What are the challenges facing Medicare in Canada? Can we afford them?
A majority of the professionals in healthcare, along with the rest of the Canadians, are quite committed to the tenets of Medicare. This being the case, it has not been lost to everyone that the Canadian healthcare system is plagued by serious problems, and oftentimes, it fails to provide the expected care, at least from the perspective of the public (Campbell & Marchildon, 2007). As such, the issue of the challenges that face Medicare in Canada is increasingly turning out to be a controversial subject; even as far as the politics of Canada are concerned (Madore, 2002).
According to Madore (2002), “The measure of “overall health system performance” derives from adjusting “goal attainment” for educational attainment. Although goal attainment is in theory based on five measures (level and distribution of health, level and distribution of “responsiveness” and “fairness of financial contribution”), the true values that got assigned to a majority of the countries, and this include Canada as well, never actually got to be measured. The ensuing scores therefore fail to take into account information relating to how the system actually works, except the reflection of the system in terms of life expectancy. The chief reason as to why the health care system in Canada has received such a low rating has to do with the comparatively highly educated population, in comparison with say, France, as opposed to anyone given aspect of the country’s health system (Walker & Esmail, 2002).
According to a recent report that was released by the Canadian Health Council, “Herein lies one of the puzzles of Canadian health care: Canadians increasingly view the health care system as unsustainable and under threat, even as their own experiences with the system are mostly positive.” (Irvine et al 2002). Health care provision analysts believe that the root cause of this problem in the Canadian health care system may be traced back to the successful attempt at controlling the costs incurred by this sector back in the 1990s. At this time, per capita, public health expenditure, along with the inflation-adjusted dollar, was actually seen to witness a massive fall (Madore, 2002). The chief reason as to why the health care system in Canada has received such a low rating has to do with the comparatively highly educated population, in comparison with say, France, as opposed to anyone given aspect of the country’s health system (Walker & Esmail 2002).
The 1990s efforts came about as a result of attempts by the Canadian federal government to contain its deficit, thereby resulting in a cut as far as provincial transfers were concerned and consequently, the hospital budgets, along with the reimbursements of the physicians were also further squeezed. There was also a massive drop in terms of the physicians that were receiving training. The repercussions to this came in the form of increased wait times, and especially as far as elective procedures are concerned. Lately, the Canadian government is trying hard to re-invest in the confidence of the government about the health care issue, albeit with low progress (Irvine et al, 2002).
Some of the most common complaints regarding the Canadian health care system has to do with access, often to elective surgery ( in the particular knee and hip replacement, as well as surgery for cataract), in addition to diagnostic imaging. Apparently, these have essentially been targeted by the reinvestments into healthcare. The idea of having in place a parallel private healthcare system in Canada has also been blamed for the challenges that have of late faced the Medicare system in Canada. Several think tanks and politicians have been open to the argument of removing the existing barriers in as far as a private and parallel health care system. It has also been the argument of other health care professionals in Canada that such systems act to impede equity, and also erode cost control (Madore, 2002).
According to a 2001 Fyke report, a majority of the Canadian cites limited funds as the reason behind poor quality healthcare. Nevertheless, analysis and evidence have sought to refute these kinds of claims, to the effect that a poor quality is usually too dear in healthcare when compared to good quality. Furthermore, good quality often affords the sustainability of a healthcare system (Campbell & Marchildon, 2007). For example, the aftercare program for patients with congestive heart failure in Alberta led to a 60 percent reduction in terms of use of hospital care in the future for the patients. In addition, each of the participants ended up saving $ 2500. In another case, the Royal Columbian Hospital in New Westminster helped pain complications due to heart surgery by about 80 percent. In addition, the length of time by which the patient’s hand to be admitted to the hospital was also reduced by 33 percent.
