National Health Policy

1
National Health Policy

Ervin B. Podgorsak McGill University Montreal,
Quebec, Canada
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• North America
• Canada
• USA
• Mexico
• Canada
• Federal parliamentary monarchy
• Federation of
• 10 provinces
• 3 territories
• USA
• Federal presidential republic
• Federation of
• 50 states

3

• North America
• Canada
• USA
• Mexico
• Tenets of Constitution
• USA
• Life
• Liberty
• Pursuit of happiness
• Canada
• Peace
• Order
• Good government

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North America (2003)
U.S. Canada U.S./Canada Populatio
n (million) 288 32 9
1 GNP (billion US) 10 450 728
14.4 1 (1 0.07) GNP per capita (
US) 34 320 27 130 1.3 1 (1
0.77) SOURCE HDR 2003
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UNITED STATES vs.CANADA

• Similar political systems
• Similar economic and social systems
• One anothers best trading partner
• Differences between the two countries
• - World view
• - Foreign policy
• - Gun control
• - Organization and financing of health care

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Canada versus the United States
Canadians see themselves as part of the
world. Americans see themselves as part of the
United States.
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Health Care

• The most important characteristics
• of a health care system are
• Quality Cost Access

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MODELS FOR HEALTH CARE FINANCING

• Nationalized
• public
• single-payer
• not-for-profit
• Privatized
• multi-payer
• for-profit
• Combination of public and private

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Health Care in North America (2003)
Shares of total health expenditures

• Public () Private ()
• Canada 71 29
• United States 44 56
• OECD average 72 28
• SOURCE OECD

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THE GREAT AMERICAN HEALTH CARE DEBATE

• Americans are aware that their health care
• system is expensive, overly bureaucratic,
• inequitable, and socially unjust.
• Americans agree in principle that all residents
• of the U.S. should have access to high quality
• health care regardless of their ability to pay
• however, there is not enough political will
• to reform the system.

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THE GREAT AMERICAN HEALTH CARE DEBATE

• Despite numerous attempts by various presidents
• during the past 2 decades to reform the U.S.
  health
• care system, the reform of the system is as
  elusive
• as ever.
• Despite having by far the most expensive health
• care system in the world, in ranking on health
• care indicators the U.S. achieves only a mediocre
  place among the 30 OECD countries.

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THE GREAT CANADIAN HEALTH CARE DEBATE

• Canadians are both proud of, and unhappy
• with, their health care system.
• During the 1980s and 1990s the debate
• concentrated on perceived excessive costs.
• During the past 5 years the debate shifted to
• a much more ominous symptom
• the problems with access to diagnostic
• and therapeutic services.

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THE GREAT CANADIAN HEALTH CARE DEBATE

• Canadians generally agree that their health
• care system needs reform.
• There is no agreement on how to solve
• the current problems.
• Proposed solutions range from pumping
• much more public money into the system
• to an outright privatization.

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Health Care in North America (2004)

• Main issue in Canada
• How to best ensure the universal and timely
  access to the public health care system in an
  era of severe fiscal restraint by governments.
• Main issue in the United States
• How to use government intervention to make the
  current health care system universally
  accessible and more cost- effective.

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Health Care in North America

• During 1970s and 1980s Americans have paid
  considerable attention to the structure and
  history of the Canadian health care system with
  its
• universal coverage
• lower cost
• high standards
• public administration
• clinical autonomy of physicians
• During 1990s health care reforms in the United
  States failed and, concurrently, the Canadian
  health care system run into serious financial
  trouble.

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HEALTH CARE in CANADA in 2004 The main concern
of the Canadian Governments is the high cost
of health care. The main concern of the Canadian
public is access to health care.
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CANADIAN HEALTH CARE SYSTEM

• The Canadian health care is financed publicly and
  has three primary players
• Provincial governments Under the Canadian
  Constitution health care is the jurisdiction of
  provincial governments who manage, deliver and
  plan health care services.
• Federal government Sets and enforces national
  health care standards through the Canada Health
  Act and assists the provinces in health care
  system financing through the transfer of tax
  revenue to the provinces.
• Private physicians paid on a fee-for-service
  basis by provincial governments to deliver
  publicly-funded health services. The fees are
  negotiated between the provincial goverments and
  physician associations.

