Public health-care provision in the Canadian provinces and American states

Canadian Public Administration

Volumn 45, Issue 2, 2002, Pages 217-238

  Boychuk, Gerard W ^a  

^a UNIVERSITY OF WATERLOO   (Canada)

Author keywords

[No Author keywords available]

Indexed keywords

EID: 0040079867     PISSN: 00084840     EISSN: None     Source Type: Journal    
DOI: 10.1111/j.1754-7121.2002.tb01081.x     Document Type: Article

References (45)

1. See, for example, Canada, Parliament Senate, Standing Committee on Social Affairs, Science and Technology, "The Health of Canadians-The Federal Role. Interim Report, Volume One -The Story So Far, March 2001." Available at http://www.parl.gc.ca/37/1/parlbus/commbus/senate/com-E/SOCI-E/rep-e/ repintsep01-e.htm, pp. 101, 106-107; Alberta, Premier's Advisory Council on Health, A Framework for Reform: Report of the Premier's Advisory Council on Health (Edmonton: Queen's Printer, 2001), pp. 5, 23.
2. See, for example, Canada, Parliament Senate, Standing Committee on Social Affairs, Science and Technology, "The Health of Canadians-The Federal Role. Interim Report, Volume One -The Story So Far, March 2001." Available at http://www.parl.gc.ca/37/1/parlbus/commbus/senate/com-E/SOCI-E/rep-e/ repintsep01-e.htm, pp. 101, 106-107; Alberta, Premier's Advisory Council on Health, A Framework for Reform: Report of the Premier's Advisory Council on Health (Edmonton: Queen's Printer, 2001), pp. 5, 23.
3. See, for example, Robert Chernomas and Ardeshir Sepheri, eds., How to Choose? A Comparison of the US and Canadian Health Care Systems (Amityville: Baywood, 1998); Carolyn Bennett, Kill or Cure: How Canadians Can Remake Their Health Care System (Toronto: HarperCollins, 2000); Pat and Hugh Armstrong with Claudia Fegan, Universal Health Care: What the United States Can Learn from the Canadian Experience (New York: New York Press, 1998); Colleen Fuller, Caring for Profit: How Corporations are Taking Over Canada's Health Care System (Vancouver: New Star Books, 1998); Michael Rachlis et al., Revitalizing Medicare: Shared Problems, Public Solutions (Vancouver: Tommy Douglas Research Institute, 2001).
4. See, for example, Robert Chernomas and Ardeshir Sepheri, eds., How to Choose? A Comparison of the US and Canadian Health Care Systems (Amityville: Baywood, 1998); Carolyn Bennett, Kill or Cure: How Canadians Can Remake Their Health Care System (Toronto: HarperCollins, 2000); Pat and Hugh Armstrong with Claudia Fegan, Universal Health Care: What the United States Can Learn from the Canadian Experience (New York: New York Press, 1998); Colleen Fuller, Caring for Profit: How Corporations are Taking Over Canada's Health Care System (Vancouver: New Star Books, 1998); Michael Rachlis et al., Revitalizing Medicare: Shared Problems, Public Solutions (Vancouver: Tommy Douglas Research Institute, 2001).
5. See, for example, Robert Chernomas and Ardeshir Sepheri, eds., How to Choose? A Comparison of the US and Canadian Health Care Systems (Amityville: Baywood, 1998); Carolyn Bennett, Kill or Cure: How Canadians Can Remake Their Health Care System (Toronto: HarperCollins, 2000); Pat and Hugh Armstrong with Claudia Fegan, Universal Health Care: What the United States Can Learn from the Canadian Experience (New York: New York Press, 1998); Colleen Fuller, Caring for Profit: How Corporations are Taking Over Canada's Health Care System (Vancouver: New Star Books, 1998); Michael Rachlis et al., Revitalizing Medicare: Shared Problems, Public Solutions (Vancouver: Tommy Douglas Research Institute, 2001).
6. See, for example, Robert Chernomas and Ardeshir Sepheri, eds., How to Choose? A Comparison of the US and Canadian Health Care Systems (Amityville: Baywood, 1998); Carolyn Bennett, Kill or Cure: How Canadians Can Remake Their Health Care System (Toronto: HarperCollins, 2000); Pat and Hugh Armstrong with Claudia Fegan, Universal Health Care: What the United States Can Learn from the Canadian Experience (New York: New York Press, 1998); Colleen Fuller, Caring for Profit: How Corporations are Taking Over Canada's Health Care System (Vancouver: New Star Books, 1998); Michael Rachlis et al., Revitalizing Medicare: Shared Problems, Public Solutions (Vancouver: Tommy Douglas Research Institute, 2001).
7. See, for example, Robert Chernomas and Ardeshir Sepheri, eds., How to Choose? A Comparison of the US and Canadian Health Care Systems (Amityville: Baywood, 1998); Carolyn Bennett, Kill or Cure: How Canadians Can Remake Their Health Care System (Toronto: HarperCollins, 2000); Pat and Hugh Armstrong with Claudia Fegan, Universal Health Care: What the United States Can Learn from the Canadian Experience (New York: New York Press, 1998); Colleen Fuller, Caring for Profit: How Corporations are Taking Over Canada's Health Care System (Vancouver: New Star Books, 1998); Michael Rachlis et al., Revitalizing Medicare: Shared Problems, Public Solutions (Vancouver: Tommy Douglas Research Institute, 2001).
