The Health Care Debate in Canada: One Canadian Radiologist's View

Article Outline

• Government and the Canada Health Act
• The Profession
• The Public
• The Current System and the Future
• Acknowledgement
• References
• Copyright

Perception often is confused with fact. On each side of the Canadian–US border Canadians and Americans traditionally have held that each other's own style of health care provision is better than the other, just needing a few tweaks to get it perfect. Of late, the reality faced by both countries is that business as usual cannot be sustained, and that changes will be introduced either through research and discussion, or will be thrust upon us as the money runs out. There has been a noticeable upsurge in the interest of many US physicians in the Canadian model, fueled in part by the looming apprehension that the US system needs improvement. The alarming increase in the American debt as well as the other stressors on the health care system of which we are so well aware (aging population, expensive technologies, more informed and demanding population, inadequate care for the working poor, and so forth) warns of a brick wall up ahead. In addition, Michael Moore's recent movie Sicko has shocked those who care about the system by showing half truths: that the American system is callous, inefficient, profit driven, and unfair, while other systems including those of Canada, Britain, and France are sanctuaries of compassion, accessibility, affordability, and serene satisfaction for its citizens.

It is not within my knowledge or prerogative to comment on the limitations of the American health care system, except to acknowledge what we all know—that some of the finest medical institutions of higher learning and care in the world reside there. Nor am I in a position to speak with understanding of the systems in Great Britain or France.

I have practiced radiology for 28 years in Canada in 4 provinces, and before that was trained in Canadian medical schools and residency programs. I have been a patient within the Canadian system, and have ongoing interactions with the system at this level for myself and my family. Our system is good, but far from perfect. To discuss the Canadian System, I will break it into 4 separate discussion points: government and the Canada Health Act, the profession, the public, and the current system and its future.

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Government and the Canada Health Act 

Health care in Canada is administered by the provincial governments (this along with education and highways are assigned responsibilities of provincial governments by the British North America Act, now called the Constitution Act). Health care per se was not mentioned in the British North America Act but regulation of hospitals was, and the provincial governments seized the health care mandate. As part of our federal make-up, the federal government of Canada has an interest in promoting some uniformity and standards of health care across the country. This has created a certain tension between the federal and provincial governments regarding who makes the rules. Despite this, the provinces are bound by certain fiscal controls that ensure some federal government input into health care policy at the provincial level.

Canada's system of government health insurance (Medicare) has its roots in the Province of Saskatchewan, where in 1946 near-universal government-provided coverage was introduced by then premier Tommy Douglas and the Cooperative Commonwealth Federation (CCF) party (forerunner to the federal socialist leaning New Democratic Party of today). By 1961 all 10 provinces had agreed to a federal program that allowed the federal government to pay for 50% of all costs of hospital and diagnostic care. This gradually progressed to the adoption of the Canadian Medicare system, a universal health insurance plan, set up in all provinces by 1966. Medicare is essentially 13 separate systems operating in the provinces and territories, partially funded by the federal government. The Canada Health Act (CHA) followed in 1984.

The CHA has come to be synonymous with the Canadian Health Care system. “The principles of the Canada Health Act began as simple conditions attached to federal funding for Medicare. Over time, they became much more than that. Today, they represent both the values underlying the health care system and the conditions that governments attach to funding a national system of public health care. The principles have stood the test of time and continue to reflect the values of Canadians” [1]. Adherence to the principles of the CHA is necessary for each province to receive its full complement of funding from federal transfers. Of late, there is no longer earmarking of federal transfers for health care, and federal transfers are now part of the Canada Health and Social Transfer (a block amount of yearly federal transfer individualized to each province but not designated for any specific purpose such as health, education, or welfare), which forces the provincial governments to make priority decisions between health care, social programs, and education. This has weakened the federal influence over the way provinces provide health care, an argument being made that the federal promise of 50% earmarked support has been broken, but nevertheless there is always provincial apprehension of further federal funding cuts should the tenets of the CHA not be met to federal satisfaction.

The fundamental 5 principles of the CHA are as follows: public administration (government controlled), comprehensiveness (adequate menu of services), universality (everyone is covered), portability (a citizen can get services anywhere in Canada), and accessibility (there is much debate on what this really means). Specifically, the act guarantees provincial government-funded health care for all Canadian residents. A few exceptions include Native Canadians who are provided health care directly by the federal government.

