1. Health Care in Canada and the United States March 25, 2002

2. National Stereotypes – Canada and the United States “Canada...is a more...statist, collectivity-oriented... society than the United States.” S.M. Lipset, Continental Divide “Canada...is a more...statist, collectivity-oriented... society than the United States.” S.M. Lipset, Continental Divide “The differences between the two countries are particularly striking with respect to the role of government in medical care.” S.M. Lipset, Continental Divide “The differences between the two countries are particularly striking with respect to the role of government in medical care.” S.M. Lipset, Continental Divide

3. Myths of Canadian Health Care the Canadian model is a universal health care system the Canadian model is a universal health care system universality is a unique trait of Canadian (as opposed to American) health care provision universality is a unique trait of Canadian (as opposed to American) health care provision there is a more limited public role in health care financing and provision in the US there is a more limited public role in health care financing and provision in the US

4. Universal Public Health Care in Canada? prior to universal health care programs, health care systems in Canada and the US basically the same prior to universal health care programs, health care systems in Canada and the US basically the same government role in health care in Canada government role in health care in Canada – hospital insurance Saskatchewan, 1948 Saskatchewan, 1948 federal hospital insurance, 1957 federal hospital insurance, 1957 – medical care (e.g. physician) insurance Saskatchewan, 1961 Saskatchewan, 1961 federal Medicare, 1966 federal Medicare, 1966

5. Universal Public Health Care in Canada? federal/provincial roles federal/provincial roles – provinces jurisdiction jurisdiction actually provide health care actually provide health care – federal government (spending power) transfers funds to the provinces transfers funds to the provinces set conditions under Canada Health Act (CHA) set conditions under Canada Health Act (CHA) –comprehensive, universal, portable, accessible, public administration

6. Health Care Expenditures, 1999 Universal (CHA applies) Non-Universal (CHA does not apply)

7. Universal Public Health Care in Canada? Canadian system -- universal hospital and physician care Canadian system -- universal hospital and physician care passive privatization of system passive privatization of system – currently, 1/3 of total health expenditures in Canada are private pharmaceuticals are the fasting growing component of health care system pharmaceuticals are the fasting growing component of health care system physician care increasingly centred around access to pharmaceuticals physician care increasingly centred around access to pharmaceuticals

8. Myths of Canadian Health Care the Canadian model is a universal health care system the Canadian model is a universal health care system universality is a unique trait of Canadian (as opposed to American) health care provision universality is a unique trait of Canadian (as opposed to American) health care provision there is a more limited public role in health care financing and provision in the US there is a more limited public role in health care financing and provision in the US

9. Public Health Care Provision in the United States large private component of health care system large private component of health care system public components public components – Medicare universal hospital and physician care for all seniors universal hospital and physician care for all seniors – Medicaid hospital and physician care for the poor hospital and physician care for the poor

10. Myths of Canadian Health Care the Canadian model is a universal health care system the Canadian model is a universal health care system half the system is universal (and declining) half the system is universal (and declining) universality is a unique trait of Canadian (as opposed to American) health care provision universality is a unique trait of Canadian (as opposed to American) health care provision 45% of Canadian public health expenditures are for the elderly 45% of Canadian public health expenditures are for the elderly in US, universal Medicare for elderly in US, universal Medicare for elderly

11. “How worried are you that if you become seriously ill, you will not be able to get the medical care you need because you cannot afford it?”

12. “How worried are you that you will be unable to pay for (private) care for you parents, grandparents, or spouse if they need nursing home care for a long- term illness?”

