Canada | Commonwealth Fund

how does universal health coverage work?

Canadian Medicare, Canada’s publicly funded universal health care system, was established through federal legislation originally passed in 1957 and 1966. The Canada Health Act of 1984 supersedes and consolidates the two previous laws and sets national standards for medically necessary hospital, diagnostic, and medical services. To be eligible to receive full federal cash contributions for health care, each provincial and territorial (p/t) health insurance plan must meet the five pillars of the canada health law, which stipulates that it must be:

  1. publicly administered
  2. comprehensive under hedging conditions
  3. universal
  4. portable between provinces
  5. affordable (eg no user fees).
  6. role of government: Canadian p/t governments have primary responsibility for financing, organizing and delivering health services and supervising providers. jurisdictions directly fund physician and drug programs, and contract with delegated health authorities (either a single provincial authority or multiple sub-provincial regional authorities) to provide hospital, community, and long-term care, as well as public health services and mental.

    Reading: How does canadian health insurance work

    The federal government co-funds p/t universal health insurance programs and administers a range of services for certain populations, including eligible First Nations and Inuit peoples, members of the Canadian Armed Forces, veterans, resettled refugees, and some applicants. asylum and inmates in federal penitentiaries. It also regulates the safety and efficacy of medical devices, pharmaceuticals, and natural health products, funds health research and some information technology systems, and administers various public health functions on a national scale.

    At the national level, a variety of government agencies oversee specific functions:

    • health canada, which is the federal ministry of health, plays a key regulatory role in food and drug safety, review of medical technology and devices, and advocating for national standards for universal coverage of health.
    • Canada’s public health agency is responsible for public health, emergency preparedness and response, control and prevention of chronic and infectious diseases, and health promotion.
    • A new department of the federal government, Indigenous Services Canada, funds certain health services for First Nations and Inuit.
    • Most providers are autonomous under the p/t law; are registered with a provincial regulatory body (such as the College of Physicians and Surgeons) which ensures standards of education, training, and quality of care are met.

      Most provinces have an ombudsman who advocates on behalf of patients.

      Canada Organization Graphic

      Role of public health insurance:Total health spending is estimated to have reached 11.5% of GDP in 2017; the public and private sectors accounted for approximately 70 percent and 30 percent of total health expenditures, respectively.1 each p/t health insurance plan covers all medically necessary hospital and physician services (on an annual basis). prepaid). Ancillary services, or those not covered by Canadian Medicare, are largely privately funded, either through patient out-of-pocket payments or through private or employer-based insurance.

      Provinces and territories cover all of their own residents according to their respective residency requirements.2 Temporary legal visitors, undocumented immigrants, visitors staying in Canada beyond the duration of a legal permit, and those entering the country illegally are not covered by any federal program or p/t. provinces and territories provide limited emergency services to these populations: no doctor or hospital can refuse to provide care in an emergency, and midwives provide some maternity services.3

      The main source of financing is the government’s general income p/t. most of the p/t revenues come from taxes. About 24% (an estimated CAD37 billion, or $29.4 billion, in 2017-2018) is provided by Canada Health Transfer, the federal program that funds health care for provinces and territories.4

      Role of private health insurance: Private insurance, held by about two-thirds of Canadians, covers services excluded under universal health coverage, such as vision and dental care, medications prescribed for outpatients, rehabilitation services, and private hospital rooms. in 2015, about 90 percent of private health plan premiums were paid through employers, unions, or other organizations under a group contract or an uninsured contract (whereby the plan sponsor provides benefits to a group outside an insurance contract). in 2017, private insurance was estimated to account for 12 percent of total health spending. 5 most insurers are for-profit.6

      Canada Coverage Graphic

      Covered Services: To qualify for federal financial contributions, p/t insurance plans must provide first-dollar coverage of medically necessary medical, diagnostic, and hospital services (including prescription drugs for inpatient) for all eligible. residents all p/t governments also provide public health and prevention services (including immunizations) as part of their public programs.

      however, there is no nationally defined statutory benefit package; most public coverage decisions are made by p/t governments in conjunction with the medical profession. Because of this, coverage varies between p/t insurance plans for services that the federal government does not establish as medically necessary, including outpatient prescription drugs, mental health care, vision care, dental care, home care, midwifery services, medical equipment, and hospice care.

