04 - How does Canada do it? Part 1

canada’s System of government

Federation

• National government (federal government)

• Sub-national jurisdictions (provinces and territories)

• Balancing act

What should be standard across the country vs local?

Jordan River Anderson

• A genetic disorder requires long-term hospitalization 

• After 2 years, doctors said he could be cared for at home 

• Federal and provincial governments argued over who should cover the costs 

• He is a First Nations child. How is that relevant 

  • Federal = First Nation 

• Continued to stay in the hospital while the dispute persisted

  • Both governments refused to take responsibility 

• Died at 5, never having the chance to love outside of the hospital

Jordan River Anderson Relevance to healthcare in Canada

• Policy failed here

      • New first contact policy

      • No delays in accessing care

• Signalled complexities involved in organizing and delivering healthcare

      • Need for clear policies that prioritize care over bureaucratic hurdles

      • Tragic event leading to meaningful reform

Constitutional responsibilities: Feds

Feds: issues of national interest, expensive

• Section 91, “Quarantine and the Establishment

and Maintenance of Marine Hospitals”

• Territories

• First Nations living on reserve

• Armed services

Constitutional responsibilities:Provinces

Provinces: issues of local variation, less expensive

• Section 92, “The Establishment, Maintenance and Management of Hospitals, Asylums, Charities and Eleemosynary Institutions in and for the Province, other than Marine Hospitals”

• Professional Licensure

• Public health is more ambiguous

Jurisdictional issues - MAID

Healthcare a provincial issue, and justice a federal responsibility

• MAID

• Legal as of 2015 with conditions

      • Still federal jurisdiction – sets conditions

       • Bill C-14 (2016) and Bill C-7 (2021)

• Provinces decide on access and proces

Jurisdictional issues - Safe injection site

• BC first site (2003)

• High rates of overdose deaths

• Received federal exemption

• Harper government shut it down

• Supreme court said violated charter of rights and freedoms

Safe injection sites – a public health initiative

• Controlled substances

• Requires federal exemption

• Healthcare services are provided

Problem of variation

Differences in wealth of provinces, what they could afford to do

What does it mean to be a citizen (resident) of a country vs a sub-national jurisdiction as it relates to access to services?

The Burlington Experience

• Intended to improve access to healthcare / primary care

  • Study on introducing nurse practitioners (NPs) into suburban family practices. 

  • NPs could do routine procedures and follow-ups → reduced doctors’ burden.

• Several barriers 

  • Funding models did not permit fee-for-service 

    • No sustainable funding model 

  • Opposition from physicians 

    • Resistance from physicians, but study showed patients benefited.

  • No clear legislative framework 

• Limited access to healthcare/primary care 

• No financial incentive to move care out of hospitals 

  • Care remained institutionalized and based on “physician services”

Public health insurance galvanized by

depression and WWII

History of financing; 1944

Saskatchewan

• Social democratic government elected, led by Tommy Douglas

• Committed to ensuring that residents would have access to hospitals

• Begins funding capital construction of hospitals

• Fundamentally egalitarian ideology

History of financing: 1947

Saskatchewan

• Introduces single-payer universal hospital insurance program (first in NA)

• Followed by BC and Alberta

History of financing:1957

Hospital Insurance and Diagnostic Services Act

• Provided federal funds to provinces to cover ~half costs of publicly funded

hospital insurance programs (should they choose to have one), as long as they

complied with national conditions

History of financing: 1961

• Hospital insurance programs in all provinces

History of financing: 1962

Saskatchewan

• Single-payer universal insurance program to cover physician services

• Tommy Douglas now first leader of federal NDP

• Doctors strike

• Agreement reached whereby doctors would continue to be independent professionals

paid by fee-for-service (i.e., not salaried employees of public program)

History of financing: 1966

– Medical Care Act

• Federal cost-sharing to provinces with universal single-payer provincial

insurance plans for medically necessary physician services

Implications of early health funding models (cost-shared hospitals & physicians only)

• Only hospitals and physicians were covered.