13. Myths of Canadian Health Care the Canadian model is a universal health care system the Canadian model is a universal health care system universality is a unique trait of Canadian (as opposed to American) health care provision universality is a unique trait of Canadian (as opposed to American) health care provision there is a more limited public role in health care financing and provision in the US there is a more limited public role in health care financing and provision in the US – main difficulty with comparisons is the wide variation among US states

14. Public Health Care Financing, Provision and Regulation in the United States public health care spending public health care spending – a higher proportion of total health care spending in Canada is public e.g. 66% public in Ontario e.g. 66% public in Ontario ranges from 40%-60% in American states ranges from 40%-60% in American states – HOWEVER... total (public and private) health care spending is higher in US total (public and private) health care spending is higher in US

17. Public Health Care Financing, Provision and Regulation in the United States public health care spending public health care spending state regulation of private insurance state regulation of private insurance guaranteed issue legislation guaranteed issue legislation pre-existing condition legislation pre-existing condition legislation community-rating legislation community-rating legislation guaranteed renewal legislation guaranteed renewal legislation mandatory loss ratio mandatory loss ratio – varies widely by state

18. No Regulation Limited Regulation (1-3) Moderate Regulation (4-5) Strong Regulation (6-8) AlabamaArkansasMichiganPennsylvania Alaska, Arizona Colorado, Delaware Florida, Georgia Kansas, Illinois Indiana, Massachusetts Maryland, Missouri Montana, Nebraska N. Carolina, New Mexico Nevada, Oklahoma Rhode Island S. Dakota Tennessee, Texas Virginia, Wisconsin West Virginia CaliforniaConnecticutIdahoIowaLouisianaMinnesotaOhioOregon South Carolina UtahWyomingKentuckyMaine North Dakota New Jersey New Hampshire New York VermontWashington

19. Public Health Care Financing, Provision, and Regulation in the United States public health care spending public health care spending state regulation of private insurance state regulation of private insurance uncompensated care uncompensated care NO hospital in the US can legally refuse treatment to someone requiring emergency medical attention NO hospital in the US can legally refuse treatment to someone requiring emergency medical attention depending on state, large numbers of publicly owned hospitals (receiving gov’t subsidies for uncompensated care) depending on state, large numbers of publicly owned hospitals (receiving gov’t subsidies for uncompensated care) all not-for-profit hospitals receive designation based on uncompensated care all not-for-profit hospitals receive designation based on uncompensated care – mix of hospital control varies widely by state

21. Myths of Canadian Health Care the Canadian model is a universal health care system the Canadian model is a universal health care system universality is a unique trait of Canadian (as opposed to American) health care provision universality is a unique trait of Canadian (as opposed to American) health care provision there is a more limited public role in health care financing and provision in the US there is a more limited public role in health care financing and provision in the US – main difficulty with comparisons is the wide variation among US states

22. National Stereotypes – Canada and the United States “Canada...is a more...statist, collectivity-oriented... society than the United States.” S.M. Lipset, Continental Divide “Canada...is a more...statist, collectivity-oriented... society than the United States.” S.M. Lipset, Continental Divide “The differences between the two countries are particularly striking with respect to the role of government in medical care.” S.M. Lipset, Continental Divide “The differences between the two countries are particularly striking with respect to the role of government in medical care.” S.M. Lipset, Continental Divide

23. National Stereotypes – Canada and the United States important differences in public role in health care in Canada and the United States important differences in public role in health care in Canada and the United States – NOT primarily in the role of government in providing health care – primarily in the role of government prohibiting private health care provision in Canada

24. National Stereotypes – Canada and the United States important differences in public role in health care in Canada and the United States important differences in public role in health care in Canada and the United States explaining differences? explaining differences? – political culture not that American distrust of government leads to less public provision of health care not that American distrust of government leads to less public provision of health care American emphasis on individual rights makes prohibition of private health care difficult American emphasis on individual rights makes prohibition of private health care difficult

25. National Stereotypes – Canada and the United States important differences in public role in health care in Canada and the United States important differences in public role in health care in Canada and the United States explaining differences? explaining differences? – political culture – politics of race universal (i.e. integrated) health care not politically feasible in the US at the time Canadian universal health care developing universal (i.e. integrated) health care not politically feasible in the US at the time Canadian universal health care developing