Healthcare in Canada
Healthcare in Canada is delivered through the provincial and territorial systems of publicly funded health care, informally called Medicare.[1][2] It is guided by the provisions of the Canada Health Act of 1984,[3] and is universal.[4]: 81 The 2002 Royal Commission, known as the Romanow Report, revealed that Canadians consider universal access to publicly funded health services as a "fundamental value that ensures national health care insurance for everyone wherever they live in the country."[5][6]
Canadian Medicare provides coverage for approximately 70 percent of Canadians' healthcare needs, and the remaining 30 percent is paid for through the private sector.[7][8] The 30 percent typically relates to services not covered or only partially covered by Medicare, such as prescription drugs, eye care, medical devices, gender care, psychotherapy, physical therapy and dentistry.[7][8] About 65-75 percent of Canadians have some form of supplementary health insurance related to the aforementioned reasons; many receive it through their employers or use secondary social service programs related to extended coverage for families receiving social assistance or vulnerable demographics, such as seniors, minors, and those with disabilities.[9]
According to the Canadian Institute for Health Information (CIHI), by 2019, Canada's aging population represents an increase in healthcare costs of approximately one percent a year, which is a modest increase.[7] In a 2020 Statistics Canada Canadian Perspectives Survey Series (CPSS), 69 percent of Canadians self-reported that they had excellent or very good physical health—an improvement from 60 percent in 2018.[10] In 2019, 80 percent of Canadian adults self-reported having at least one major risk factor for chronic disease: smoking, physical inactivity, unhealthy eating or excessive alcohol use.[11] Canada has one of the highest rates of adult obesity among Organisation for Economic Co-operation and Development (OECD) countries attributing to approximately 2.7 million cases of diabetes (types 1 and 2 combined).[11] Four chronic diseases—cancer (a leading cause of death), cardiovascular diseases, respiratory diseases and diabetes account for 65 percent of deaths in Canada.[11]
In 2021, the Canadian Institute for Health Information reported that healthcare spending reached $308 billion, or 12.7 percent of Canada's GDP for that year.[12] In 2022 Canada's per-capita spending on health expenditures ranked 12th among health-care systems in the OECD.[13] Canada has performed close to the average on the majority of OECD health indicators since the early 2000s,[14] and ranks above average for access to care, but the number of doctors and hospital beds are considerably below the OECD average.[15] The Commonwealth Funds 2021 report comparing the healthcare systems of the 11 most developed countries ranked Canada second-to-last.[16] Identified weaknesses of Canada's system were comparatively higher infant mortality rate, the prevalence of chronic conditions, long wait times, poor availability of after-hours care, and a lack of prescription drugs coverage.[17] An increasing problem in Canada's health system is a shortage of healthcare professionals and hospital capacity.[18][19]
Canadian healthcare policy[edit]
The primary objective of the Canadian healthcare policy, as set out in the 1984 Canada Health Act (CHA), is to "protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers."[20][21] The federal government ensures compliance with its requirements that all Canadians have "reasonable access to medically necessary hospital, physician, and surgical-dental services that require a hospital" by providing cash to provinces and territories through the Canada Health Transfer (CHT) based on their fulfilling certain "criteria and conditions related to insured health services and extended health care services."[21]
In his widely cited 1987 book, Malcolm G. Taylor traced the roots of Medicare and federal-provincial negotiations involving "issues of jurisdiction, cost allocations, revenue transfers, and taxing authorities" that resulted in the current system that provides healthcare to "Canadians on the basis of need, irrespective of financial circumstances."[22][23]
Monitoring and measuring healthcare in Canada[edit]
Health Canada, under the direction of the Health Minister, is the ministry responsible for overseeing Canada's healthcare, including its public policies and implementations. This includes the maintenance and improvement of the health of the Canadian population, which is "among the healthiest in the world as measured by longevity, lifestyle and effective use of the public health care system."[24]
Health Canada, a federal department, publishes a series of surveys of the healthcare system in Canada.[25] Although life-threatening cases are dealt with immediately, some services needed are non-urgent and patients are seen at the next-available appointment in their local chosen facility.