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Health Care in Canada (2004)

• Difficulties with financing
• Decline in public support
• Shortages of staff and equipment
• Low morale among health care workers
• Increased tension between federal government
  and provinces
• Restricted access to specialists
• Waiting times for diagnostic procedures
• Waiting times for non-emergency surgery and
  cancer therapy

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Health Care System in Canada

• IN PRINCIPLE
• The single payer, publicly-administered health
  care system
• provides universal access to health care for
  all citizens
• is less expensive and more efficient than the
  private health care system
• - because of its lower administrative costs
• - because governments can set global budgets
  for hospitals and negotiate fees with
  physicians

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Health Care in North America

• Canada
• - Health care is publicly administered.
• - All residents enjoy universal access to
  hospital care and physicians services without
  any cost-sharing requirements.
• United States
• - Health care financing is based on
  profit-driven private insurance plans and
  health maintenance organizations (HMOs).
• - Publicly financed are Medicare and
  Medicaid, covering 40 of the population for
  hospital insurance and 25 of population
• for medical coverage.
• - An estimated 44 million Americans are not
  insured.

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Milestones Health Care in the United States

• 1935 Social Security Act (does not include
  health insurance)
• 1939, 1943, Attempts to introduce a national
  health insurance
• late 1940s plan were defeated by the Congress
• Early 1960s President Kennedys attempts were
  unsuccessful
• 1964 Medicare and Medicaid programs pass

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Milestones Health Care in the United States

• 1973 Health Maintenance Organization (HMO) Act
• encourages development of prepaid group plans
  to restrain providers and centralize health
  care delivery.
• 1982 to control Medicare costs the government
  introduces a fee schedule based on Diagnostic
  Related Groups (DRGs) and beneficiaries were
  encouraged to use Preferred Provider
  Organizations.
• 1992 President Bush proposed a tax credit and
  health insurance voucher program.
• 1993 President Clintons Health Security Plan
  which would ensure health coverage for all
  Americans and control costs through managed
  competition is defeated.

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Milestones Health Care in Canada

• 1957 Hospital Insurance and Diagnostic Services
  Act
• universal hospital insurance plan
• administered by provinces
• financed jointly by the provinces and the
  federal government on a 5050 basis

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Milestones Health Care in Canada

• 1966 Medical Care Insurance Act
• universal health care plan providing coverage
  of
• hospital care, diagnostic services, and
  physicians fees
• Administered by provinces.
• Financed by provinces and the federal
  government on a 5050 basis.
• Patients have free choice of hospitals and
  physicians.
• Hospitals are paid through the imposition of
  annual global budgets.
• Physicians are reimbursed for their services
  according to negotiated fee schedules.

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Milestones Health Care in Canada

• 1977 Established Programs Financing Act
• Replaced cost sharing with block grants that
  were tied to the GNP growth and transferred
  federal tax points to the provinces to raise
  additional revenues.
• Federal government abandons the 5050 cost
  sharing formula and its share of total health
  care expenditures declines from 50 in 1977 to
  15 in 2002
• 1977 (50) 1980 (45) 1990 (37)
  1997 (23)
• 2002 (15)

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Milestones Health Care in Canada

• 1984 Canada Health Act
• amalgamated hospital and medical insurance
  into one statute
• banned extra-billing by physicians
• banned user fees for insured health services
• proscribed five health act principles
• - universal coverage
• - equal access to health care
• - comprehensive benefits
• - portability across provinces
• - public administration

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CANADA HEALTH ACT (CHA)

• The CHA sets the Canadian national health care
  standards and ensures that all Canadian residents
  have access to necessary health services
  regardless of their ability to pay.
• Provincial insurance plans must meet CHA
  standards to qualify for full federal health
  contributions.

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CANADA HEALTH ACT (CHA)

• CHA stipulates the following five criteria
• (1) Public administration
• (2) Comprehensiveness
• (3) Universality
• (4) Portability
• (5) Accessibility

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It is no longer acceptable morally, ethically,
or economically for so many of our people to
be uninsured or seriously under-insured.
JAMA 1991 15 years later, not much has
changed.
30
Human Development Index (HDI)

• Serves as an alternative measure of social
  development, supplementing GNP
• Accounts for three distinct indicators
• - longevity and health care
• - adult literacy rate and education
• - GNP per capita (real and PPP adjusted)

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Human Development Index (HDI)

• Indicators
• - Life expectancy at birth (health care)
• - Education
• literacy of adults (2/3)
• attendance at 3 levels of
  schooling (1/3)
• - Income
• Goals
• - Life expectancy 85 years
• - Education accessible for all
• - Reasonable income for all

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Human Development Index (HDI) Ranking of 175
countries

