From 1969 to 1972 the Canadian Medicare programs were established throughout all provinces and territories of Canada (Evans, R.G., Barer, M.L., Lewis, S., Rachus, M., And Stoddart, G.L. 2000).
Canada has collective health coverage for their citizenry but spend a smaller percent of the GNP on health care. Business leaders articulated significant interest in the Canadian system, which relieves businesses of accountability for administering healthcare benefits. Canadian citizens pay a 7 percent tax on goods and services and businesses pay a 1 to 2 percent payroll tax (varying by province). These taxes, plus 13 percent of personal income taxes, fund health services and post-secondary education expenses. Health-care funding is administered by the regional governments, which negotiate suitable fees with physicians’ associations and reimburse physicians openly for their charges. Canadian hospitals, somewhat than charging by the patient or by individual services provided, work on an annual budget. It is negotiated with the Provincial Minister of Health and is based on their costs for the prior year. The provincial government must approve new hospital construction and acquire high-tech equipment. The Canadian system appealed to businesses because of its effortlessness, lower costs, and fixed, limited liability to businesses for the health-care costs of employees. Canadian business overhead is lower: there is no require for staff to oversee and administer health benefits, nor do budgets have to be readjusted annually as of increasing health insurance payments.
As businesses were calling mind to the virtues of the Canadian system, the AMA, uneasy about the lower incomes and weaker political position of Canadian physicians, was publicizing prospective drawbacks of the Canadian health-care plan. They noted that Canadians tend to get put on waiting lists for such non-emergency matters as elective surgery, unless they pay for this privately. Waiting periods range between one and 72 weeks.
The Canadian health-care plan’s provisions exposed the progressively more adversarial interests of the business community and health-care providers. Because of this, and because the Canadian system also eradicates any role for the health insurance industry, which had provided the impulsion for veto groups in earlier attempts to widen a national health insurance plan.
The Canadian system of medical care diverges from the health care system in the America in several respects. With the spirited system of health care in the United States, a large amount of the health care expenditures are borne by the company and all the way through private individual insurance. A main difference between the two systems, though, is in the public expenditures sector. In about 1980, the United States’ public health expenditures were about 42% of total health expenditures, and remain so through 1989. Canada’s public health expenditures as a percentage of total health expenditures remained at concerning 75 percent from 1980 through 1989. Canada’s percentages are about 1.8 times those of the United States, yet it has not yet been shown that the quality of Canada’s medical care is better to that in the United States (Eyles, J., Birch, S., And Newbold, Kb. 1995).
The Canadian Assistance Plan has been slow to bring in the latest technology like CT scan and MRI diagnostic equipment all through the provinces. Both proliferate in the health care networks in America, even in smaller, non-metropolitan areas. possibly the difference in ancillary or health care environmental services and the contemporary technology are the partial cause of the per capita health spending in the United States versus Canada.
The United States spent about $2,354 per capita for health care as compared to the $1,683 in Canada. Canada practiced cost repression measures after a number of years of testing varying levels of federal-provincial financing. The Canada Health Act of 1984 also consolidated previous national health insurance laws so as to reform the fee for service practices of the physicians–the physicians are usually salaried employees of the provinces. As Roemer describes the reforms in 1984:
The conditions set in the two original laws for provincial receipt of federal allotments were also tightened in 1984: (a) the program should be administered by a public authority accountable to the provincial government; (b) the program must cover all essential hospital and medical care and surgical-dental services rendered in hospitals; (c) 100 percent of the provincial residents must be permitted to insured services; and (d) reasonable access to insured services must not be impeded directly or ultimately by charger or other mechanisms. (Milton Roemer, National Health Systems of the World, op. cit., p. 167)
Notice that the reforms above did not mention the spectrum of health care services surrounding strict medical care that Americans take for approved. The Canadian system of medical care is analogous to the old time country store–it has most, perhaps all, of the bare essentials, but very little, if any, of the ancillary products that balance the basic essentials. (Bertha Bryant , 1981:442-447)
There are certain national systems that pact the medical profession and its collegial processes mainly strong positions. The social insurance systems of continental Europe present a likely set of possibilities, given the degree to which they incorporate formal roles for medical relations into the systems of finance and management as buffers between the state or sickness funds on the one hand and individual working physicians on the other (Hanlon, N.T., And Rosenberg, M.W. 1998).