In 1996, in response to an interest in renewing its healthcare system, the federal government established the Canadian Health Services Research Foundation (CHRSF) in the 1996 federal budget to conduct research in collaboration with "provincial governments, health institutions, and the private sector" to identify the successes and failures in the health system.[26]: 113
The Canadian Institute for Health Information (CIHI) is a not-for-profit, independent organization established by the provincial, territorial, and federal government to make healthcare information publicly available.[27] The CIHI was established in 1994 to serve as a national "coordinating council and an independent institute for health information" in response to the 1991 report, "Health Information for Canada" produced by the National Task Force on Health Information.[28] In 1994, the CIHI merged the Hospital Medical Records Institute (HMRI) and The Management Information Systems (MIS) Group.[28]
Reports include topics such as the evaluating and suggested improvements for the efficiency of healthcare services. Regions that were similar in factors such as education levels and immigration numbers were found to have different efficiency levels in health care provision. The study concluded if increased efficiency of the current system was set as a goal, the death rate could be decreased by 18%-35%.[29] The study notes that supporting physician leadership and facilitating engagement of the care providers could reap great gains in efficiency. Additionally, the study suggested facilitating the exchange of information and interaction between health providers and government figures as well as flexible funding would also contribute to the improvement and solve the problem of differences in regional care by allowing regions to determine the needs of their general populace and meet those needs more efficiently by allowing target-specific allocation of funds.[30]
For 24 years, the CIHI has produced an annual detailed report updating "National Health Expenditure Trends" which includes data tables with the most recent report published in January 2021.[31][32] Other CIHI research topics include hospital care, organ and joint replacements, health system performance, seniors and aging, health workforce, health inequality, quality and safety, mental health and addictions, pharmaceuticals, international comparisons, emergency care, patient experience, residential care, population health, community care, patient outcomes, access and wait times, children and youth, and First Nations, Inuit and Métis.
In 2003, at the First Ministers' Accord on Health Care Renewal, the Health Council of Canada (HCC)—an independent national agency—was established to monitor and report on Canada's healthcare system.[33] For over a decade, until 2014, the HCC produced 60 reports on access and wait times, health promotion, seniors healthcare, aboriginal healthcare, home and community care, pharmaceuticals management, and primary health care.[34]
Coverage[edit]
Mental health[edit]
The Canada Health Act covers the services of psychiatrists, medical doctors with additional training in psychiatry. In Canada, psychiatrists tend to focus on the treatment of mental illness with medication.[61] However, the Canada Health Act excludes care provided in a "hospital or institution primarily for the mentally disordered."[62] Some institutional care is provided by provinces. The Canada Health Act does not cover treatment by a psychologist[63] or psychotherapist unless the practitioner is also a medical doctor. Goods and Services Tax or Harmonized Sales Tax (depending on the province) applies to the services of psychotherapists.[64] Some coverage for mental health care and substance abuse treatment may be available under other government programs. For example, in Alberta, the province provides funding for mental health care through Alberta Health Services.[65] Most or all provinces and territories offer government-funded drug and alcohol addiction rehabilitation, although waiting lists may exist.[66] The cost of treatment by a psychologist or psychotherapist in Canada has been cited as a contributing factor in the high suicide rate among first responders such as police officers, EMTs and paramedics. According to a CBC report, some police forces "offer benefits plans that cover only a handful of sessions with community psychologists, forcing those seeking help to join lengthy waiting lists to seek free psychiatric assistance."[67]
Oral health[edit]
Among the OECD countries, Canada ranks second to last in the public funding of oral healthcare. Those who need dental care are usually responsible for the finances and some may benefit from the coverage available through employment, under provincial plans, or private dental care plans. "As opposed to its national system of public health insurance, dental care in Canada is almost wholly privately financed, with approximately 60% of dental care paid through employment-based insurance, and 35% through out-of-pocket expenditures. Of the approximately 5% of publicly financed care that remains, most has focused on socially marginalized groups (e.g., low-income children and adults), and is supported by different levels of government depending on the group insured."[68] It is true that compared to primary care checkups, dental care checkups depend on the ability of people being able to pay those fees.
Studies in Quebec and Ontario provide data on the extent of dental health care. For example, studies in Quebec showed that there was a strong relation among dental services and the socioeconomic factors of income and education whereas in Ontario older adults heavily relied on dental insurance with visits to the dentist. "According to the National Public Health Service in 1996/1997, it showed a whopping difference of people who were in different classes. About half of Canadians aged 15 or older (53%) reported having dental insurance. Coverage tended to be highest among middle-aged people. At older ages, the rate dropped, and only one-fifth of the 65-or-older age group (21%) was covered."[69] Attributes that can contribute to these outcomes is household income, employment, as well as education. Those individuals who are in the middle class may be covered through the benefits of their employment whereas older individuals may not due to the fact of retirement.
