades Mortality rates for both ischemic heart disease and cerebrovascular diseases were higher for Registered Indians than for Non-Aboriginals Ischemic heart disease mortality rates were not found to be different for residents of Inuit regions and Canadians overall Cerebrovascular disease mortality rates are higher for residents of Inuit regions compared to Canada overall

Leading Causes of Death in the US Heart disease: 599,413 Cancer: 567,628 Chronic lower respiratory diseases: 137,353 Stroke (cerebrovascular diseases): 128,842 Accidents (unintentional injuries): 118,021 Alzheimer's disease: 79,003 Diabetes: 68,705 Influenza and Pneumonia: 53,692 Nephritis, nephrotic syndrome, and nephrosis: 48,935 Intentional self-harm (suicide): 36,909

Canada vs. U.S. Population Health Status United States Total population 33,316,000 304,177,000 Life expectancy at birth (years) 80.7 78.0 Overweight and obese aged 15 and over 60 68 Infant Mortality per 1000 5.1 6.5 Per Capita Spending (2006) $3673 $6719 Note: Many will argue that utilizing vital statistics in comparisons of countries and regions is unreliable given the vast differences in population race and genetic dispositions.

Problems With Canadian Healthcare

References Canada Department of Health. (2012). Health Canada. Retrieved April 17, 2012, from http://www.hc-sc.gc.ca/index-eng.php Canadian Health Care (2012). Health care funding. Retrieved April 17, 2012, from http://www.canadian-healthcare.org/page8.html Canadian Institute for Health Information. (2011). Canada’s health care system. Retrieved April 17, 2012, from http://www.hc-sc.gc.ca/hcs-sss/pubs/system-regime/2011-hcs-sss/index-eng.php Centers for Disease Control and Prevention. (2009). Leading causes of death. Retrieved April 17, 2012, from http://www.cdc.gov/nchs/fastats/lcod.htm Fillmore, R. (2009). The evolution of the U.S. healthcare system. Retrieved from http://www.sciencescribe.net/articles/The_Evolution_of_the_U.S._Healthcare_System.pdf

References Henry Kaiser Foundation (2012). Health policy explained. Retrieved April 17,2012, from http://www.kaiseredu.org/Topics.aspx Organization for Economic Co-operation and Development. (2011). Country statistical profiles: Key tables from OECD. doi: 10.1787/csp-can-table-2011-1-en Suarez, R. (2009). Comparing international health care systems retrieved from http://www.pbs.org/newshour/globalhealth/july-dec09/insurance_1006.html U.S. Department of Health and Human Services (2001). Achievements in public health, 1900-1999: Changes in the public health system. Retrieved April 17, 2012, from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4850a1.htm US Department of Health and Human Services (n.d.). Historical highlights. Retrieved April 17, 2012, from http://www.hhs.gov/about/hhshist.html