The long waiting list appears to be the reason behind the prevailing pressures to have the health care system in Canada partially privatized. For those Canadians in support of having the health care system privatized, the waiting list is a manifestation of a diminished capacity of the Canadian health care system of delivery. There are critics of the system who hold the argument that in order for the lists to be minimized, Canada ought to adopt a two-tiered system of care’ (Rachis 2004). Here, both the private and public sectors should co-exist with each other, so that those patients whose healthcare is privately insured are able to attain a faster access to health care services, thus reducing the congestion in the system. Even then, there are still other Canadians who are of the view that the system’s gross under-funding, as opposed to believing in an equity principle, ought to be blamed for the poor quality of the health care system in Canada. By enhancing funding of the healthcare system, these critics reckon that there is no need for Canada to implement a two-tiered system.
At the moment, there appear to be no barriers to private clinics, under the Health Act of Canada, but provincial governments are at liberty to either permit these or not. Individual physicians have also been known to operate their private clinics. The opinion of the United States about the issue of the Canadian health care system may at best be regarded as being non-neutral. Opinions that appear to be opposed to the health care system in Canada argue that the Canadian health care system is characterized by massive budget cuts and prolonged wait times, and these have therefore resulted in a health care system that is severely impaired. So much so that there is documented evidence that Canadian mothers make the trip to the United States to have their babies delivered, as a result of a lack of nurses and rooms for nursing premature babies at some of the hospitals in Canada (Irvine et al, 2002).
Evidence of an under-funded health care system, when compared with that of the United States also exists. For example, in 2003, the Canadian government spent $ 2, 998 USD per capita on the nation’s health care. On the other hand, the United States government spent $ 5, 7, per capita on the same. The fact that health care providers in Canada lack competition mean that health care unions now enjoy a monopoly about the provision of essential services, thereby ensuring that they occupy quite a strong bargaining position (Ovretveit, 2002). At the moment, Nova Scotia is debating legislation on healthcare, whose aim is to eliminate the threat of healthcare workers involved in strikes, in effect replacing these with binding arbitration (Maynard & Dixon, 2002).
What can (should) be done to improve health care in Canada?
An increase in the funding of the Canadian health care system is one of the proposed solutions that could help improve this sector. Those in support of such an approach often cite the escalation in the economic policies of neo-conservatives in the country, along with the related reduced expenditure on welfare state program (especially within the provinces) from the 1980s moving forward, as the principal causes of the observed degradation of the healthcare system. Evidence also exists to support claims that the total government expenditure (in terms of percentage) on healthcare has been on the rise, partially due to the percentage rise in the number of older Canadians. (Irvine et al, 2002).
Nevertheless, there are those critics that think that increased funding of the health care system may not ultimately solve the prevailing problem, in addition to infrastructure, escalation in the cost of medical technology, and wages. These critics opine that as a result of the proximity of Canada to the United States, this in itself helps escalate the incidences of doctors and nurses who have been trained in Canada (‘brain drain). In the United States, there is the prospect of private hospitals paying remarkably higher wages, and the rates of income tax are also quite modest. This is especially the case, seeing that in the United States taxation is not responsible for covering health care. There are also critics that are open to the idea that increase privatization of the provision of health care in Canada could enhance the country’s health infrastructure. On the other hand, there are those that are opposed to a privatization (Maynard & Dixon, 2002).
Those criticizing the idea of systemic reform within the health care sector argue that healthcare ought to remain public, partly because a public health care system separates Americans and Canadians through a mandate on fairness and equality as far as health care is concerned. It is worthy of note here that the Canadian health care system may not be regarded as purely public, if at all we were to compare the system with that in Italy, whereby the salary of doctors is pegged on a per capita basis. Rather, the health care system gets funded publicity, an approach that a majority of the Canadians not only desire, but also appreciate (Rachlis 2004). At the moment, those hospitals that are owned and operated privately allow their patients to foot their medical bills on an out-of-pocket basis. These therefore are not in a position to get any funding in Canada, seeing that they act contrary to Canada Health Act and its “equal accessibility” tenets. Several medical professionals and politicians have submitted proposals to enable these hospitals access public funding. In Quebec for example, a recent change in the legal statutes of the province has paved the way for this reform.
The Canadian Supreme Council overturned a law in the province that sought to prevent individuals from purchasing private health insurance for purposes of settling medical services that are provided courtesy of a system funded by the public. The ruling that was made in June 2005 nevertheless is not applicable outside of Quebec. Such insurance companies as Green Shield, Blue Cross, and Manulife have for a long time now provided medical cover for services that Medicare does not seem to cater for, such as eye and dental care. In addition, a majority of the employers also provide private insurance to their employees, as a benefit (Irvine et al 2002).
