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The term medicare (in lowercase) (French: assurance-maladie) is the unofficial name for Canada's universal public health insurance system. Under the terms of the Canada Health Act, the provinces provide all residents with health insurance cards, which entitle the bearer to receive free medical care for almost all procedures. Patients are free to choose their own doctor, hospital, etc. Health institutions are either private and not-for-profit (such as university hospitals) or state-run (such as Quebec's CLSC system). Doctors in private practice are entrepreneurs who bill the medicare system for their fees.
Services coveredWhile basic care from a doctor or a hospital is covered by the state to a greater degree than any other country in the world (except some ex-Soviet countries, such as Russia), Canada compensates by having one of the most limited public health systems. Dental care is still almost wholly private, drugs are only partially covered, optometry is only partially covered and only in certain provinces. As a result the fraction of health spending that is covered by the government is lower in Canada than the average for a developed country. There is also an increasing trend toward delisting services that medicare covers. For example ten years ago having vision checked was covered as needed in Ontario. Several years ago the Ontario government put a limit on tests of vision every two years. In 2004 the government delisted vision tests. It is still possible to have coverage to see an eye doctor in certain cases and if you were seeing an eye doctor the medical care would often include vision tests, but a patient would need to be referred by their family physician to a specialist (usually due to medical needs other than vision tests). The specialist then makes the decision on how often the patient should see them. However even when exceptions like this exist they are not well known. As a result it is often the more advantaged who manage to find their way through the system for coverage that is limited in these sorts of ways. Access can also depend on how much the referring doctor knows about the medicare system (for example that in some cases ophthalmology is covered in Ontario). Opinions on medicareMost Canadians highly value their medicare program. Polling data in the last few years have consistently cited it as the most important political issue in the minds of Canadian voters. Along with peacekeeping and the CBC a poll found medicare to be one the most defining characteristics of Canada. It has increasingly become a source of controversy in Canadian politics, mostly due to the common perception that the quality of care provided has been decreasing, particularly throughout the past two decades. Commonly referenced problems include: limited access to diagnostic equipment (such as MRIs and CT Scanners), lengthy wait times for surgeries and serious physician shortages, which are particularly prevalent for General Practitioners(GP)/Family Doctors. In some parts of the country waiting times to acquire a GP have been quoted at several years. Some Canadians are also sent to the United States for treatment. As a result some right-wing political figures and think tanks have proposed removing barriers to the existence of a parallel private health care system. Though polling suggests support for such reforms has been increasing, it has yet to be adopted as official policy by any of the main federal political parties. While complaints of a steadily worsening system are common, statistical data is mixed on the issue. Polling data often simultaneously reports support for maintaining the status quo, and allowing privatization reforms. A common concern is to see solid, visible, results from funding changes such as reduced waiting periods. Canadians are generally wary that increases in taxes or increased spending will now acrually affect real change. Canadians may not get the same very high standard of care that a privately-insured US citizen would get, however many are aware that Canadian citizens are by far better covered than an American without any private health insurance. The system is much more affordable for certain items such as on patented drugs and this difference in price has created a large prescription drug exporting industry in Canada. Older medicines that are off patent tend to be somewhat more expensive due to less competition as entry into the Canadian market suffers from government barriers. The Canadian governments spend the same amount per capita on health care as the United States governments, but almost every Canadian citizen is fully covered. In the United States there are large percentages of the population who are uncovered or only marginally covered, despite equally proportional spending along with large private investment. Even more are just a job loss away from not having coverage (although in most cases the employer must maintain health care with copayment of the patient for a period of time after employment in the United States.) In Canada the waiting lists for some procedures and treatments can be very long. Tests such as MRI can have waiting lists that are months long, and procedures such as hip replacement can have waits that can be up to two years. Unlike other industrialized countries, in Canada citizens with money cannot by law pay for quicker service in a private clinic or hospital and must wait with everyone else. Though some, who can afford the cost, elect to have tests and occasionally procedures performed at private health care facilities in other countries, usually in the United States. Proposed reformsThough most Canadian politicians and citizens acknowledge that there are some problems with the system, the proposed solutions often spark passionate debate. On one hand there are those who believe that the problem is simply one of under funding. They point to the rise of neo-conservative economic policies in Canada, and the associated reduction in welfare state expenditure (particularly in the provinces) from the 1980s onwards as the cause of degradation in the system. However, it is commonly estimated that costs associated with the medicare system have still been creeping upwards as a percent of total government expenditures. Again, many critics argue that neo-conservative governments merely made huge cuts to other programs as a reason for health care creeping to high percentages of government spending. The increasing costs are also directly linked to Canada's ageing population. On the other hand, there are those who argue that the system in its current form is financially unsustainable. They suggest that the rising cost of medical technology, infrastructure and wages are partly to blame. Canada's proximity to the United States is also cited as a serious problem, on account of the infamous "Brain Drain" - a phenomenon which describes the migration of Canadian-trained doctors and nurses (as well as other professionals) to the United States, where private hospitals can pay much higher wages and income tax rates are lower. There are other proposed reforms that come from the populist left and centre wings and also those with a special interest in health care. While right wing reforms often get more attention, there is a grass roots movement to try and keep medicare public in Canada and to avoid privatization. This is usually presented as a value the separates Canadians from Americans by mandating equality and fairness in health care. Since the early 1990s Ontario, as with other provinces, has worked at trying to reduce health care costs. Some examples of ways that costs were reduced or could be reduced follow. None of these systems are forced on patients at the moment, but they attempt help