Access to the Canadian health care system - Essay Example

Running head: Access to the Canadian Health Care System Access to the Canadian Health Care System [The of the appears here] [The name of institution appears here] Access to the Canadian Health Care System Human geographers have long been concerned with issues of geographic accessibility. In health geography, access to health care services has consistently been identified as a key theme of research. Within Canada, accessibility takes on special meaning for geographers in general, health geographers in particular and most critically to all Canadians because of the fifth principle of the 1984 Canada Health Act (CHA). The CHA is the only piece of Federal legislation that governs health care delivery in the provinces and territories. According to the CHA, all provinces and territories in Canada must abide by five principles in order to receive federal funds: universality; comprehensiveness; portability; public administration; and accessibility. The underlying sentiment of accessibility' in the CHA is to ensure access to medically necessary health care services for all Canadians regardless of ability to pay. In fact, the act states that to meet the requirements of accessibility, provincial health insurance plans "must provide for insured health services on uniform terms and conditions and on a basis that does not impede or preclude, either directly or indirectly whether by charges made to insured persons or otherwise, reasonable access to those services by insured persons." www.bcma.org/public/news_publications/ publications/policy_backgrounders/healthcareaccess.asp The single-payer system as it has functioned in Canada has reduced Canada's health care costs substantially below those of the United States. It has also produced much higher satisfaction levels among Canadians. The Canadian system is a mixed federal and provincial government system with the federal government laying down the basic requirements which govern the health plans offered by the provinces. These plans must provide all medically necessary health care to all Canadian residents. The plans must be portable among the provinces, operate on a nonprofit basis, and be managed by public agencies accountable to the provincial governments. Thus each Canadian province is a separate insurer and has the discretion to cover other services such as prescription drugs for the elderly and dental care for children. The provinces receive capitation grants from the federal government amounting to about 38 percent of total costs, a 12 percent decline from the original federal contribution. They are free to finance their health care from any source although user fees may not be imposed. Most of the provinces rely solely on general tax revenues. Four provinces impose small premium charges. In Canada, the provincial governments make all the critical decisions about how much money is spent annually on health costs, whether to insure services beyond those mandated by the federal government, and how to finance their health care plans. Canadian hospitals negotiate their annual global budgets with the provincial governments. Hospitals have no billing responsibilities which substantially cut administrative expenses. Capital budgets require special provincial government approval. Physicians and health care professionals negotiate the fees they can charge with their provincial governments. Provincial governments also control the number of new medical students and interns and the ratio of specialists to generalists. Physicians submit monthly bills to the provincial government, substantially reducing the amount of paperwork and administration needed to get reimbursed for their services. They are not permitted to engage in balanced billing. Insurance companies may not offer policies covering the mandated government health care package but may offer coverage on other health care services not in the mandated coverage. There are some downsides to the Canadian health care system. Canadian patients do not receive the same intensive high tech medicine as do U.S. citizens. It is generally agreed that the United States more rapidly adopts high technology health care equipment than Canada. For example, in Canada, only three hospitals for every three million persons are equipped to perform heart surgery. The Canadian Health Ministry, in consultation with cardiac surgeons, deliberately limited heart surgery wards in order to concentrate procedures and experience at a few centers. Some hospitals may be less comfortable, with hand cranked hospital beds and may use treatments causing more discomfort for patients. Physicians lacking CAT scans must perform examinations manually. There are substantially fewer cardiac catheterization labs, lithotripters (for crushing kidney stones), and MRI scanners per patient in Canada than in the United States. Canadian physicians reportedly employ more conservative treatment protocols. For example, U.S. physicians tend to advise cholesterol testing for anyone over age 20 and treat patients with cholesterol levels in excess of 200. Canadian physicians, on the other hand, test only persons with a risk of heart disease and do not pursue treatment unless levels exceed 256. They claim that medical studies support these more conservative protocols. It is not clear whether these practice differences have resulted from Canada's single-payer system or simply reflect medical practice differences between the two countries. Finally, there are waiting lists for access to hospitals for certain nonemergency procedures. Canadian patients must wait up to three months for cataract surgery, three to six months for coronary bypass, and five months for hip replacement. In addition, Canadians may have to travel some distances for certain procedures. Travel expenses are reimbursed for patients, but not for accompanying family members. (The Washington Post 1991d, 1991e; The Wall Street Journal 1991; Neuschler 1991). However, despite these real and alleged drawbacks, both Canadians and the Canadian health care establishment are wholly supportive of their system. Every person is insured from birth or upon entry into Canada; no person is denied coverage for any health or financial reason; benefits provided are more comprehensive than those typically provided in the United States; and the cost of health care is lower per capita in Canada than in the United States. (Conklin 1991). Some researchers have argued that the CHA is unclear in its discussion of what constitutes reasonable access' to medically necessary services. However, recently, Health Canada has distinguished between two types of reasonable access--economic and physical. According to Health Canada, economic accessibility refers to the provision of health care services without financial charges, either direct or indirect. Physical access, on the other hand, is "interpreted under the Canada Health Act using the "where and