Hannah Hoch
The United States health care system differs greatly compared to other developed countries around the world. Most developed countries have universal healthcare with the government playing a dominant role. Canada’s approach to health care is unique in comparison to the United States health care system. Many critics of health care believe that the Canadian system of universal healthcare would be a good model for the U.S. to follow. Canada has a single-player, mostly publicly funded system in contrast to the U.S. who has a heavily private, multi-player system.
Canada’s constitution sets out the powers of the federal, provincial and territorial governments. Under the Constitution Act, 1867, the provinces were responsible for establishing, maintaining, and managing hospitals, asylums, charities, and charitable institutions. The federal government was given jurisdiction over marine hospitals and quarantine. They were also given powers to tax and borrow, and to spend such money as long as this did not infringe on provincial powers. The federal department of Agriculture covered federal health responsibilities from 1867 until 1919, when the department of Health was created. Before World War II, health care in Canada was mostly privately delivered and funded. In 1957, the federal government passed the Hospital Insurance and Diagnostic Services Act which provided publicly administered universal coverage for a specific set of services under uniform terms and conditions. In 1996 the Medical Care Act was passed which offered to reimburse, or cost share, half of the provincial and territorial costs for medical services provided by a doctor outside hospitals. Within six years, all provinces and territories had universal physician services insurance plans. In 1984, federal legislation, the Canada Health Act, was passed. This replaced the federal hospital and medical insurance acts, and merged their principles by establishing criteria on portability, accessibility, universality, comprehensiveness, and public administration. This Act also prohibited extra billing and user fees for insured services. In 2003, the first ministers agreed on the Accord on Health Care Renewal, which provided for structural change to the health care system to support access, quality and long-term sustainability. The Accord committed governments to work toward targeted reforms in areas such as accelerated primary health care renewal; supporting information technology (e.g., electronic health records, telehealth); coverage for certain home care services and drugs; enhanced access to diagnostic and medical equipment; and better accountability from governments.
In Canada, like most developed countries, the government plays a central role in delivering healthcare. In the United States on the other hand, the private sector plays the dominant role. Canada’s publicly funded health care is financed with general revenue raised through federal, provincial and territorial taxation, such as personal and corporate taxes, sales taxes, payroll levies and other revenue. Provinces may also charge a health premium on their residents to help pay for publicly funded health care services, but non-payment of a premium must not limit access to medically necessary health services. The Canadian government pays for 70% of total health care spending while only 30% is private spending for drugs, dentist and optometry. The financing of U.S. healthcare is shared between private and public sources, with the government paying only 43% of all health care expenditures. In the U.S., two-thirds of people receive insurance from private companies, the other one-third being covered by the government. In the US, direct government funding of health care is limited to Medicare, Medicaid, and the State Children's Health Insurance Program (SCHIP), which cover eligible senior citizens, the very poor, disabled persons, and children. The federal government also runs the Veterans Administration, which provides care to retired or disabled veterans, their families, and survivors through medical centers and clinics.
The provinces and territories administer and deliver most of Canada's health care services, with all provincial and territorial health insurance plans expected to meet national principles set out under the Canada Health Act. Medically necessary services are not defined in the Canada Health Act. It is up to the provincial and territorial health insurance plans, in consultation with their respective physician colleges or groups, to determine which services are medically necessary for health insurance purposes. If it is determined that a service is medically necessary, the full cost of the service must be covered by the public health insurance plan to be in compliance with the Act. If a service is not considered to be medically required, the province or territory need not cover it through its health insurance plan.
When Canadians need health care, they most often turn to primary health care services, which are the first point of contact with the health care system. In general, primary health care serves a dual function. First, it provides direct provision of first-contact health care services. Second, it coordinates patients' health care services to ensure continuity of care and ease of movement across the health care system when more specialized services are needed (e.g., from specialists or in hospitals). The point of entry and coordination of primary care is the same in both Canada and in the U.S. The differences in primary care is that in the United States, people go to a hospital first before seeing a primary care doctor. There are more specialists in the U.S. than primary care doctors.
Doctors in private practice are generally paid through fee-for-service schedules that itemize each service and pay a fee to the doctor for each service rendered. These are negotiated between each provincial and territorial government and the medical professions in their respective jurisdictions. Those in other practice settings, such as clinics, community health centers and group practices, are more likely to be paid through an alternative payment scheme, such as salaries or a blended payment (e.g., fee-for-service payments plus incentives for providing certain services such as the enhanced management of chronic diseases). Nurses and other health professionals are generally paid salaries that are negotiated between their unions and their employers. In the United States, under Managed Care Organizations, providers are paid using three payment arrangements: capitation, discounted fees/fee for service, and salaries.
Hospitals in Canada are publicly funded and required to operate on a fixed budget, one way the Canadian system tries to control spending. Most family physicians are private and operate on a fee-for service basis. This is how the Canadian system is recognized as a single player system but not socialized medicine, public spending but private delivery system. Canada negotiates at a federal level for drugs, which is another way they control spending.
The Canada Health Act covers the services of psychiatrists, but does not cover services by psychologists. In the U.S., the Affordable Care Act includes prevention, early intervention, and treatment of mental disorders as an “essential health benefit.”