• Community-based, non-physician services (e.g., mental health, physiotherapy) were excluded.

• Incentivized hospital- and doctor-centered care, even if cheaper alternatives existed.

History of financing1977

Federal-Provincial Fiscal Arrangements and Established Programs Financing Act (EFP)

• Replaced federal cash transfers for Hospital and Diagnostic Services Act and Medical Care Act

• Mix of cash transfers and tax points

implications of Federal-Provincial Fiscal Arrangements and Established Programs Financing Act (EFP)

Implications

• Effectively reduced federal power over health care

• New user fees / extra billing

• Diverting funds from healthcare

Fiscal federalism

Variety of mechanisms to transfer resources from national to subnational, equalize fiscal capacity, allow provision of comparable level of services

cash grants and tax room 

cash grants

• Direct transfers from one level of government to another

• Can be tied to terms and conditions, withheld if in violation

tax room

• Agreement whereby senior level of government decreases its tax rate, leaving room for sub-national units to increase their tax rates, without increasing total tax burden on taxpayer

• Senior level of government loses power to enforce use of resources

Health Accord (2004)

• Increased and stabilized funding

• Identified priorities

• Not renewed by the Harper government(2014)

• Trudeau government

      • 200 Billion over 10 years

             • Access to family health services

             • Supporting healthcare workers

             • Improving mental health

      • Comes with strings

             • Measurable outcomes

2 parts of Canada Health Act (1984)  

2 pieces of legislation

• Canada Health Transfer

• Canada Health Act

Canada Health Transfer

• How much federal money is transferred

Canada Health Act

Defines the terms and conditions that must be met by provincial insurance plans to qualify for full contribution from federal government

services of the cha

emergency and physicians = • Insured services

• Extended healthcare services =  Not subject to CHA

• Nursing homes, residential care, home care, ambulatory health care service (e.g., not needing hospital - diagnostics, dialysis, vaccinations, PT, OT, urgent care)

is there an equivalent of the cha

• No equivalent

• Not applicable to non-physician medically necessary services

     • Primary care, home care

CHA: Accessibility

ensuring all insured persons have reasonable access to medically necessary healthcare services without financial or other barriers.

• Patients should not face extra charges, and services should be provided based on medical need rather than ability to pay.

CHA: Comprehensiveness

Requires that provincial and territorial health insurance plans cover all medically necessary hospital, physician, and surgical-dental services.

• While basic healthcare is covered, services like prescription drugs, dental, and vision care often require private insurance or out-of-pocket payments.

• Insured person = resident, insured health service = medicaly nessecary 

CHA: Portability

Ensures that Canadians maintain their healthcare coverage when moving between provinces or traveling within Canada.

• Eg. A resident of Ontario traveling to British Columbia will still have access to medically necessary services without losing coverage.

• Some provision for out of country care

CHA: Public administration

Requires that provincial and territorial health insurance plans be operated on a non-profit basis by a public authority accountable to the government.

• Requires that provincial and territorial health insurance plans be operated on a non-profit basis by a public authority accountable to the government.

• Not delivery, but insurance plan

CHA: Universality

Guarantees that all eligible residents of a province or territory are entitled to the same level of insured healthcare services.

• Every Canadian citizen and permanent resident has equal access to publicly funded healthcare, regardless of income or employment status.

Romanow Report (2002)

• Upheld principles of CHA

• Called for more accountability on healthcare spending

• Extend coverage beyond hospitals and physicians

• Team based primary care

• Rejected a two-tiered system

      • Egalitarian ideology

Regional models in Ontario

Ontario LHIN (2007)

OHTs (2019)

Ontario Health

Centralized health authorities in Alberta

• Planning, managing and funding based on geographical areas and needs

• Ontario LHIN (2007)

• Managed hospitals, LTC, home care, community health services – bridge between provincial government and healthcare providers

• Focused on funding and administration

• OHTs (2019)

• Integrated care, patient centered care, avoid disconnected providers

Ontario Health

• Super-agency looking after the province’s healthcare system