as available" rule. Thus, residents of a province or territory are entitled to have access to insured health care services at the setting "where" the services are provided and "as" the services are available in that setting;" (Health Canada 2000). The provinces and the territories have interpreted the latter part of the accessibility principle to mean that they have a responsibility to provide health services in large cities and small towns, rural areas and remote areas. They do so through various mechanisms ranging from incentives for physicians to locate in underserviced areas to telemedicine to programs that subsidize the costs of patients who need to travel to specialized medical facilities found only in the largest cities or even outside of Canada. Access to health care services is, therefore, an important issue for geographers to consider given its importance in the CHA and the importance that Canada's public, universal and comprehensive health care systems holds in the Canadian psyche. Access to health care services is also an especially salient issue to explore given the current political and social climate in which the future of the health care system in Canada is being debated. Throughout the 1990s and into the present decade, there is increasing concern that the Canadian health care system is in a state of crisis. One crisis theme often mentioned is that fiscal decisions of various kinds are reducing accessibility as defined by the CHA. While there is much anecdotal evidence of the existence of a crisis, there are few systematic studies to assess whether a crisis exists and what type of crisis is it. Geographic access to health care services has been and continues to be an important area of research for health geographers. As early as the 1980s Joseph and Phillips (1984) examined accessibility to health care services from both a spatial and theoretical perspective. In 1988, Rosenberg extended accessibility research further by identifying and distinguishing between geographic and economic accessibility. One of the underlying assumptions of geographic/physical access to services is that people living in regions with more services will have greater access to health care (Rosenberg and Hanlon 1996). In this vein, researchers have focused on access to services within under serviced regions and the impacts of hospital closures on access to care. In the Canadian context, research on access to health care delivery needs to be seen from the perspective of the constitutional responsibility of the provinces and territories vis a vis the federal government. Since the provinces and territories are permitted to establish various health institutions and implement health policies as long as they fulfill the stipulations of the federal Canada Health Act, there exists 13 different provincial/territorial health care systems within Canada. Access to health care is an especially salient issue when considered in the context of the CHA. The CHA is a unique piece of legislation because it is the only federal health care legislation concerned with geographic and economic accessibility. The primary objective of health care policy as outlined in the 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." Based on the recommendations of the Hall Commission (1980), the spirit and purpose of the CHA is to ensure equality of access to medically necessary services by prohibiting the use of extra-billing and user fees. As such, the underlying sentiment of the CHA is to create an even playing field for accessing services both geographically and economically. As noted earlier, there is also the de facto provincial intent to provide reasonable geographic access to health services. By exploring access to health care services in each of the provinces, this paper gives insight into the accessibility to health care services and whether crises of accessibility vary from province to province. Recently, supporters and critics of the Canadian health care system have engaged in numerous debates concerning the viability of the CHA and the extent to which access to health care services, as mandated by the CHA, is being achieved. It is argued that reductions in federal government transfers to the provinces have resulted in a health care system characterized by under-funding in key areas and policy decisions based more on provincial fiscal concerns than the health needs of their constituents. Provincial governments have responded to reduced levels in federal funding by undertaking aggressive restructuring tactics such as the closure of hospitals and the deinsuring of medical services from provincial health plans (Hanlon and Rosenberg 1998). The end result of this restructuring, as argued by the media, consumer groups and indeed some health researchers, is a state of crisis (i.e., lower levels of accessibility, long waiting lists, overcrowding in hospitals and increasing costs of medication) and decreasing confidence in the Canadian health care system. While there is much anecdotal evidence of the existence of a crisis, there are few systematic studies to assess whether a crisis exists and what type of crisis is it. For example, often cited as evidence of a health care crisis, the Fraser Institute's study on waiting times in Canada is actually based on physician perceptions of waiting times, not on the analysis of how much time people actually wait to receive services (Rachlis et al. 2001). While the information provided by opinion polls, and media and health reports is important, they are not necessarily a direct reflection of people's experience with their provincial or territorial health care systems. Opinion polls and media and health reports also say little about the extent to which a crisis varies spatially. Reference: Conklin, D. (1991), "Health Care: What Can the United States and Canada Learn from Each Other" National Planning Association, National Health Care: Is It the Answer (US Canada Outlook): 3. HEALTH CANADA (2000). Canada Health Act Annual Report 1999-2000 (Ottawa: Minister of Public Works and Government Services Canada) dsp-psd.pwgsc.gc.ca/Collection/H1-4-2001E.pdf JOSEPH, A.E., and PHILLIPS, D.R (1984). Accessibility and Utilization: Geographical Perspectives on Health Care Delivery (New York: Harper and Row), 114-126 Neuschler (1991), "Is Canadian Style Government Health Insurance the Answer for the United States Health Care Cost and Access Woes" NPA, National Health Care: Is It the Answer (US Canada Outlook): 49-58. RACHLIS, M., EVANS, R.G. LEWIS, P., and BARER, M.L (2001). Revitalizing Medicare: Shared Problems, Public Solutions (Vancouver: Tommy Douglas Research Institute), 24-26 ROSENBERG, M.W., and HANLON, N.T (1996). Access and utilization: a continuum of health service environments' Social Science and Medicine 43, 975-983 The Washington Post (1991d), (April 30): 1, 16. The Washington Post (1991e), (July 17): 9. The Wall Street Journal (1991), (December 23): 1. Read More