Abstract
This book helps non-Canadians understand the Canadian health-care system in addition to its stated purpose of helping Canadian citizens grasp both the policies related to health care and the politics that shape those policies. The author augments this understanding by showing how the Canadian system contrasts with other health-care systems around the world, including that of the United States.
As a US citizen, I have experienced numerous “sound-bites” about Canadian health care from groups with specific political agendas to either praise or denigrate the Canadian system. Dr Fierlbeck’s book broadened my understanding of the Canadian system in relation to the US system and the rest of the world beyond the superficial descriptions available in the United States. In addition, it was an excellent introduction to the analysis of health policy at the national level, for someone who does specialize in the area, highly useful because knowledge of policy background is essential to understanding the context of any ethical issue.
First, the book describes how health care is funded in Canada. Canadians have publicly provided coverage for primary (physician) care, hospitalization, and diagnostic services performed in hospitals. About 70% of health care in Canada is publicly supported, the remaining 30% being privately purchased.
The first revelation for a person from the United States was that the Canadian health-care system is decentralized; essentially each province has its own system with central federal funding mechanisms that cover only about 20% of publicly provided health care in Canada. The provinces provide the remainder of public funding. Under the Canada Health Act (CHA), the provinces are required to meet five conditions to receive federal support:
Public administration. Administration must be through a nonprofit governmental authority accountable to provincial or territorial government.
Comprehensiveness. The provincial plan must cover all covered services.
Universality. Must cover all eligible residents.
Portability. Must be transferable to other provinces.
Accessibility. Must ensure reasonable access.
The central government maintains some control over health care through the CHA. Also, the Canadian Charter of Rights and Freedoms established in 1982 as a set of rights constitutionally guaranteed to Canadians have been applied to health care include equality rights; mobility rights; and rights of life, liberty, and security.
The chief feature of the Canadian health system that receives attention in the US media is that the majority of health care for Canadians is publicly financed. The author makes a convincing case that Canadians are committed to a vision of health care as a right and public good despite political tension regarding the degree to which the government funnels the money for health care through a private mechanism. Therefore, she contends that it would be political suicide for a Canadian politician to suggest scraping a system of publicly funded health care in favor of a US-style free-market, commodity approach to the provision of health care.
The book continues to cover specific areas of health care such as public health, drug coverage, and mental health. In these sections, one learns that drug coverage is not included in the federal mandate. This means that many Canadians get drug coverage through their employer and that public drug coverage varies considerably among the provinces: some having needs-based coverage, coverage for all seniors, and mandated purchase of drug coverage. Regarding mental health treatment, the reader learns that there is some pressure to provide inpatient care of the mentally ill because the federal mandate covers inpatient care but not specialty outpatient care. Meanwhile in the United States, the financial pressure on mental health treatment has driven care out of the hospital. This provides a good example of how the details of a national system drive the specifics of care.
At the end of the book, Dr Fierlbeck reviews different systems of funding health care globally. She divides these into the following:
Beveridge systems. Those funded through general tax revenues, including the UK, Sweden, and Canada;
Bismarck systems. Those based on social insurance co-financed by employers and employees, including France and Germany;
Mandated private insurance. Including the Netherlands and possibly the United States in the future.
Of special interest to US readers is the chapter on mandated private insurance that reviews current US reform efforts including the recently passed Patient Protection and Affordable Care Act, often labeled as Obamacare. The aspect about US health care that stands out most prominently is the extraordinary amount of money that goes to administrative costs related to the demands of the private payer system in comparison to other countries.
Throughout the book, the author contends that there is no perfect system and that each system has trade-offs. Chief among the trade-offs is access versus choice. In Canada, access is enhanced, and choice is inhibited through prohibiting charging for services that are mandated as a condition of receiving federal support—a much-challenged feature of the Canadian system—while in the United States, the choice is kept broad by treating health care as a commodity, but access is severely limited by costs of care.
The book offers detailed information on the Canadian health-care system and its place among other national systems and the forces that shape the system, as well as a good introduction to the analysis of health policy at the national level. The book can be of great use to nurse ethicists interested in placing ethical issues in the context of a national health-care system, even more so because the author provides enough background on the health policy analysis to make it accessible to persons whose academic expertise is not in policy.
Review comments from a Canadian perspective
Janet L Storch, University of Victoria, Canada
It is most interesting to read a non-Canadian’s uptake of Fierlbeck’s book, a book that is a fine addition to previous books on Canadian health care. Doug Olsen’s surprise at the decentralized nature of the Canadian health-care system caught me by surprise. While we do not consider it a system in the true sense of what “system” means, most Canadians would consider our health-care services more unified than Doug’s account suggests. That, I believe, is because Canadians often utilize unique ways to work together at the federal and provincial level. The means to do so might be called “gentlemen’s” or “gentlewomen’s” agreements. One example of such an agreement outside of health care directly is our approach to research ethics. We do not have a law compelling researchers and their institutions to abide by the Canadian Tri-Council Policy Statement (TCPS-2), which outlines requirements for research ethics and its review. But we do have an agreement or understanding that unless researchers and institutions do so, their funding from national granting councils will be cut. Similarly, for the past many years Canadian health-care providers have functioned under a set of principles (noted by Fierlbeck as “conditions”) that binds them to provide health services to Canadians in particular ways or suffer consequences of reduced federal funding. At a time when federal funding was closer to 50% of health-care funding to the provinces, the threat of reduction of funds was real. But since the federal government transferred tax points to the provinces and reduced cash funding as well, the threat of funding reduction is not as worrisome.
As Fierlbeck notes in her book, Canada’s most basic health-care challenges are the continuing increase in expenditure on health care, a lack of accountability for health-care outcomes, and dependency on the market for publicly uninsured goods and services. Since publication of her book, and in preparation for discussions about renewing a 10-year agreement on the federal transfer of funds to the provinces, the federal government issued a warning that present levels of federal funding would not continue in future years. The effect of the agreement on transfer payments to be reached in 2014 could further decentralize health care, leaving provinces free to limit their attention to the principles of health care. Should this type of response be taken by the provinces with the support of the public, this could fundamentally mean a change in the Canadian sentiment of having moral responsibility for each other in health care.