However, Canada offers a more appropriate case. (Among other things, there are advantages, to be discussed shortly, to confining the comparison to Anglo-American countries.) Canadian medicare, as we shall see, rested from its commencement in the 1960s on a basic lodging between the medical profession and the state, under which physicians retained their position as independent professionals, trading off a amount of entrepreneurial discretion (chiefly over price but not, as in Britain, over location and perform inputs) in order to keep substantial collective and individual independence in clinical matters. Within broad budgetary limitations recognized by provincial governments, physicians have been vital to decision-making systems at different levels from central joint profession-government “management” groups at the provincial level, to the level of separately constituted hospital medical staffs, to the level of autonomous individual medical practices (Gosselin, M. 2000).
Canada, characterize the broad range of systems suggested by the ideal-typical categories of state hierarchical, private market, and professional collegial systems. although they also share important characteristics that can structure a comparative analysis. In the first place, they share a broadly similar tradition of state-society relations which, among other things, implies an autonomous base for professions vis-à-vis the state, in contradiction of the more “statist” or “state-corporatist” model of continental Europe. They also share a roughly similar structure for the organization of capital, with a peculiarity between “real” and “financial” capital and a heavy reliance on equity markets, again in contrast to a more incorporated continental European model (Ng, E., Wilkins, R., Pole, J., And Adams, O.B. 1999).
Hence for the three main categories of actors in the health care arena–the state, the professions, and private finance-Britain, Canada, and the United States share a roughly similar cultural and structural framework when viewed in broad cross-national perspective. This selection of cases, then, while it misses some interesting questions, permits us to focus on shifts in the balance of influence across the state, the medical profession, and private finance within moderately similar systems.
The distinguishing characteristics of the health care arenas of Britain, the United States, and Canada imitate the timing of the major policy episodes that established their fundamental institutional and structural parameters. The British NHS was a product of its genesis in the 1940s, after the centralization and expansion of government influence in the wartime period. Canadian medicare bears the marks of its birth in the 1960s, an era of high public expectations and government expansiveness, in which the remuneration model of private insurance had become traditional and the public underwriting of the costs of a professionally dominated system appeared feasible. The U.S. Medicare and Medicaid systems were born in the same period, and were fashioned on a similar model. But as we shall see they were introduced in a national context in which the legacy of past policy failures conditioned policy-makers to adopt an incremental approach that paradoxically sowed the seeds of future policy failures.
If Britain, the United States, and Canada present various possible admixtures of hierarchy, collegiality, and market and probable balances across state, professional, and private financial actors in the health care arena, they also present diverse histories of change in the late twentieth century. Each has reacted in different ways to the evolving logic of health care economics, with its insinuations for the development of bargaining relationships between relatively large, sophisticated, and independent entities. Britain presents the most sweeping policy change in the OECD, brought about in the nineties: the National Health Service and Community Care Act of 1990 sought a fundamental transformation of the NHS hierarchy through the creation of an “internal market” made up of organizationally distinct “purchasers” and “providers” within the tax-financed system (Rosenberg, M.W., And Hanlon, N.T. 1996). The United States, on the contrary, presents perhaps the most spectacular example of the failure of an attempt at sweeping strategy change-the defeat of President Clinton’s proposal for health care reform through “managed competition” in 1993. Yet it nonetheless stands as the most remarkable example of structural and institutional change. In the absence of major policy change, it is perhaps the case that the institutional mix of hierarchical, collegial, and market instruments, as well as the balance of influence across the state, the medical profession, and private finance, have both shifted more radically in the United States in the late twentieth century than in any other OECD nation. The rise of large corporate entities on both the supply and the demand sides of the market has malformed the decision-making systems of the health care arena. And Canada presents a case in which policy development has generally acquiesced only incremental alterations in the basic institutional mix or structural balance of the health care arena. The state has undergone inner reorganization through the formation of regionalized structures in most provinces and has sought to assert its role more stoutly through the extension of traditional blunt instruments (such as budget caps) and targeted intervention into the hospital sector to attain some horizontal integration. But the basic structure of Canada’s “internal market,” the balance between public and private finance and, most considerably, the influence of the medical profession and the importance of uncompetitive mechanisms of decision-making remain essentially unchanged. Whether this relative stability can endure in the face of the unprecedented fiscal restriction of the 1990s, however, is a key question to be addressed.