Under the government healthcare system in Canada, routine dental care is not covered.[70][71] There are a couple of provinces that offer child prevention programs such as Nova Scotia and Quebec.[72] Other provinces make patients pay for medical dental procedures that are performed in the hospital. Some dental services that are possibly not covered by Medicare may include cavity fillings, routine dental check-ups, restorative dental care, and preventive care, dentures, dental implants, bridges, crowns, veneers, and in-lays, X-rays, and orthodontic procedures.
In 2022, however, the federal government announced the creation of a new Canada Dental Benefit which reimburses low- to middle-income parents up to $650 of dental fees per child.[73] This was a transitional policy on the way to universal, public coverage of dental care. In 2023, the government established the Canadian Dental Care Plan, which began a staggered enrolment rollout in December 2023, to pay costs for covered dental services of eligible residents.[74]
Physiotherapy, occupational therapy, and massage therapy[edit]
Coverage for services by physiotherapists, occupational therapists (also known as OTs) and Registered Massage Therapists (RMTs) varies by province. For example, in Ontario the provincial health plan, OHIP, does cover physiotherapy following hospital discharge and occupational therapy[75] but does not cover massage therapy. To be eligible for coverage for physiotherapy in Ontario, insured individuals must have been discharged as an inpatient of a hospital after an overnight stay and require physiotherapy for the condition, illness or injury, or be age 19 or younger or age 65 or older.[76]
Other coverage limitations[edit]
Coverage varies for care related to the feet. In Ontario, as of 2019, Medicare covers between $7–16 of each visit to a registered podiatrist up to $135 per patient per year, plus $30 for x-rays.[77] Although the elderly, as well as diabetic patients, may have needs that greatly exceed that limit, such costs would have to be covered by patients or private supplemental insurance.
As of 2014, most, but not all provinces and territories provide some coverage for sex reassignment surgery (also known as gender confirming surgery) and other treatment for gender dysphoria.[78] In Ontario, sex reassignment surgery requires prior approval before being covered.[79]
However, access to care does not meet WPATH guidelines in provinces covering 84% of Canada's population (excepting British Columbia, Prince Edward Island and Yukon Territory). Wait times are extensive for gender care in Canada, and can be as long as eight years.[80]
There are wide discrepancies in coverage for various assistive devices such as wheelchairs and respiratory equipment in Canada. Ontario, which has one of the most generous programs, pays 75% of the cost for listed equipment and supplies for persons with a disability requiring such equipment or supplies for six months or longer.[81] The program does not have age or income restrictions. As with other health coverage, veterans and others covered by federal programs are not eligible under the provincial program. Only certain types of equipment and supplies are covered, and within categories only approved models of equipment from approved vendors are covered, and vendors may not charge more than specified prices established by the government.[82]
Indigenous peoples[edit]
The largest group the federal government is directly responsible for is First Nations. Native peoples are a federal responsibility and the federal government guarantees complete coverage of their health needs. For the last twenty years and despite health care being a guaranteed right for First Nations due to the many treaties the government of Canada signed for access to First Nations lands and resources, the amount of coverage provided by the Federal government's Non-Insured Health Benefits program has diminished drastically for optometry, dentistry, and medicines. Status First Nations individuals qualify for a set number of visits to the optometrist and dentist, with a limited amount of coverage for glasses, eye exams, fillings, root canals, etc. For the most part, First Nations people use normal hospitals and the federal government then fully compensates the provincial government for the expense. The federal government also covers any user fees the province charges. The federal government maintains a network of clinics and health centers on First Nations reserves. At the provincial level, there are also several much smaller health programs alongside Medicare. The largest of these is the health care costs paid by the workers' compensation system. Regardless of federal efforts, healthcare for First Nations has generally not been considered effective.[87][88][89] Despite being a provincial responsibility, the large health costs have long been partially funded by the federal government.
Healthcare spending[edit]
While the Canadian healthcare system has been called a single payer system, Canada "does not have a single health care system" according to a 2018 Library of Parliament report.[90] The provinces and territories provide "publicly funded health care" through provincial and territorial public health insurance systems.[90] The total health expenditure in Canada includes expenditures for those health services not covered by either federal funds or these public insurance systems, that are paid by private insurance or by individuals out-of-pocket.[90]
In 2017, the Canadian Institute for Health Information reported that healthcare spending is expected to reach $242 billion, or 11.5% of Canada's gross domestic product for that year.