      Most provinces have public prescription drug coverage programs for specific populations, such as welfare recipients, people over 65, children, and youth. some programs charge premiums, often related to income.7

      There are some health services that are mostly not covered by any p/t insurance plan, including dental services, physical therapy, psychologist visits, chiropractic care, and cosmetic or plastic surgery.

      Cost Sharing and Out-of-Pocket Costs: There is no cost sharing for publicly insured medical, diagnostic, and hospital services. Physicians are not allowed to charge patients prices above the negotiated fee schedule.

      In 2016, out-of-pocket payments were estimated to account for about 15% of total health spending; most of it was spent on non-hospital institutions (mainly long-term care homes), prescription drugs, dental care, and vision care.8

      Safety Nets: To help cover needed prescription drugs, provinces and territories provide outpatient drug plans to some people who lack private employer-sponsored insurance. Most p/t outpatient drug plans operate as payers of last resort, targeting people on welfare or retirement age. these plans vary considerably. For example, Quebec administers a universal drug plan by requiring eligible individuals to have private coverage and enrolling those who are not eligible for private coverage in the public plan. By contrast, Ontario, Canada’s most populous province, administers a universal prescription drug program for older adults, children and youth without private coverage, and welfare recipients.

      p/t Governments also provide some relief to people with high out-of-pocket costs. After citizens pay more than 3 percent of their net income, or CAD 2,288 (USD 1,816), whichever is less, for eligible medical expenses per year, they can receive a 15 percent tax credit for any remaining expenses. 9

      In addition, provinces and territories pay room and board (beyond nursing care) for indigent people in publicly funded long-term care facilities.

      Canada Copayment Graphic

      How is the delivery system organized and how are suppliers paid?

      Medical Education and Workforce: Students who obtained a medical degree from one of Canada’s 17 public medical schools paid an average annual tuition of cad 14,780 ($11,730) in 2018-2019.10 About 27 percent of medical doctors in Canada received their degree outside of Canada.11

      In 2017, 92% of physicians practiced in urban areas.12 There are no national programs to ensure the supply of physicians in rural and remote areas. however, most provinces have rural practice initiatives. For example, the Rural, Remote and Northern Alberta program guarantees physicians an income of over CAD50,000 (US$39,382).13

      See also: How much is fluoxetine without insurance?

      primary care: in 2017 there were 2.3 practicing doctors for every 1,000 inhabitants; about half (1.2 per 1,000 population) were family doctors or general practitioners (GPs) and the rest specialists (1.15 per 1,000 population).14 GPS act largely as gatekeepers, with many provinces paying higher fees referrals to specialists for non-referred consultations.

      Most doctors are self-employed in private practices. In 2014, the last year of the national survey of physicians, about 46 percent of GPS worked in a group practice, 19 percent in an interprofessional practice, and 15 percent in an individual practice.15 Across several provinces, GPS networks work together and share resources, with variations between provinces in the composition and size of teams.16

      In 2017, about 62% of regulated nurses (registered nurses, nurse practitioners, and licensed practical nurses) worked in hospitals and 15% in community health centers with salaries.17 in the three northern territories (yukon, Northwest Territories and Nunavut), primary care is often nurse-led.

      In theory, patients have a free choice of GP; in practice, however, patients may not be accepted into a doctor’s practice if the doctor has a closed list. requirements for patient registration vary considerably by province and territory, but no jurisdiction has implemented strict registration.18 quebec, through family medicine groups, has used patient registration and added resources (human and financial) ) to improve access to care.

      Fee-for-service is the main form of payment for physicians, although there has been a move towards alternative forms of payment, such as capitation. In 2016-2017, fee-for-service payments represented about 45% of GP payments in Ontario, 72% in Quebec, and 82% in British Columbia; capitation and, to a lesser extent, salaries made up the rest of the payments.19

      In 2016-2017, the average clinical payment was CAD 276,761 (USD 219,651) for family medicine, CAD 357,264 (USD 283,543) for medical specialties, and CAD 477,406 (USD 378,894) for surgical specialties. 20 In most provinces, specialists have the same fee schedule as primary care physicians.