From its beginnings the National Health Service was supposed to offer a clear strategy dazzling health promotion and treatment of ill health. However, in terms of allocating equal resources for both areas it is only in recent times that the government has began to center on health promotion issues. A number of documents identify the need to rouse discussion regarding the potential for escalating the scope of modern preventive medicine within much wider parameters than the previous post-war boundaries.
Health activity applies to the work of health care professionals. They are primary, secondary and tertiary care. Primary health care focuses on encouraging a healthy lifestyle, secondary health care deals with existing ill-health and tertiary health care on optimizing independence within the confines of existing disability. Primary health care has also been described as the continued health and social welfare offered suitably to needful individuals living in private households.
According to the figures contained in the government sponsored consultative document, Primary care: the future (NHSE 1996), the total expenditure on primary care (including community health services) is around $12.45 billion. This represents over 36% of total NHS spending. The document (NHSE 1996) went on to suggest that primary health care staff should aim to improve partnership and foster an ethos towards community development. The document identified significant development areas towards achieving this strategy. First, it aimed to ensure a fairer national distribution of primary care services. Second, it recommended a balance between the resources given to primary and secondary care. Third, it aspired to ensure greater flexibility in the use of local resources. Finally, the White Paper (Department of Health 1996) highlights a require to strengthen opportunities for encouraging personal growth and development for all primary health care staff mainly in areas such as information technology.
In 2000, the government also launched a period of consultation to look at the future direction for primary health care to form a renewed dynamic towards its further development. A number of complementary documents were published (Walker, M., And Wilson, G. 2001).
These aims to have an ‘integrated health service that meets the health requires of individual patients’. Second, it proposes that the NHS must balance the desire to provide care at home with the need to give care that is safe. It goes on to describe the pivotal role of primary care as: skilled advice; treatment; health promotion and care in partnership with other professionals and agencies (Wente, M. 2000).
From the evidence it would appear that as services persist to expand away from institutional care, professionals in the field will become significant players in policy development and implementation. Already health care professionals are anticipated to practice in different ways across a wide range of boundaries and institutional settings. At present health care professionals are not considerably influential in the higher political echelons. This does not mean, however, that things will not change. As Numas (1997) predicts in rather evocative terms, ‘The voice of the silent common, including nurses, patients and other NHS employees, will need to become audible again and, more significantly, listened to by the decision-makers’ (Numas 1997, p. 30). So as to achieve this, health care professionals must recognize the complexities of the present within a wider context, which must enable us to be proactive deliverers of the extremely best health care in the future.
The Canadian system leaves provision of services in private hands but funds it throughout public taxes. All citizens have guaranteed access to health-care services. Provincial governments control prices and reimburse health-care providers.) Others want to rely on a free market to supply services for which there is adequate demand. Most, however, have tried to transform the present mix of public and private financing for health-care services, while leaving the condition of services in the private market (Cohen, Richard E, 1994.
Advocates of a Canadian-style health-care system make access to services for everyone the utmost goal, and are eager to levy new taxes to fund this and use government directive as the route to cost control. Advocates of free-market approaches give access lower priority, stressing the significance of cost-efficient care that encourages economic prosperity. As a result they oppose new taxes and support measures to encourage flexibility and innovation amongst health-care providers (which they believe government regulation discourages).They point to failures in trying to force health-care professionals to observe regulations that divergence with professionals’ own basic values i.e., providing the highest probable standards of care and preserving their own income. Rather than embark on what they see as a lost cause of trying to control the providers of care in the name of cost control, advocates of free market approaches to health-care reform look to supply-side economic policies: bound the supply of money obtainable from various funders and let individual providers of care acclimatize to the new circumstances ingeniously.