Still, it is possible to improve the status of the public health care in Canada via an implementation of a regulated market of private health insurance. The resulting new market would mean that the public health insurer, together with the unlimited number of insurers from the private sector, are out to compete for the same customers using similar sets of rules, and on a level playing ground. In this case, the market would have to be quite heavily regulated to overcome problems that bear a correlation with market failure; as far as health insurance is concerned. It is important in this case that both the private and the public usurers offer same “basic package of benefits covering a defined range of medically necessary services” (Gratzer, 2002).
There is also the possibility of combing a medical savings account (MSA) with a flat deductible. In this case, the package could be directed at individuals with a low income. Not only is it possible then to cut the costs for Medicare, but one can also enhance accountability within the health care system, help in the establishment of market incentives in as far as service improvements are concerned, and also give individuals more power within the context of the health care system. Like any other kind of insurance, health care deductibles would allow for the setting of the highest amount of money that individuals would be required to contribute towards their personal care (Rachlis, 2004). On the other hand, a MSA may be seen as a tool that enables people to establish a poll of money (tax-free of course) for their future needs in health care. Oftentimes, the government ends up subsidizing consumers that are less affluent by means of targeted MSAs to see to it that they enjoy universal access to services that are deemed medically necessary.
Despite the anticipated competition between on the one hand, the private health care insurance providers and on the other hand, their counterparts from the public sector, in the presence of proper sectoral regulation, this acts to allow the health care consumers shorter waiting times in as far as medical care is concerned, greater choice, and higher quality service (Madore, 2002). Moreover, health professionals stand out to enjoy improved working condition, meaning that now they prefer working in Canada, as opposed to migrating to say, the United States, where they have better working terms.
This also means that the problems that accompany the processes of staff recruitment and retention are alleviated, in effect also ensuring that human resources shortages in ass far as health care is concerned, are not witnessed (Maynard & Dixon, 2002). Ultimately, this shall result in a financially sustainable system, in which costs get tied more to the demands of the consumers (Ovretveit, 2002), in addition to a minimization of perverse incentives with regard to over-prescription and over-consumption of services.
Saskatchewan pharma
Saskatchewan health in 1999, gave authorization to pharmacists to initiate requests for exception drug status (EdS). These have also come to be referred to as prior authorization (Pa). Prior to 1999, only pharmacists that had received a medication prescription had the authority to initiate requests for EdS. Further, it is required that a pharmacist that submits a request for Eds should also obtain the diagnosis of a patient from either a physician’s agent, or an actual physician. The Pharmaceutical Information Program (PIP) of Saskatchewan deserves to be lauded. The design of the PIP program is such that it helps in the establishment of a link between pharmacies, the hospital, and physicians in the community (Saskatchewan Health, 2007).
The program enables these professionals to provide shared and confidential access to the medication histories of the patients. Nevertheless, while the PIP program could prove valuable in the alleviation of prevailing barriers about pharmacists’ review of a patient’s complete medical history, nevertheless it fails to provide given pharmacists with access to additional information on the medical history of a patient (Saskatchewan Health, 2006). These may include the diagnosis of a patient, and this is a requirement if at all an EDS request is to be initiated. In this case, therefore, the Saskatchewan pharma may be seen as having a drawback.
Back in July 2006, the drug plan of Saskatchewan sought to implement changes that were geared towards a streamlining of the application process of EDS. To start with, 116 drugs (the equivalent of 442 EDS drug information numbers) were approved. In addition, 2 drugs also had their online implementation adjudicated. These drugs are rosiglitazone maleate and pioglitazone HCl. The EDS claim over these agents may be both adjudicated and submitted discretely through a transactional claims processing system, online (Saskatchewan Health, 2006). This system makes use of as ‘smart edit’ for purposes of evidence “of prior use of first-line therapy or prior use of the target drug that would have been associated with an EDS approval”.