      Provincial ministries of health negotiate physician fees (for primary and specialized care) with medical associations. In some provinces, such as British Columbia and Ontario, pay incentives have been linked to performance.

      Specialist outpatient care: Specialists are mostly self-employed. there are few formal multi-specialty clinics.

      Most specialized care is provided in hospitals, both inpatient and outpatient, although there is a trend to provide less complex services in non-hospital diagnostic or surgical facilities.

      Specialists are paid primarily on a fee-for-service basis, although there are variations between provinces. For example, in Quebec, alternative payment structures accounted for about 15% of total payments to specialists in 2016-2017, compared to 22% in British Columbia and 33% in Saskatchewan.

      Patients may choose to go directly to a specialist, but it is more common for GPS to refer patients to specialized care. Specialists who bill public insurance plans p/t cannot receive payment from privately insured patients for services that would be covered by public insurance.

      Administrative mechanisms for direct payments from patients to providers: Most doctors and specialists bill governments p/t directly, although some receive a salary from a hospital or facility. patients may be required to pay out of pocket for services not covered by public insurance plans.

      After-hours care:After-hours care is often provided at physician-run walk-in clinics and hospital emergency rooms. In most provinces and territories, a free phone service allows citizens to get health advice from a registered nurse 24 hours a day.

      Historically, general practitioners have not been required to provide after-hours care, although newer group practice arrangements stipulate requirements or financial incentives to provide after-hours medical care to registered patients.21 in 2015, 48 percent of general practitioners in canada (67 percent in ontario) reported having arrangements for patients to see a doctor or nurse after hours.22 however, in 2016, only 34 percent of patients reported accessing after-hours care through their GP.23

      Hospitals: Hospitals are a mix of public and private organizations, predominantly not-for-profit. they are often managed by delegated health authorities or hospital boards that represent the community. In most provinces and territories, many hospitals are publicly owned,24 while in Ontario they are predominantly private, not-for-profit corporations.25

      There is no specific data on the number of private for-profit clinics (mainly diagnostic and surgical). however, a 2017 survey identified 136 private for-profit clinics across Canada.26

      hospitals in canada generally operate under annual global budgets, negotiated with the provincial ministry of health or delegated health authority. however, several provinces, including ontario, alberta, and british columbia, have considered introducing activity-based financing for hospitals, paying a fixed amount for some services provided to patients.27

      Hospital doctors are generally not employees of the hospital and are paid a fee-for-service directly by provincial health ministries.

      mental health care: mental health care provided by a physician is covered by canadian medicare, in addition to a fragmented system of allied services. Inpatient mental health care is provided in specialized psychiatric hospitals and in general hospitals with mental health beds. all p/t governments provide a range of community mental health and addiction services, including case management, support for families and caregivers, community-based crisis services, and supportive housing.28

      Private psychologists are paid out of pocket or through private insurance. psychologists who work in publicly funded organizations receive a salary.

      Mental health has not been formally integrated into primary care. however, some organizations and provinces have initiated efforts to coordinate or co-locate mental health services with primary care. For example, in Ontario, an intersectoral mental health strategy has been in place since 2011 and was expanded in 2014 to better integrate mental health and primary care.29

      Long-term care and social support: Long-term care and end-of-life care provided in non-hospital settings and in the community are not considered insured services under the health law from Canada. All p/t governments fund such services through general taxes, but coverage varies across jurisdictions. All provinces provide some form of residential care and some combination of case management and nursing care for home care clients, but there is considerable variation when it comes to other services, including medical equipment, supplies and home support. many jurisdictions require copays.

      Eligibility for long-term residential and home care services is generally determined through a needs assessment based on health status and functional impairment. some jurisdictions also include means tests. about half of p/t governments provide home care without means testing, but access may depend on both assessed priority and availability of services within limited budgets.30

      The government funds nursing and personal care in long-term residential facilities. Additionally, financial supplements based on ability to pay can help cover room and board costs. some provinces have established minimum periods of residence as a condition of eligibility for admission to facilities.