Despite the concept that all health care is government provided, this is not actually the case. Approximately 30% of expenses are provided privately. These include adult dentistry, prescription drugs (except senior citizens), and optometry, as well as some services that are not listed such as certain cosmetic, ophthalmologic, and reproductive care items. In addition, there are a few private clinics in Canada that provide diagnostic and surgical services that appear to contravene the law, but for individualized reasons in each of these cases, the clinics have been allowed to function. Often the word private is misused and misunderstood in the rhetoric over health care. Most so-called private care in Canada is in fact publicly funded, but simply provided in a private facility, and thus not outside of the Medicare system.

Currently in Canada, every citizen receives almost all health care (with the exceptions listed earlier) by access through a single line, paid for entirely by one's provincial health care plan. This includes visits to the doctor, clinic, and hospital for most diagnostic and therapeutic services. It is illegal to seek these services outside of the public system, and generally it is considered unethical to attempt to jump places in the line by inside influence. In reality, some inside influence frequently is brought to bear. Friends of health care workers often get squeezed into booking schedules, as do hostile or intolerant squeaky wheels who refuse to wait in line with everyone else. But these represent a small minority of cases. Access to all services is allocated when possible by medical urgency, the most critical cases always waiting the least time by being fitted into urgent slots.

All physicians, including radiologists, are remunerated almost entirely by the provincial health care programs (minor exceptions such as workers compensation cases exist). I was offered a $100 bill (US) by an American patient for whom I came in late at night to perform an ultrasound examination some years ago. I remember being horrified at the prospect of actually accepting money for a medical service (and I refused to accept it). We have been taught that government will look after all remuneration behind the scenes, and the sight of money has no place in the ultrasound room.

Diagnostic imaging equipment mainly is hospital based, paid for by hospital global budgets, which ultimately come from the provincial government. Some provinces also permit independent health care facilities where imaging equipment such as computerized tomography (CT), magnetic resonance imaging (MRI), ultrasound, mammography, and computed radiography (CR) are paid for by radiologists, with costs recovered through technical fees paid back by the government on a per-case basis. Imaging equipment infrastructure recently was upgraded by a substantial earmarked federal transfer of funds to the provinces, and the number of MRI machines have been increased significantly throughout the country.

At the beginning of 2005, Canada had 176 MRI scanners, up from 157 in 2004 and 130 five years earlier. The number of CT scanners also grew, but not at the same pace as MRIs. The number of CT scanners installed as of January 2005 increased to 361, up from 346 the year before and 303 five years earlier. Compared with the 20 Organization for Economic Cooperation and Development (OECD) countries reporting MRI data for the latest year comparable data were available, Canada ranked 12th, reporting 5.5 MRI scanners per million people. Japan and the United States had the highest number, with 35.3 and 27.0 per million, respectively. The median was 6.7. Canada ranked 15th among the 21 OECD countries reporting data on CT scanners, with 11.3 per million population. Japan and the United States had the highest number again, at 92.6 and 32.0 per million, respectively. The median was 14.0 [2].

Canada's system is not classically socialized medicine because physicians are predominately not paid by salary (although this is slowly changing as more physicians every year are opting for alternatives to fee-for-service payment) and institutions providing health care are independent and largely not-for-profit organizations not owned by the government. An undercurrent of the issue of publicly funded health care, however, is that the costs of the system are borne by the highest wage earners in society through an aggressive system of progressive taxation. Unlike private insurance, therefore, there is no link between the cost borne and the consumption of the individual payer.

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The Profession 

Organized medicine in Canada has been of mixed and changeable opinion over the years in its leadership and official policy about the single-payer model. At the time of the institution of the CHA, the Canadian Medical Association (CMA) stood in opposition and for some time maintained a war chest of funds to fight the constitutionality of the CHA in court. The argument against the new system was the removal of the freedom of choice allowed to Canadian citizens to choose their health care, thereby forcing everyone into a single queue. In addition, it was seen to endanger physician autonomy by forcing physicians into a potentially compromised employee relationship with government, a position that many of us feared greatly. The CMA's position was discredited by its critics as a veiled strategy to allow physicians to impose entrepreneurial market forces on the backs of ill Canadians while neglecting those Canadians without the means to pay for their care. After a few years, and many a recurrent debate, the CMA capitulated, sensing on one hand the futility of fighting city hall and, on the other, the inescapable weight of public opinion that had moved to the view that the CHA was a Canadian value that was sacrosanct. Opposition to any aspect became seen as un-Canadian, or uncaring of society's disadvantaged.

The CMA therefore changed its approach in the early 1990s. Instead of pointing to the inadequacies that a single lineup for care created, it embraced the CHA, charging the government to make it work.