• 1995 1997 1999 2001 2003
• Canada 1 1 2 3 8
• USA 2 3 5 6 7

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Human Development Index (HDI) 2003

• 1. Norway 6. Belgium
• 2. Iceland 7. United States
• 3. Sweden 8. Canada
• 4. Australia 9. Japan
• 5. Netherlands 10. Switzerland

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HEALTH CARE COSTS as percentage of GDP
USA
CANADA
GNP
35
Health Care Expenditures (2002)

• Per capita ( US) Percentage of GNP
• United States 4887 13.9
• Germany 2808 10.7
• Canada 2792 9.7
• Japan 2009 8.0
• United Kingdom 1992 7.6
• OECD average 2117 8.4
• Source OECD 2004

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Health Care Expenditures as percentage of GNP

• 1960 1975 1990 1993 1998 2001
• Canada 5.4 7.2 9.2 9.9 9.1 9.7
• United States 5.2 8.4 12.6 13.3 13.0 13.9
• Japan 3.0 5.6 6.1 6.6 7.1 8.0
• U.K. 3.9 5.5 6.0 6.9 6.9 7.6
• Germany 4.8 8.1 8.7 10.0 10.6 10.7
• source OECD 2004

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Health Care Indicators

• Accessibility
• Per capita spending on health care
• Percentage of GNP spent for health care
• Life expectancy
• Infant mortality rate
• Maternal mortality rate
• Waiting lists for diagnostic and therapeutic
  procedures
• Access to high technology equipment

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Life expectancy at birth (years)

• Japan 81.3
• Sweden 79.7
• Canada 79.2
• United Kingdom 77.4
• United States 76.9
• China 71
• India 64
• Range 34 to 81.3
  SOURCE HDR (2003)

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Life expectancy at birth (years)

• Cigarettes of
• per adult
  population
• per year daily
  smokers
• Japan 81.3 2950 31
• Sweden 79.7 1085 19
• Canada 79.2 1820 18
• United Kingdom 77.4 1553 27
• United States 76.9 2092 19
• China 71 1780
• India 64 112
• Range 34 to 81.3
  SOURCE HDR (2003)

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United States
Canada
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Infant mortality (per 1000 live births)

• Japan 3.1
• Sweden 3.4
• Canada 5.3
• United Kingdom 5.6
• United States 6.9
• Range 3.1 to 182 SOURCE OECD (2003)

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Maternal mortality (per 100 000 live births)

• Sweden 5
• Canada 6
• United Kingdom 7
• United States 8
• (whites 6, hispanics 10, African Americans
  25)
• Japan 8
• Range 5 to 1800 SOURCE HDR 2003

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United States vs. Canada

• HDI indicators U.S. Canada OECD
• Life expectancy 78.6 79.4 74.3
• (years)
• Infant mortality 6.9 5.3 6.6
• (per 1000 live births)
• Maternal mortality 8 6
• (per 100 000 live births)
• Population over 65 years 12.4 12.7 13.9

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Health Care in North America (2002)Physicians
and Nurses

• United States Canada
• Physicians
• number 690 000 60 900
• number per 1000 population 2.7 2.1
• population per physician 370 476
• Nurses
• number 2 300 000 231 500
• number per 100 000 population 8.1 9.9
• population per nurse 123 101

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Physicians per 1000 population

• U.K. 1.6 (1 per 610)
• Canada 2.1 (1 per 476)
• Japan 2.0 (1 per 508)
• United States 2.7 (1 per 370)
• Italy 5.7 (1 per 176)
• Range 1 - 5.9 (world average 1.2) SOURCE
  WHO and OECD

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Medical Schools

• Accredited by the Liaison Committee on Medical
  Education (LCME)
• United States 125
• Canada 16

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Health Care in Canada Physicians (2002)

• Total number 60 900
• Family physicians 31 500
• Specialists 29 400
• Estimated needs
• 2500 per year to compensate
• for retirement (2100) and emigration (400 per
  year)
• Actual increase
• 1750 per year (Canadian graduates and
  immigrants)
• Source Southam Medical Database

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Health Care in Canada Cost containment during
1990s

• Policy of restricting supply
• Reduction in number of students enrolled in
  Canadas medical and nursing schools.
• Tight restrictions on the purchase of high
  technology medical equipment through a
  centralized approval process.
• Closing or merger of hospitals resulting in
  decrease in number of hospital beds.

