You Say You Want a Single-Payer System: The Canada Health Act

Senator Warren says that

President Obama tried to move us forward with health-care coverage by using a conservative model that came from one of the conservative think tanks that had been advanced by a Republican governor in Massachusetts. Now it’s time for the next step. And the next step is single payer.

Representative Conyers has introduced a Medicare for All bill into the House. Senator Sanders is drafting one for the Senate. For Canada Day/Fête du Canada, here’s a brief introduction to the key legislation underlying Canada’s health care system, the Canada Health Act.

The first thing to know is that Canada does not have a single-payer system. There is a single-payer insurer in each province and territory. The Canadian federal government makes a block grant contribution to each province amounting to about 20% of the province’s health care spending. The Canada Health Act lays out requirements for those provincial single-payers to get that cash:

The purpose of this Act is to establish criteria and conditions in respect of insured health services and extended health care services provided under provincial law that must be met before a full cash contribution may be made… the health care insurance plan of the province must, throughout the fiscal year, satisfy the criteria… respecting the following matters:

(a) public administration;

(b) comprehensiveness;

(c) universality;

(d) portability; and

(e) accessibility.

These five points are what single-payer is supposed to accomplish. These goals are what matters, single-payer is a means to these goals, not an end in itself. Here’s what they mean:

Public administration means that the insurer must be non-profit, responsible to the provincial government, and meet requirements for transparency.

Comprehensiveness means that

the health care insurance plan of a province must insure all insured health services provided by hospitals, medical practitioners or dentists, and where the law of the province so permits, similar or additional services rendered by other health care practitioners.

Whether Canadian care is truly comprehensive depends on how “similar or additional services rendered by other health care practitioners” is understood. It hasn’t been interpreted as including outpatient services provided by psychologists or social workers, meaning that a lot of mental health care isn’t covered. Moreover, covering services does not mean covering drugs unless they are delivered in hospitals. Whether drug costs should be covered is a major health policy dispute in Canada.

Universality means that

the health care insurance plan of a province must entitle one hundred per cent of the insured persons of the province to the insured health services provided for by the plan on uniform terms and conditions.

On this one, Canada delivers.

Portability more or less means that my Ontario Health Insurance Plan card will be accepted when I’m in any other province, and vice-versa.

Accessibility means that the insurers must give reasonable compensation to hospitals and providers and

must provide for insured health services 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.

You can cover everyone universally, but that doesn’t mean that everyone can access care. If you hadn’t heard, Canada is a big place. Providing care in remote areas is an enormous challenge and there are important disparities in the abilities of different ethnic and linguistic groups to access care.

These are the goals of the Canadian health care system. They are, in my opinion, the right ones. Universality is just the first step: achieiving true comprehensiveness and universality is an ongoing struggle.

So, Happy Canada Day / Joyeux Fête du Canada! The Confederation is 150 years today.


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