      See also: When Does Health Insurance Expire After Leaving a Job? – K Health

      Spending on non-hospital institutions, most of which are residential long-term care facilities, was estimated to account for just over 11% of total health spending in 2017, funded primarily from public sources (70 %).31 Combination of private for-profit, private not-for-profit, and public facilities providing long-term care in facilities.

      Public funding of home care is provided through government p/t contracts with agencies that provide services or through government stipends for patients to purchase their own services. for example, british columbia’s independent living support program allows clients to purchase their own in-home support services.32

      Provinces and territories are responsible for providing hospice and end-of-life care in hospitals (covered by Canadian Medicare), where the majority of such costs occur. but many provide some coverage for services outside of those settings, such as doctor and nursing services and drug coverage in hospices, nursing facilities, and in the home.

      In June 2016, the federal government introduced legislation that amended the criminal code to allow eligible adults to request medical assistance in dying from a physician or nurse practitioner. since then, p/t governments and medical associations have established processes and regulatory frameworks to allow medical assistance in the death of people facing terminal or irreversible illnesses.

      It is estimated that more than 8 million Canadians provided unpaid support to people living with chronic health and social needs in 2012.33 Support for informal caregivers (estimated to provide between 66% and 84% of care of the elderly) varies by province and territory. .34 For example, the Nova Scotia Caregiver Benefits Program offers eligible caregivers and care recipients CAD 400 ($317) per month.35 There are also some federal programs, including the Canada Caregiver Credit and the Canada Caregiver Benefit. compassionate care of employment insurance.

      what are the main strategies to guarantee the quality of care?

      Many provinces have agencies responsible for producing health care system reports and monitoring system performance. In addition, the Canadian Institute for Health Information produces periodic public reports on the performance of the health system, including performance indicators for hospitals and long-term care facilities. To date, there is no publicly available information on the performance of physicians across the country. most provinces post inspection summary reports online.

      Home care agencies do not have similar reporting standards as residential long-term care. The Canadian Institute for Health Information maintains the Home Care Reporting System, which contains demographic, clinical, functional, and resource utilization data for clients served by publicly funded programs across Canada. however, in 2018, only eight jurisdictions submitted data.36

      The use of financial incentives to improve quality is limited. at the medical level, to date they have had little demonstrable effect on quality.37 Recertification requirements for physicians, including continuing education and peer review, vary by province.

      A variety of other quality initiatives are in progress:

      • the federally funded Canadian Patient Safety Institute promotes best practices and develops strategies, standards and tools.
      • provincial quality councils facilitate process improvements to produce higher quality health care.
      • The Optimal Use Projects Program, operated by the Canadian Agency for Medicines and Health Technologies, provides recommendations (although not formal clinical guidelines) to providers and consumers to encourage appropriate prescription, purchase and use of medicines.
      • the federally funded canadian healthcare improvement foundation works with p/t governments to implement performance improvement initiatives.
      • Accreditation Canada, a non-governmental organization, provides voluntary accreditation services to some 1,200 healthcare organizations across Canada, including regional health authorities, hospitals, long-term care facilities and community organizations.
      • Provincial cancer registries submit data to the Canadian Cancer Registry, a national administrative survey that tracks cancer incidence.
      • There is no national patient survey, although a standardized survey of acute care hospital inpatients developed by the Canadian Institute of Health Information has been implemented in several provinces. each province has its own strategies and programs to address chronic diseases.
      • The Prime Ministers p/t, or Prime Ministers, established the Health Care Innovation Task Force in 2012 to improve quality, for example by promoting guidelines to treat heart disease and diabetes, and reduce costs.
      • what is being done to reduce disparities?

        The Public Health Agency of Canada includes reporting on health disparities in its mandate, and the Canadian Institute for Health Information also reports on disparities in health care and health outcomes, with a focus on low-income Canadians. income.38 no formal or periodic process exists to measure disparities; however, several p/t governments have departments and agencies dedicated to addressing population health and health inequities.