The provinces and territories health spending accounted for approximately "64.2% of total health expenditure" in 2018. [90][91] Public sources of revenue for the public healthcare system include provincial financing which represented 64.2% of the total in 2018. This includes funds transferred from the federal government to the provinces in the form of the CHT.[90] Direct funding from the federal government, as well as funds from municipal governments and social security funds represented 4.8% in 2018.[90][91]: 11
According to the CIHI 2019 report, since 1997, the 70–30 split between public and private sector healthcare spending has remained relatively consistent with approximately 70% of Canada's total health expenditures from the public sector and 30% from the private sector.[7][8] Public-sector funding, which has represented approximately 70% of total health expenditure since 1997, "includes payments by governments at the federal, provincial/territorial and municipal levels and by workers' compensation boards and other social security schemes".[91]: 11
Public opinion[edit]
According to a 2020 survey, 75% of Canadians "were proud of their health-care system."[131]
An August 31, 2020 PBS article comparing the American healthcare system to Canada's, cited the director of the University of Ottawa's Centre for Health Law, Policy and Ethics, Colleen Flood, who said that there was "no perfect health care system", and the "Canadian system is not without flaws." However, Canadians "feel grateful for what they have." At times, the complacency has resulted in Canadians not demanding for "better outcomes for lower costs". She said that, Canadians are "always relieved that at least [our healthcare system] is not the American system."[132]
A 2009 Nanos Research poll found that 86.2% of Canadians "supported or strongly supported" "public solutions" to make Canadian "public health care stronger."[133] According to the survey report, commissioned by the Canadian Healthcare Coalition, there was "compelling evidence" that Canadians "across all demographics" prefer a "public over a for-profit health-care system."[133][134] A Strategic Counsel survey found 91% of Canadians prefer their healthcare system instead of a U.S. style system.[135][136]
A 2009 Harris-Decima poll found 82% of Canadians preferred their healthcare system to the one in the United States.[137]
A 2003 Gallup poll found 57% of Canadians compared to 50% in the UK, and 25% of Americans, were either "very" or "somewhat" satisfied with "the availability of affordable healthcare in the nation". Only 17% of Canadians were "very dissatisfied" compared to 44% of Americans. In 2003, 48% of Americans, 52% of Canadians, and 42% of Britons say they were satisfied.[138]
A 2016 Canadian Institute for Health Information survey found that Canadians wait longer to access health care services than citizens in 11 other countries including the United States and Switzerland.[139]
In a 2021 Ipsos poll, 71% of Canadians agreed that their health care system is too bureaucratic to respond to the needs of the population.[140]
Healthcare debates in Canada[edit]
Canada has robust debates between those who support the one-tier public healthcare, such as the Canadian Health Coalition, a group that formed following the publication of the Romanov Report in 2002,[5] and a number of pro-privatization organizations, such as the conservative Fraser Institute, that call for a two-tiered healthcare system. American organizations that support privatization of health services, such as the Cato Institute and the Americans for Prosperity[142][143][144] have focused criticism of the Canadian healthcare system on wait times.[145]
Wendell Potter, who had worked for multinational American health insurance company Cigna from 1993 until 2008, told PBS that the American health industry felt threatened by Canada's healthcare system as it "exposed shortcomings in the private U.S. health system and potentially threatened their profits."[132] He said that corporate PR used the tactic of repeating misinformation about the publicly funded Canadian system by focusing on wait times for elective surgeries.[132][146]
As healthcare debate in the United States reached the top of the U.S. domestic policy agenda during the U.S. 2008 presidential race with a combination of "soaring costs" in the healthcare system and an increasing number of Americans without health insurance because of job loss during the recession, the long wait lists of Canada's so-called "socialized" healthcare system[147] became a key Republican argument against Obama's health reforms.[147] The Huffington Post described it as the "American politics of Canadian healthcare."[148] A 2009 Huffington Post article described how American insurance companies were concerned that they would not be as profitable if his healthcare reforms were implemented.[149]
Starting in July 2009, Canadian Shona Holmes of Waterdown, Ontario became the poster child of the Americans for Prosperity support for Republican presidential candidates against then-candidate and President Barack Obama's who ran on health reform and the Affordable Care Act.[142][143][150][144] In 2005, Holmes had paid $100,000 out-of-pocket for immediate treatment for a condition called Rathke's cleft cyst at the U.S. Mayo Clinic, one of the best hospitals in the world,[151] the Singapore General Hospital, and the Charité hospital in Berlin[151] instead of waiting for an appointment with specialists in her home province of Ontario.[152][153] In 2007, she filed a lawsuit against the Ontario government when OHIP refused to re-imburse her $100,000. The media attention from the Americans for Prosperity advertisements resulted in further scrutiny of Holmes' story. A 2009 CBC report consulted medical experts who found discrepancies in her story, including that Rathke's cleft cyst was neither cancerous or life-threatening.[154] The mortality rate for patients with a Rathke's cleft cyst is zero percent.[155]
Since 1990, the Fraser Institute has focused on investigating the Canadian healthcare system's historic and problematic wait times by publishing an annual report based on a nationwide survey of physicians and health care practitioners, entitled Waiting Your Turn: Wait Times for Health Care in Canada. The 2021 edition of the report found that the average waiting time between referral from a general practitioner and delivery of elective treatment by a specialist rose from 9.3 weeks in 1993 to 25.6 weeks in 2021.[156] Waiting times ranged from a low of 18.5 weeks in Ontario to 53.2 weeks in Nova Scotia.