On the one hand, this could be seen as a positive step towards the addressing of a number of the issues that seem to characterize PA programs, thanks to administrative workloads. Alternatively, this system of online adjudication at the moment includes just two drugs. There is a need therefore to ensure that the Saskatchewan program is replicated in other regions as well, so that patients may benefit from the advances in technology to get access to medication (Saskatchewan Health, 2006). In addition, there is a need to ensure that more drugs are included in the online adjudication system.
National pharma care plan
Pharmaceutical happens to be a key problem of the health care system in Canada and which appears to be getting out of hand. For a long time now, prescription drugs have come to be viewed as “a cornerstone to modern healthcare, but (outside hospitals) they have never been covered by Canada’s universal, single-payer, federal-provincial Medicare system” (St-Hilaire & Jeremy, 2008). Although Justice Emmett Hall, who was the Canadian Royal Commission in 1964 had identified national pharmacare “as an important policy goal” (St-Hilaire & Jeremy 2008), he nevertheless saw it fit to recommend that such a plan be delayed up to the point at which the rise in the cost of drugs would hit a plateau. Clearly, this was, without doubt, a fatal error that the policymakers have had to make do with since then.
Against this backdrop, it is not a wonder then, that the release of a policy paper on the Canadian national pharmacare plan in February 2006 was seen as a process long-overdue. This national pharmacare plan is an attempt at facilitating easy access to and affordability of surgical drugs costs within Canada. This plan could not have come at a better time, seeing that the current patchwork of both the private and the public drug plans has proved to be quite inequitable, since access to drug costs coverage does not get determined on a need basis. Rather, the determining factor is the place of residence of a beneficiary, as well as their place of work (St-Hilaire & Jeremy, 2008).
Given that the prices of drugs are seen to be skyrocketing as time goes by, the status quos is also proving to be quite unsustainable. There is also the issue of negative influence of the companies dealing with pharmaceuticals, about safety and cost, and this is proving to be a threat to the Canadian public Medicare, and the Canadians as well. As such, there is a need for a new system that shall not only be affordable, but accessible, and places the safety of their beneficiaries before everything else.
For over fifty years, Canadians have waited to have a national Pharmacare plan. For all this time, the country has been characterized by a single-payer system for physician and hospital care. The time is ripe, therefore, for the country to shift from the prevailing chaotic patchwork of private and public drug plans, and replace this with “a national single-payer plan for pharmaceutical care as well” (Walker & Esmail, 2002).
Works Cited
- Aba, S, Goodman, W. D. & Mintz, J. M. 2002. Funding Public Provision of Private Health: The case for a co-payment contribution through the tax system. Ottawa: C.D. Howe Institute, 2002.
- Campbell, B & Marchildon, G. Medicare; Facts, Myths, Problems & Promise. Toronto: James Lorimer & Company Ltd, 2007
- Gratzer, D. Better Medicine: Reforming Canadian Health Care. Toronto: ECW Press, 2002.
- Irvine, C, Hjertqvist, J. &. Gratzer, D. Health Reform Abroad in Better Medicine: Reforming Canadian Health Toronto: ECW Press, 2002.
- Madore, O. 2000. Canada Health Act: Overview and Options. Ottawa: Statistics Canada.
- Maynard, A. & Dixon, A. Private health insurance and medical savings accounts in Funding health care: options for Europe. WHO, 2002.
- Ovretveit, J. The Changing Public-Private Mix in Nordic Healthcare – An Analysis. Stockholm: The Nordic School of Public Health and Faculty of Medicine, Bergen University, 2002
- Rachlis, M. Prescription for excellence: how innovation is saving Canada’s health care system. Vancouver: HarperCollinsPublishersLtd, 2004
- Saskatchewan Health. Drug Plan and Extended Benefits Branch Annual Statistical Report 2005-2006. Regina, SK, Canada: Government of Saskatchewan
- Saskatchewan Health, 2007-2008 Saskatchewan Provincial Budget. Regina, SK: Government of Saskatchewan; 2007.
- Walker, M. & Esmail, N. How Good is Canadian Health Care? An International Comparison of Health Care Systems. Vancouver: Fraser Institute, 2002