8. See, for example, Keith G. Banting and Stan Corbett, eds., Health Policy and Federalism: A Comparative Perspective on Multi-Level Governance (Montreal and Kingston: McGill-Queen's University Press, 2002).
9. Keith G. Banting and Stan Corbett, "Health Policy and Federalism: An Introduction, " in Ibid., p. 3.
10. James Bjorkman, quoted in Canada, Parliament, Senate, Standing Committee on Social Affairs, Science and Technology, "The Health of Canadians - The Federal Role. Interim Report, Volume Three - Health Care Systems in Other Countries, January 2002, " Available at http://www.parl.gc.ca/37/1/parlbus/commbus/senate/com-e/SOCI-E/rep-e/rep-e/ repjan01vol3-e.htm, p. 65.
11. Drawn from Chernomas and Sepehri, How to Choose?
12. Colleen Flood, presentation to Ontario Health Coalition public forum "Does Medicare Work?" Toronto, 3 April 2002.
13. Robert G. Evans, "Two Systems in Restraint: Contrasting Experiences with Cost Control in the 1990s, " in David M. Thomas, ed., Canada and the United States: Differences that Count, 2nd edition (Peterborough: Broadview, 2000), pp. 25-6.
14. Steven G. Morgan, "Issues for Canadian Pharmaceutical Policy, " in National Forum on Health, Canada Health Action: Building on the Legacy, Vol. 4: Health Care Systems in Canada and Elsewhere (Sainte-Foy: Éditions MultiMondes, 1998), p. 683.
15. Lawrence O. Gostin, "Public health law in a new century, part II: Public health powers and limits, " Journal of the American Medical Association 283, no. 22 (14 June 2000), p. 2979. Since employer-provided health-insurance benefits are not counted as taxable income, private health insurance is publicly subsidized. This tax expenditure was US$111 billion in 1998. These expenditures are roughly one-fifth the magnitude of total public-health expenditures and, as John Inglehart notes, "If this were a federal health program, it would be the third most expensive one after Medicare and Medicaid." John K. Inglehart, "The American health care system: expenditures, " New England Journal of Medicine 340, no. 1 (7 January 1999), p. 71. (Despite their significance, these expenditures are not generally included in calculations of public health expenditures and are not included in the comparisons of public health expenditures presented in this article.) Employer-provided extended health benefits beyond the universal insurance coverage provided in each province are similarly subsidized in Canada. However, these subsidies are a less significant element of the federal contribution to health-care provision in Canada than in the U.S.
16. Lawrence O. Gostin, "Public health law in a new century, part II: Public health powers and limits, " Journal of the American Medical Association 283, no. 22 (14 June 2000), p. 2979. Since employer-provided health-insurance benefits are not counted as taxable income, private health insurance is publicly subsidized. This tax expenditure was US$111 billion in 1998. These expenditures are roughly one-fifth the magnitude of total public-health expenditures and, as John Inglehart notes, "If this were a federal health program, it would be the third most expensive one after Medicare and Medicaid." John K. Inglehart, "The American health care system: expenditures, " New England Journal of Medicine 340, no. 1 (7 January 1999), p. 71. (Despite their significance, these expenditures are not generally included in calculations of public health expenditures and are not included in the comparisons of public health expenditures presented in this article.) Employer-provided extended health benefits beyond the universal insurance coverage provided in each province are similarly subsidized in Canada. However, these subsidies are a less significant element of the federal contribution to health-care provision in Canada than in the U.S.
17. Medicare has two components. Part A provides hospital insurance and is predicated on social insurance principles: "workers make mandatory contributions to a dedicated trust fund during their working years, with the promise of receiving benefits after they retire. By law, the nation's employers … and employees are required to pay equal amounts." Part B, the Supplementary Medical Insurance Program, finances physician care, outpatient, home health and other services. This element of Medicare is voluntary and enrollees are required to pay flat-rate monthly premiums. However, premiums comprise only twenty-four per cent of total expenditures under Part B and virtually everyone eligible enrolls. Ibid., p. 72.