A 2015 Fraser Institute article focused on Canadians who sought healthcare in other countries and reported that the percentage of Canadian patients who travelled abroad to receive non-emergency medical care was 1.1% in 2014, and 0.9% in 2013, with British Columbia being the province with the highest proportion of its citizens making such trips.[157] A 2017 Fraser Institute cost-effectiveness analysis promoted a two-tiered system with more privatization, arguing that "although Canada ranks among the most expensive universal-access health-care systems in the OECD, its performance for availability and access to resources is generally below that of the average OECD country, while its performance for use of resources and quality and clinical performance is mixed."[158][145]
Portability and provincial residency requirements[edit]
The Canada Health Act covers residents of Canada, which are persons "lawfully entitled to be or to remain in Canada who makes his home and is ordinarily present in the province, but does not include a tourist, a transient or a visitor to the province."[285] When traveling within Canada, a Canadian's health card from his or her home province or territory is accepted for hospital and physician services.[285]
Each province has residency and physical presence requirements to qualify for health care coverage. For example, to qualify for coverage in Ontario, with certain exceptions, one must be physically present in Ontario for 153 days in any given 12-month period. Most provinces require 183 days of physical presence in any given 12-month period. Exceptions may be made for mobile workers, if the individual can provide documentation from his or her employer verifying that the individual's work requires frequent travel in and out of the province.[286] Transients, self-employed itinerant workers (e.g. farm workers) who move from province to province several times within a year, and peripatetic retired or unemployed individuals who move from province to province (e.g. staying with various relatives, or living in a recreational vehicle) may find themselves ineligible for health coverage in any province or territory, even though they are Canadian citizens or landed immigrants physically present in Canada 365 days a year. "Snowbirds" (Canadians who winter in warm climates) and other Canadians who are out their home province or territory for a total of more than 183 days in twelve months lose all coverage, which is reinstated after a three-month waiting period.[287] Students attending a university or college outside their home province are generally covered by the health insurance program of their home province, however, "Typically this coverage (while out-of-province but within Canada) is for physician and hospital services only."[286] The Ontario Ministry of Health and Long Term Care, for example, states, "Therefore, when travelling outside of Ontario but within Canada, the ministry recommends that you obtain private supplementary health insurance for non-physician/non-hospital services."[286] Such services might include prescription drugs, or ground and air ambulance services that might be covered in one's home province.[288]
Canadian healthcare contribution to Climate Change[edit]
Climate change is a growing concern all around the world, and its causes vary from multiple factors. It has been identified that Climate change is the single greatest public health threat of the 21st century.[318] The healthcare sector in Canada contributes to climate change, and it was responsible for 4.6% of national greenhouse gas emission in 2009 to 2015.[318][319][320]With the relationship between air pollution and human health, it was estimated by researchers that "every year, health care emissions result in 23 000 years of life lost due to disability or early death".[319]
The health sector has contributed to pollution in various ways, with Hospitals and Pharmaceutical companies as the largest drivers of its emissions according to the PLOS Medicine study. There is also the impact of medical waste, anesthetics used in surgery, and unsustainable materials which are all greenhouse gases.[319][318]
There have been projects led by The Canadian Coalition for Green Health Care with the aim to reduce the environmental impacts of providing healthcare, such as reducing toxic chemicals when cleaning and promoting sustainable foods in hospitals.[319] They recently studied medical imaging equipment's energy consumption.[319] When patients and hospital staff travel to hospitals and clinics they release greenhouse gas, which can be viewed as part of the equation.[319][318]