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Health Care in Canada Results of Cost
Containment

• Education
• - First year medical students (16 medical
  schools)
• 1983 (1887) 1998 (1581)
• - Nursing school students
• 1993 (12 621) 1997 (5063)
• High technology equipment
• Of the 30 OECD countries, Canada is in the
  bottom third.
• Hospitals
• 1991 (1128 hospitals - 175 000 acute care
  beds)
• 1998 (877 hospitals - 122 000 acute care
  beds)

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United States (2300)
United States 8.1 Canada 2.5
OECD average 6.5
Canada (80)
Number of MRI units per million population
51
Canada
United States
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United States vs. Canada

• U.S. Canada OECD
• Health expenditures 13.9 9.7 8.4
• ( of GDP)
• Health expenditures 4887 2937 -
• ( US)
• Health expenditures 44 71 72
• ( public share)
• Prescription drugs 12.4 16.4 -
• ( of total)
• Private insurance 35.6 11.4 -
• ( of total)

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Aging and Health Care Cost
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United States vs. Canada

• U.S. Canada OECD
• Life expectancy (years) 76.8 79.4 74.3
• Infant mortality (per 1000) 6.9 5.3
  6.6
• Maternal mortality 8 6
• Population ( over 65) 12.4 12.7 13.9
  

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CANADIAN HEALTH CARE SYSTEM

• The Canadian health care is financed publicly
• and has three primary players
• Provincial governments
• Federal government (Canada Health Act)
• Private physicians

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CANADIAN HEALTH CARE REFORM

• Current options
• Status quo.
• Make the present system work better.
• Modify the Canada Health Act and introduce a
  two-tier health care system that will allow
  private, for-profit organizations to insure and
  provide services already offered by the public
  system.

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Health Care in North America (2003)

• U.S. Canada U.S./Canada
• Population (million) 288 32 9 1
  (1 0.11)
• GNP (billion US) 10 450 728 14.5
  1 (1 0.07)
• GNP per capita (US) 34 320 27 130
  1.6 1 (1 0.63)
• Health care costs 13.9 9.7 1.43
  1 (1 0.7)
• ( of GNP)
• Health care costs 1400 89 16
  1 (1 0.064)
• (billion US)
• Health care costs 4887 2792 1.75
  1 (1 0.57)
• (per capita US)

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United States Canada

• Area (million sq. km) 9.16 9.22
• Area (million sq. miles) 3.54 3.56
• Population (millions) 288 32
• Population density (people/sq. km) 3.4 0.27
• GNP ( US per person per year) 38 100 23 100
• Government Presidential Federal
• federal
  parliamentary
• republic monarchy
• Federation 50 states 10 provinces/
• 3 territories

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CONCLUSIONS

• Health care should not be treated as an ordinary
  market commodity, because, when left completely
  unregulated, the outcomes are not optimal, either
  in terms of peoples health or in terms of
  economic efficiency.
• Too much bureaucratic government involvement in
  health care, on the other hand, results in
  mediocre services, inefficient workforce, and
  shortages of staff and equipment.

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CONCLUSIONS

• Canada uses a mixed public (71) and private
  (29) health care system. The public component is
  shared between the provinces (83) and the
  federal government (17).
• Canadas expenditure for health care at 9.7 of
  its GNP is above the OECD average (8.4) but
  considerably lower than that of the U.S. at
  13.9.
• Health care indicators place Canada among the
  best performers in the OECD group, ahead of the
  U.S.

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CONCLUSIONS (cont.)

• Both the U.S. and Canada have severe problems
  with access to, and financing of, health care
  services.
• In the U.S. some 44 million people have no
  health insurance because they cannot afford the
  cost of private insurance.
• In Canada long waiting lists for diagnostic and
  therapeutic services persist because of
  equipment and health personnel shortages.

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CONCLUSIONS (cont.)

• The U.S. spends almost 14 of its GNP on health
  care, yet 15 of its people are not covered by
  health insurance.
• Only 44 of health care costs in the U.S. are
  financed publicly, the remaining 56 are
  financed privately.
• Administrative costs of the U.S. health care
  system amount to 25 of the total health care
  costs.

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HEALTH CARE IN THE U.S. AND CANADA

• Public perception in both countries
• Health care systems in both countries are in
  serious trouble.
• Americans have no respect for the Canadian
  approach to health care financing and delivery
  Canadians have similar feelings about the
  American approach.
• Problems with cost and access must be corrected
  urgently.
• The 2004 federal election in Canada will feature
  health care as one of the most important domestic
  issues.
• The 2004 presidential election in the U.S. will
  again side-track the health care issue.

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A healthy man has a thousand wishes, a sick
man has only one. Slovenian proverb