        Health disparities between Aboriginal and non-Aboriginal Canadians are a concern for the government at both the federal and p/t levels. The 2018 federal budget provides new funding of CAD5 billion ($3.9 billion) for indigenous peoples, building on previous investments totaling CAD11.8 billion ($9.3 billion). the money goes to education, the environment (for example, water quality), and health and social services.39

        in 2015, the truth and reconciliation commission, which was established to collect stories about the events and effects of the legacy of indigenous residential schools, launched a series of calls to action, including several addressing disparities that affect indigenous communities.40

        in ontario, a strategy to improve the health of indigenous peoples was launched in 2016, with an emphasis on investments in primary care, cultural competency training for health care providers, access to fresh fruits and vegetables, and mental health services for first nations youth.41

        what is being done to promote integration of the delivery system and coordination of care?

        Provinces and territories have introduced several initiatives to improve the integration and coordination of care for chronically ill patients with complex needs. These include Divisions of Family Medicine (British Columbia), Family Medicine Groups (Quebec), the Regulated Network of Health Professions (Nova Scotia), and Health Links (Ontario).

        In addition, Ontario has long-standing community-based and multidisciplinary primary care models, including community health centers and Aboriginal health access centers. Ontario is also continuing to expand a pilot program that bundles payments between different providers. This alternative payment approach is expected to improve care coordination for patients as they transition from the hospital to the community.42

        What is the status of the electronic medical record?

        The acceptance of health information technologies has slowly increased in recent years. Provinces and territories are responsible for developing their own electronic information systems, with national funding and support through Canada Health Infoway. however, there is no national strategy to implement electronic health records or a national patient identifier.

        according to canada health infoway, provinces have systems in place to collect data electronically for most of their populations; however, interoperability is limited. In 2017, 85% of GPS reported using electronic medical records, but patients have limited access to their own electronic health information.43

        how are costs contained?

        Costs are controlled primarily through single-payer purchases, and increases in real spending primarily reflect government investment decisions or budget overruns. Cost control measures include:

        • compulsory global budgets for hospitals and regional health authorities
        • negotiated fee schedules for providers
        • drug formularies for provincial drug plans
        • resource constraints for doctors and nurses (such as provincial quotas for students admitted annually)
        • restrictions on new investments in capital and technology.
        • The Canadian Agency for Medicines and Health Technologies oversees the National Health Technology Assessment process, which is a mechanism to contain the costs of new technologies. This agency produces information on the clinical efficacy, cost-effectiveness, and broader impact of medicines, medical technologies, and health systems. the agency’s common drug review assesses the clinical efficacy and cost-effectiveness of drugs and provides common, non-binding formulary recommendations to publicly funded provincial drug plans (except in quebec) to support greater consistency in access and evidence-based resource allocation.

          The federal Patent Drug Price Review Board, an independent quasi-judicial body, regulates the launch prices of new patented drugs. The board regulates factory gate prices, but has no jurisdiction over wholesale or pharmacy prices, or pharmacists’ professional fees.

          Since 2010, the pan-Canadian pharmaceutical alliance has negotiated lower prices for 95 brand-name drugs and has set price caps of 18% of equivalent brand-name drug prices for the 15 most common generics.44 collaboration, jurisdiction over generic prices and control over pricing and purchases under public drug plans (and, in some cases, pricing under private plans) are in the hands of the provinces, leading to some interprovincial variations.

          In addition, the Choosing Wisely Canada campaign provides recommendations to governments, providers and the public on how to reduce low-value care.45

          What important innovations and reforms have been recently introduced?

          As stated above, prescription drugs, outside of hospitals, are not universally covered. At the federal level, there are signs of renewed interest in a pan-Canadian drug coverage system. The National Pharmacare Implementation Advisory Council was established in 2018, and an interim report was produced in 2019.46 If a national program moves forward, it will be the largest expansion of coverage and public funding since Canadian Medicare was introduced.

          Provinces and territories continue to implement structural reforms to improve efficiency. The latest example occurred in 2017 when Saskatchewan replaced its 12 regional health authorities with a single provincial health authority. This initiative reflects a national trend towards greater administrative centralization. Similarly, as part of an evolving reform effort, Manitoba established a single provincial organization, Shared Health, to centralize some clinical and administrative services. In 2019, the Government of Ontario announced plans to consolidate several independent provincial agencies, along with the 14 sub-provincial health authorities (Local Health Integration Networks) that manage and deliver health care to their local populations, into a single provincial agency. .47

          See also: Health Insurance 101 | TeenSpeak