18. "The federal Medicare program … requires patients to pay 'deductibles' in each of its two components (Part A for hospitals and Part B for physicians' services). Only those costs that exceed a certain amount in each year are reimbursable. Patients must also pay a "co-insurance" of twenty per cent of all subsequent reimbursable expenses for physicians' services, plus any amount which a provider may choose to extra-bill above rates allowed by Medicare. … Since these out-of-pocket expenses can be substantial, there is a large market in 'Medigap' insurance, privately sold to cover them." Evans, "Two Systems in Restraints, " in Thomas, Canada and the United States, p. 27. However, despite premiums and other out-of-pocket payments, "most beneficiaries who require medical care receive far more from the program than they contributed in payroll taxes." For example, future benefits have an estimated value of up to six times the lifetime contributions for a retiring couple with one earner. John K. Inglehart, "The American health care system: Medicare, " New England Journal of Medicine 340, no. 4 (28 January 1999), p. 328.
19. "The federal Medicare program … requires patients to pay 'deductibles' in each of its two components (Part A for hospitals and Part B for physicians' services). Only those costs that exceed a certain amount in each year are reimbursable. Patients must also pay a "co-insurance" of twenty per cent of all subsequent reimbursable expenses for physicians' services, plus any amount which a provider may choose to extra-bill above rates allowed by Medicare. … Since these out-of-pocket expenses can be substantial, there is a large market in 'Medigap' insurance, privately sold to cover them." Evans, "Two Systems in Restraints, " in Thomas, Canada and the United States, p. 27. However, despite premiums and other out-of-pocket payments, "most beneficiaries who require medical care receive far more from the program than they contributed in payroll taxes." For example, future benefits have an estimated value of up to six times the lifetime contributions for a retiring couple with one earner. John K. Inglehart, "The American health care system: Medicare, " New England Journal of Medicine 340, no. 4 (28 January 1999), p. 328.
20. State expenditures in 1994 constituted approximately forty-three per cent of program expenditures. Mark C. Rom, "Transforming State Health and Welfare Programs, " in Virginia Gray et al., eds., Politics in the American States: A Comparative Analysis, 7th edition (Washington, D.C.: Congressional Quarterly, 1999), p. 351.
21. John K. Inglehart, "The American health care system: Medicaid, " New England Journal of Medicine 340, no. 5 (4 February 1999), pp. 403, 407, 403, respectively.
22. However, as an example of federal parameters, "states are now required to set reimbursement rates high enough so that Medicaid services will actually be available to recipients, at least to the extent that they are available to other residents in the state. Health care providers cannot charge Medicaid patients additional fees above these amounts." Rom, "Transforming State and Welfare Programs, " in Gray et al., Politics in the American States, p. 353.
23. Inglehart, "The American health care system: Medicaid, " New England Journal of Medicine, p. 404.
24. In 1997, the federal government devoted new funds for cost-sharing state expansions in health insurance coverage for children under the SCHIP (State Children Health Insurance Plan) program; however, total expenditures under this program are not very significant in comparison to total spending under Medicaid.
25. National Governors Association, Health Policy Studies Division, ERISA Case Law Update (Washington, D.C.: National Governors Association, 2000).
26. Daniel M. Fox and John K. Inglehart, Five States that Could Not Wait: Lessons for Health Reform from Florida, Hawaii, Minnesota, Oregon and Vermont (Cambridge, Mass.: Health Affairs and Milbank Memorial Fund, 1994).
27. Len M. Nichols and Linda J. Blumberg, "A Different Kind of 'New Federalism'? The Health Insurance Portability and Accountability Act of 1996, " Health Affairs 17, no. 3 (May/June 1998), pp. 25-12.
28. Banting and Corbett, "Health Policy and Federalism, " in Banting and Corbett, Health Policy and Federalism, pp. 23-4. Regionalization is one of the most important sources of inter-provincial variation in the management and delivery of health care. There are notable differences among provinces in the way in which regionalization has been conducted and in the powers that have been allocated to regional boards within various provinces. However, these differences in management and delivery in and of themselves do not constitute fundamental differences in the magnitude or nature of the public role in health-care provision. For an overview of provincial differences, see Ken Rasmussen, "Regionalization and Collaborative Government: A New Direction for Health System Governance, " in Duane Adams, ed., Federalism, Democracy and Health Policy in Canada (Kingston: Institute of Intergovernmental Relations, 2001), pp. 239-70.