After years of calling for reduced waiting times for elective services, a recent president of the CMA, Dr Brian Day, heralded a stunning departure from the CMA's position of the past decade by once again introducing the concept of private (not paid for by the government) health care insurance as a supplement (not a replacement) to the Medicare system. He asserted that introducing this second tier to the system will help to eliminate unnecessary waiting times while preserving universal access to all Canadians, including those unable to pay. “No one wants to adopt a so called American-style health system…there are systems with universal coverage and no wait lists. They do deliver better care at less costs than here in Canada” [3]. This new approach seems to be a result of years of frustration that no solution to the waiting list problem has been forthcoming from government.

Physician morale has been a matter of concern, appearing after the 1998 CMA national survey as being at crisis levels with many expressing dissatisfaction with excessive workloads, decreasing incomes, and frustrating waiting lists. Canada's physician workforce is 25th of the 30 highest OECD countries (2.1 physicians/1,000 population). The Untied States is close to the mean (3 physicians/1000). Current data, including an estimate of a change in work habits of the new physician work force, suggest that there is a shortfall of as many as 12,000 physicians in Canada, whereas the United States is projected to have a shortfall of physicians of between 100,000 and 200,000 by 2020 [4]. There are approximately 2,000 radiologists in Canada, estimated to be approximately 500 short of optimal levels.

A pleasing aspect of practicing fee-for-service medicine in Canada is that there is no threat of demanding insurance companies, pay for performance reviews, or bad debts. At present there is no impending Deficit Reduction Act (DRA) or other looming measures to reduce physician remuneration. The CHA guarantees each physician in this country a fair remuneration for his/her services. (What is fair is of course always in the eye of the beholder.)

There has been a yearly net emigration of Canadian physicians to the United States, as high as 508 in 1994, but decreasing in later years to a low of 209 in 2002. The most often quoted reasons for physician dissatisfaction in Canada are taxation rates, government control, and rates of remuneration. The reason for the more recent decline in physician net emigration has not been identified. Canada is a sophisticated, cheerful, and stable country in which to practice and raise a family and it may be that more MDs are concluding that the grass is greener at home.

As a percentage of the national gross domestic product (GDP), Canada spent the same as the Untied States on health care in 1970 (7%), but our systems diverged considerably thereafter. We now spend 9.9% of the GDP on health care compared with 15.5% in the United States (2004). Those who argue in favour of our system say that our spending is in line with other countries, and indicates a good deal for Canadian patients, given that our life expectancy is higher than for those in the United States, which spends considerably more. (Life expectancy at birth for Canadian males born in 1997 was 75.8 years; for females born in 1997 it was 81.4 years. These numbers are up from 73.6 and 79.9 a decade earlier. This is one of the highest in the world.) This also is argued to point to the long-term sustainability of our system [5].

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The Public 

Contrary to the serene satisfaction of the Canadian patients interviewed by Michael Moore in Sicko, the Canadian public has been somewhat dissatisfied with the state of the Canadian Health Care system. On one hand, there seems to be a majority view that the single-payer model reflects Canadian values and, on the other, there is mounting frustration and alarm that the accessibility guaranteed by the CHA is not being met, and the definition of an accessible health care system is at the heart of the health care debate.

Over the past decade surveys have shown a sharp deterioration in satisfaction with the state of the Canadian health care system. Thus, although 56% of Canadian respondents to the 1989–1990 survey indicated that “The system works pretty well,” only 20% of respondents gave this response to a similar question in a 1998 survey. The proportion of respondents who indicated that “the system needs complete rebuilding” increased over the same period from 5% to 23%. A recent Canadian survey suggested that Canadians are still highly supportive of the fundamental principles on which the system was built, but are expressing growing concern about its ability to deliver when they need it [6].

It should be noted, however, that in a cross-border comparison of poll results from 2002, there was very little difference in the public perception of crisis in health care between the United States and Canada (67% for Canada, 63% for the United States) [7].

In a landmark decision by the Supreme Court of Canada in 2005, wherein a Quebec physician sued the provincial government for failing to provide adequate access to health care related to an elective orthopaedic procedure, the judgement stated in part: “The evidence in this case shows that delays in the public health care system are widespread, and that, in some serious cases, patients die as a result of waiting lists for public health care. The evidence also demonstrates that the prohibition against private health insurance and its consequence of denying people vital health care result in physical and psychological suffering that meets a threshold test of seriousness” [8].

