1. 1 A SINGLE PAYER, UNIVERSAL HEALTH SYSTEM The Canadian Model in light of new U.S. Proposals Gregory P. Marchildon Pierre-Gerlier Forest Woodrow Wilson International Center for Scholars Washington, DC, September 23, 2003

2. 2 THE CANADIAN MODEL Does one exist? If so, can we describe its unique and/or essential components? How much of Canadian health care actually within the model? How did we end up with this particular model?

3. 3 EXISTENCE OF MODEL? Goes beyond having unique system of public health care (after all, every OECD country does!) Having aspects that are of sufficient interest to others Canada recognized by others as having a model worth examining and (in some cases) emulating

4. 4 MODEL: COMPARISON OF OUTCOMES AND SERVICE Generally good health outcomes Public and Population Health Nature of Health Services Services provided Training of providers Expectations of patients

5. 5 FOUR ESSENTIAL COMPONENTS OF MODEL Hospital care Primary physician care Provincial-federal tax-financed system Provincial control and administration, private and mixed delivery, and federal principles

6. 6 HOSPITAL CARE Hospitalization introduced in SK in 1947 HIDSA (1957) and national implementation (1958-61) Universal access without user fee Public and NFP delivery unaffected Hospital Construction = more beds

7. 7 PRIMARY PHYSICIAN CARE 1962: Saskatoon Compromise Guarantee of provincial autonomy Basket of services and remuneration: medical associations and provincial governments MCA of 1966 and implementation on national basis (1968-72) Universal access with limited (but eventually no) user fees Private FFS delivery within provincial plans and federal principles

8. 8 F/P TAX FINANCED SYSTEM Versus social insurance and co-pays Tax revenues (GRF) of both orders of government Complex history of F/P funding arrangements: a) shared-cost; b) EPF cash/tax; c) CHST block Progressive financing depends on tax sources and incidence

9. 9 FEDERAL PRINCIPLES AND FRAMEWORK FOR SYSTEM Nature of HIDSA and bilateral agreements Broad principles of MCA Severing of funding from policy objectives (EPF) The Canada Health Act (CHA), 1984 Long-term decline in federal funding Sept. 2000 Agreement and Feb. 2003 Accord

10. 10 PROVINCIAL CONTROL AND ADMINISTRATION Constitutional authority and responsibility primarily provincial Developed provincially since 1945 Innovation and variation across provinces Provincial Studies, Reports, and Current Initiatives

11. 11 PUBLIC, PRIVATE AND MIXED DELIVERY Predominantly non-governmental Historic evolution of hospitals Physician “ Entrepreneurs ” Emergence of RHAs Big business (PFP & NFP) largely absent from acute & primary care

12. 12 CHARACTERISTICS OF CANADIAN MODEL Narrow but deep coverage (complete coverage for 42% of all health services Parallel private tier prohibited or discouraged (private insurance for CHA- covered services) But enormous variation in funding, administration and delivery of non- insured services including prescription drugs, vision care, dental care, etc.

13. 13 WHAT HEALTH SPENDING INCLUDED IN MODEL Traditional hospital services and primary care services: 42.4% Provincial plans provide non-CHA services beyond this: 25.2% Private health services: 27.4% Add in another 5% for direct federal services

14. 14 CURRENT CHALLENGES TO CANADIAN MODEL Universal versus targeted access (cost) Single-payer administrative system (competition) Prohibition on user fees for CHA services (incentive effects) Legislated single-tier Declining tolerance for variation within Canada and with US: quality, access, and equity

15. 15 GENERAL CHALLENGES TO CANADIAN HEALTH CARE Timely access (waiting lists) Quality services and evidence-based practice Movement away from hospital care Nature and quality of primary care Drug therapies: appropriateness and cost Providers: number, morale, etc. Patient involvement v. citizen engagement?

16. 16 CHALLENGES re: CANADIAN AND U.S. MODELS Governance Finance Coverage/ethics Outcomes