Neither of these ideological perspectives has carried the day. The frozen tax base of the eighties and nineties has limited government income, and the public has demonstrated its aggression to new forms of taxation. Moreover, a broader public policy move toward deregulation of business, widespread doubts that regulators can ever efficiently control the regulated, and the emergence of traditional political coalitions in both the Republican and Democratic parties, have left advocates of a Canadian-style healthcare system for the United States in the minority. Meanwhile, evidence has grown that “the market” heads toward opportunities for utmost financial gain rather than public service, if left to its own devices. The continually increasing recruitment of new physicians into higher paying medical specialties somewhat than into primary care delivery, the down-sizing of the American hospital system to raise profitability rather than to guarantee access for all the population, and the ongoing growth in the number of Americans who lack access either to funding for medical expenses or to care itself, point up the limits of free-market solutions to tribulations of access to health-care services (Crawford, Robert. , 1980).
The majority of health planners, therefore, have opted for a middle route, acknowledging the political restraints and practical problems that block development of a Canadian-style health-care system, and the insufficiency of coverage that results when one leaves everything to the free market. They have sought a mix that lies somewhere between these two principles, often finding somewhat embarrassed compromises between ruling and free market strategies, or between containing costs and undertaking access to care.
Bertha Bryant, Issues on the Distribution of Health Care: Some Lessons from Canada, Public Health Reports (September-October 1981):442-447
Cohen, Richard E. “Into the swamp”. National Journal642-654, March 19, 1994.
Crawford, Robert. , 1980 “Healthism and the medicalization of everyday life (politics of self-care”). International Journal of Health Services 10(3):365-388.
Evans, R.G., Barer, M.L., Lewis, S., Rachus, M., And Stoddart, G.L. 2000 Private Highway, One-Way Street: The Deklein And Fall Of Canadian Medicare (Vancouver: The University Of British Columbia, Centre For Health Services And Policy Research)
Eyles, J., Birch, S., And Newbold, Kb. 1995 `Delivering The Goods? Access To Family Physician Services In Canada: A Comparison Of 1985 And 1991′ Journal Of Health ; Social Behavior 36, 322-332
Frketich, J. 2001 `The Worst Wait In Ontario: 600 People In Line For Radiation Therapy At Hamilton Cancer Center’ The Hamilton Spectator December 20, A1
Gosselin, M. 2000 `Government Cuts Take Care Out Of Health Care’ North Bay Nugget November 15, A6
Hanlon, N.T., And Rosenberg, M.W. 1998 `Not-So-New Public Management And The Denial Of Geography: Ontario Health-Care Reform In The 1990s’ Environment And Planning C: Government And Policy 16, 559-572
Milton Roemer, National Health Systems of the World, op. cit., p. 167
Newbold, K.B., Birch, S., And Eyles, J. 1994 `Access To Family Physician Services In Canada: A Tale Of Two Provinces’ Canadian Journal Of Regional Science 17, 311-328
Ng, E., Wilkins, R., Pole, J., And Adams, O.B. 1999 `How Far To The Nearest Physician’ Rural And Small Town Canada Analysis Bulletin 1, 1-7
NHSE 1996 Primary care: the future. HMSO, London
Numas R 1997 New Labour, new NHS. Nursing Times 93(20):30-31
Organization for Economic Cooperation and Development (OECD). 1993. OECD Health Systems: Facts and Trends 1960-1991. Paris: OECD.
Rosenberg, M.W., and Hanlon, N.T. 1996 `Access And Utilization: A Continuum Of Health Service Environments’ Social Science And Medicine 43, 975-983
Tuohy, Carolyn. 1992. Policy, and Politics in Canada: Institutionalized Ambivalence. Philadelphia: Temple University Press.
Walker, M., And Wilson, G. 2001 Waiting Your Turn: Hospital Waiting Lists In Canada (Vancouver: Fraser Institute)
Wente, M. 2000 `Medical Care That’s Not Even Fit For A Horse’ The Globe And Mail, October 24, A19