Although the effects of this judgement were not precipitous, there has been a gradual drift towards the permission of some private health care insurance in some provinces, most obvious in the province of Alberta, which appears to be on the forefront of a move to a 2-tier model for health care. The debate is far from settled. There are those who strongly contend that the single-payer model must be retained at all costs, although there is an increasing reluctance of governments to punish those who pursue private models, for fear of rejection in the courts.

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The Current System and the Future 

Although it safely could be said that nobody in Canada wishes any weakening of the principles of universal and accessible access to health care, there is no doubt that there are problems with our system. Waiting times for elective diagnostic procedures (not uncommonly 2 months for CT, and much longer for MRI and endoscopy) become accepted reluctantly as a norm. Governments see such delays as a way of controlling utilisation and discouraging frivolous and inappropriate use. But patients also fall off long waiting lists as a result of recovery or death. Long waiting times in emergency rooms (for those with non–life-threatening problems), hospitals closed to nonemergency admissions because of a lack of beds, lack of availability of general practitioners, ridiculous waiting times to see specialists (18 months is not uncommon), and lack of nursing home availability underscore illnesses in the system. Thus, although our system is universal, its accessibility can be challenged. In my hospital, we could reduce the waiting times for CT and ultrasound, but we have insufficient funding for technical time to run the machines longer. Conversely, we believe that urgent care in Canada is as good as it is anywhere in the world, and is seldom examined as a source of public dissatisfaction.

It is not as though governments are not trying. Every province is spending a greater percentage of its annual budget on health care every year. Billions of new federal dollars have been injected into the system over the past decade to improve and increase diagnostic imaging equipment (largely as a result of the effective leadership of the Canadian Association of Radiologists at the federal level). More recently, the federal government has announced a Wait Times Guarantee project, injecting $612 million in a Wait Times Trust, as well as $400 million into health information technology, with a promise to fix unacceptable wait times in the key areas of cancer care, hip and knee replacement, cardiac care, diagnostic imaging, cataract surgeries, and primary care by 2010.

Essential to the debate on the future of our system is whether the Canadian public will be satisfied by government efforts to fix the system, while opposing alternatives such as a 2-tier parallel public/private system. Will slow and subtle passive privatization solve some of our problems of the future? Can a strong single-payer system be preserved despite the fact that provincial governments spend increasing percentages of their total budgets on health care? Is it just to deny the desire of some individuals to seek alternate lineups for health care provision? Is it appropriate that some of our citizens feel forced to seek care in the United States, India, or elsewhere rather than wait in a long line for service in their own country? Can health care wants be really separated from health care needs and thereby provided at different levels of accessibility by government? Why has no other country persisted successfully with a single-payer model? If a single-payer model is suitable for health care, and nutrition is arguably as important as health care, why do we not outlaw restaurants and legislate that all citizens eat at government-provided facilities that serve an equal level of cuisine for all Canadians? Are Canadian values so different from other countries that a fundamentally different approach is necessary? Or perhaps to the point, is our system the best we can design? Will the US model last? Or will both countries find that the most workable alternatives lie somewhere in between?

The debate is far from over. Changes are occurring almost daily, and the exact nature of our system in the future is not predictable. There is strong reason to believe that federal and provincial governments do not have a lasting solution, and that increasing wants/needs of the aging baby-boomer cohort will result in a significant tipping point in this debate within the next 5 years, although there are strong voices claiming that our current system is sustainable for years to come.

Interestingly, the press has noted a recent slight shift in public attention from health care to the environment, which could indicate either decreasing concern or issue fatigue. This was notable in the federal election campaign of 2008. In either case, it is unlikely that health care will ever be less than the first or second issue on the minds of Canadians and our governments for years to come. Our experiences and experimentation with alternative paths to health care should provide valuable lessons on both sides of the border.

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Acknowledgement 

The author would like to thank the American College of Radiology for granting this reprint.

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References 

1. Romanov R. Royal Commission Report on Health Care. Ottawa, 2002.
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2. Medical imaging in Canada. Canadian Institute for Health Information. 2005.
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3. Globe and Mail. August 23, 2007.
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4. Who has seen the winds of change. Canadian Medical Association; 2004.
   • View In Article
5. Dhalla I. Canada's health care system and the sustainability paradox. CMAJ. 2007;177:51–53
   • View In Article
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6. Evans R, Barer G. Health care in Canada, organization, financing, access. Presented at the Canada-Japan Social Policy Research Project; June 2001; Osaka, Japan.
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7. EnvironicsResearch Group. Presented by Maioni A at the Breakfast on the Hill Seminar 5. December 2002; Ottawa, Ontario.
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8. Supreme Court of Canada. Chaoulli v Quebec (Attorney General), 2005 SCC 35.
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