to make the system more financially sustainable. This makes them substantially different from Health Maintenance Organizations (commonly referred to as HMOs in the US) and other somewhat similar looking attempts by the United States to reduce health care costs, which appear to have reduced the average patient's access to medical care. Therefore they have been better accepted by the public. User premiumsCurrently in Ontario, people with a high enough income must pay an annual health care premium. It can range from $300-$800, depending on one's annual income. This payment is charged for those having salary above CN$38,000. Funding for medicare in Ontario also comes from a dedicated employer tax that ranges from 0.98%-1.95% of employer profit over $200,000. Premiums are not new in Ontario however. They existed into the 1980's at which point they were replaced by the employer tax. Premiums also exist in British Columbia and Alberta, though as Alberta approaches debt-free status, there has been talk of removing them. Medical clinicsProposals to reduce costs have been varied. There is a movement in Ontario to try and expand 24-hour drop-in medical clinic network. This would mean that if someone were ill, no matter what the time of day, they would be able to see a doctor without going to a hospital. As many evening hospital visits are because there is no available medical service for problems that cannot wait until morning, it is likely that this would reduce costs considerably. A registration at a hospital costs at least $250, while a visit to a doctor is often less than $30 for a general doctor. It has been proposed that doctors working late hours would get paid more per visit as an incentive. Still, the savings quickly become clear. This development parallels the more well established US "urgent care" system of private clinics that compete with hospitals for simple medical emergencies. Alternatives to fee-for-serviceThere is also a movement to try and move the system away from bill for service. The Ontario government in the early 1990's helped develop many community health care centres which provide both medical and social support. The emphasis is on medical care but the over-all approach is holistic. Collective kitchens, Internet access, anti-poverty groups and groups to help people quit smoking are common and funded in various ways. While funding has decreased for these centres, and they have had to cut back, they have been quite cost effective. They are often located in low income areas. If it is possible to reduce illness before it reaches a hospital a lot of money can be saved, although it is often hard to estimate how much and thus it is easier to cut these programs. Many of these centres are filled to capacity in terms of general doctors, and there are often fairly long waiting lists, although drop in health care is provided, often for those who have no other doctor. The centres also make use of nurse practitioners, who reduce the workload on the doctors and increase efficiency. MidwivesOntario has also recently licensed midwives and is teaching a new generation how to provide the help necessary for pregnant mothers. While midwifery cannot always take the place of a doctor, it can still reduce costs. If the mother wishes it and the birth appears uncomplicated, a hospital need not be involved. However, hospitals are now introducing birthing areas which contain their own suite, often with a hot tub (which is good for relieving pain without medication). These births often cost much less than the traditional manner of birth but are close to hospital facilities in case the need emerges. There have been occasional problems but overall the system has worked quite effectively. PrivatizationIn recent years some on the political right-wing have called for an increased role for the private sector in the delivery of hospital medicare services. Currently, privately owned and operated hospitals that allow patients to pay out-of-pocket for services cannot obtain public funding in Canada, as they contravene the "equal accessibility" tenets of the Canada Health Act. Many believe that direct advocacy for allowing a tandem private system would be met with public hostility. This has gradually changed with the continuing problems with the health care system. Some have suggested relaxation of the rules of the Act to allow such private facilities to open and operate in tandem with the publicly funded system. It is argued that this would lessen the burden on the publicly funded system as many users would simply choose to pay out-of-pocket or through private insurers for services rather than rely on the public system. However, such proposals are still controversial. As a compromise, some provincial governments have experimented with the concept of "public-private partnerships" (P3 Projects) or the contracting out of health services to private providers, whose services are paid for out of the public purse. In a P3 project situation, a private company is granted licence to build a hospital, or other facility, and to manage maintenance and infrastructure services upon its completion. However, all health services in the facility continue to be paid for and administered solely by the public system. Advocates for P3 projects in Canada often cite the successful implementation of such facilities in the National Health Service (NHS) of the United Kingdom. A significant report by the UK National Audit Committee released in early 2003 reported much success with the P3 system. However the P3 system is itself still very controversial in the UK. In the Canadian province of Ontario, the government signed deals for the construction of several P3 facilities, including one for the William Osler Hospital in Brampton and the Royal Ottawa Hospital. However, the defeat of the Progressive Conservative government of Ernie Eves in Ontario on October 2, 2003 placed the status of these projects in jeopardy, as the newly elected Liberal premier, Dalton McGuinty, had campaigned against the use of P3 hospitals. Due to the decentralized nature of the Canadian federation, the degree of privatization varies from province to province. Barriers to foreign trained practitionersOne of the main issues regarding medicare is the resistance offered by the Canadian health system to foreign trained doctors called IMGs (international medical graduates). This is the opposite of what is happening in the US which is absorbing doctors from all over the world. In practice, little has been done to solve this issue all across Canada. Many professions in Canada place barriers for entry by foreign trained people. This is done for a variety of reason, being the perceived lack of skill from the foreign professions or job protection to create an artificial scarcity of personnel in a field to keep the wages high. Provincial insurance plansThough the Canada Health Act provides national guidelines for healthcare, the provinces have exclusive jurisdiction over health under the constitution and are free to ignore these guidelines. The counterbalance to this is that the federal government requires provinces to adhere to their guidelines in order to received federal funding for healthcare. All provinces currently abide by the Canada Health Act in order to receive this funding, however Alberta has often mused about ignoring the Act should their planned health reforms require them to do so. The federal government has no direct role in the delivery of medicine in the provinces so each province has its own independent public health insurance program. Under the Canada Health Act, each province must provide services to members of plans in other provinces. List of provincial programs
See alsoExternal links
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