29. Banting and Corbett, "Health Policy and Federalism, " in Banting and Corbett, Health Policy and Federalism, pp. 23-4. Regionalization is one of the most important sources of inter-provincial variation in the management and delivery of health care. There are notable differences among provinces in the way in which regionalization has been conducted and in the powers that have been allocated to regional boards within various provinces. However, these differences in management and delivery in and of themselves do not constitute fundamental differences in the magnitude or nature of the public role in health-care provision. For an overview of provincial differences, see Ken Rasmussen, "Regionalization and Collaborative Government: A New Direction for Health System Governance, " in Duane Adams, ed., Federalism, Democracy and Health Policy in Canada (Kingston: Institute of Intergovernmental Relations, 2001), pp. 239-70.
30. See the Canadian Institute for Health Information web site at http://secure.cihi.ca/cihi-web/splash.html. Such differences may be explained by factors such as the increased costs of serving a province with a sparse population distribution.
31. Regarding differences in complementary and alternative care, see Rona Achilles et al., "Complementary Alternative Health Practices and Therapies: A Canadian Overview." Report prepared for Strategies and Systems for Health Directorate, Health Promotion and Programs Branch Health Canada (Toronto: York University Centre for Health Studies, 1999). Available at http://www.yorku.ca/ychs/data1/body_alternative.html.
32. See the Canadian Institute for Health Information web site.
33. Unfortunately, public expenditures as a percentage of total health expenditures (as reported on a national basis by the Health Care Financing Administration) are not currently available on a state-by-state basis.
34. Armstrong and Armstrong, Universal Health Care, p. 75.
35. I expect that public drug expenditures for the non-elderly are higher on a per capita basis in some American states than in certain Canadian provinces. My initial data comparisons in this area are extremely sketchy and I am awaiting updated figures from the Health Care Financing Administration that may help in exploring these issues.
36. The Kirby committee reported that private insurance practices including refusing to insure high-risk clients or forcing such clients to pay a higher premiums in order to offset increased risk are "happening increasingly in the United States." Canada, Parliament, Senate, Standing Committee on Social Affairs, Science and Technology, "The Health of Canadians - The Federal Role. Interim Report, Volume One - The Story So Far, March 2001, " p. 101.
37. Marshall W. Raffel and Norma K. Raffel, "The Health System of the United States, " in Marshall W. Raffe, ed., Health Care and Reform in Industrialized Countries (University Park: Pennsylvania University Press, 1997), p. 278. In the case of not-for-profit hospitals, it is uncompensated care that justifies their tax-exempt status. As no such legal obligation as described above or tax-exempt status applies to private physicians, physician services are more difficult to secure for the uninsured.
38. Graham Atkinson, W. David Helms and Jack Needleman, "State Trends in Hospital Uncompensated Care" Health Affairs 16, no. 4 (July/August 1997), p. 233.
39. The following is drawn from Robert J. Mills, Current Population Reports: Health Insurance Coverage, 1999 (Washington, D.C.: U.S. Census Bureau, 2000), pp. 9-11; and U.S. Census Bureau, Historical Health Insurance Historical Tables (Washington, D.C.: U.S. Census Bureau, 2000), Table HI-5. Available at http://www.census.gov/hhes/hlthins/historic/hihistt5.html.
40. The following is drawn from Robert J. Mills, Current Population Reports: Health Insurance Coverage, 1999 (Washington, D.C.: U.S. Census Bureau, 2000), pp. 9-11; and U.S. Census Bureau, Historical Health Insurance Historical Tables (Washington, D.C.: U.S. Census Bureau, 2000), Table HI-5. Available at http://www.census.gov/hhes/hlthins/historic/hihistt5.html.
41. To determine the amount of health-care services that could be purchased, expenditure figures must be adjusted using a purchasing power parity (PPP) for health services. This "indicates the rate at which one currency should be converted to another to be able to purchase an equivalent basket of health goods and services in the two countries." Delphine Arweiler, "International Comparisons of Health Expenditures, " in National Health Care Forum, Canada Health Action, Vol. 4, p. 218.
42. Kenneth E. Thorpe, "American States and Canadian Provinces: A Comparative Analysis of Health Care Spending, " in James A. Morone and Gary S. Belkin, eds., The Politics of Health Care Reform: Lessons from the Past, Prospects for the Future (Durham: Duke University Press, 1994), p. 406.
43. Ibid.
44. Bob Rae, "Health Policy in the Consumer Era, " in Margaret A. Sommerville, ed., Do We Care? Renewing Canada's Commitment to Health (Montreal and Kingston: McGill-Queen's University Press, 1999), p. 94.
45. Fuller, Caring for Profit, p. 279.