Ensuring Medicare's Future
A Submission to the Department of Finance
and to the Alternative Federal Budget Process
by the Canadian Health Coalition, December 1998
Summary
In this submission to the Department of Finance and the Alternative Federal Budget, the Canadian Health Coalition sets out the minimum budget investment necessary to ensure a reformed public health care system based on the five principles of the Canada Health Act. At the same time, it is a practical budget that recognizes both the need for fiscal responsibility and the need to address provincial/territorial concerns about federal contributions.
Anything less than this budget would profoundly undermine public health care and public support. In addition, it would not only promote an inefficient and ineffective two-tier system; it would also discourage investment while encouraging destructive provincial competition. Equally important, it is fundamentally undemocratic to do anything less, given that all parties have been elected on platforms that promise to defend the public health care system and that all polls indicate that public health care is non-negotiable for Canadians.
Introduction
Health care is not only Canada's best loved social program. It is also critical to our identity, uniting us across region, class, race, gender and age. "At a time when other traditional expressions of Canadian values have been placed under demonstrable stress, health and health care have increased in importance and prominence as a shared and common value." Indeed, the National Forum on Health that was appointed by the Prime Minister to advise him on how to improve the health system and the health of Canada's people, went on to conclude that "its significance has broadened into symbolic terms as a defining national characteristic."1
The National Forum simply confirmed what poll after poll has found. Health care remains Canada's best loved social program; indeed, it is the government intervention Canadians support the most.2 It has become their top priority.3 In spite of increases in waiting times, a substantial and growing majority of Canadians oppose allowing individuals to pay extra to get quicker access to health care services. Two-thirds oppose a two-tier system, with polls showing the support for two-tier declining over the last year.4 And a recent Ontario poll found 78% of respondents willing to forgo a promised income tax cut if the money were reinvested in nursing services.5
Every independent commission examining health care has found what most Canadians already know from personal experience. The publicly-funded system has worked to provide Canadians with accessible, high quality care at a much lower cost than the mainly for-profit system to the south.
This public health system has done more than promote Canadian identity and individual health. It has also played a significant role in promoting a healthy economy. The contribution a national health program can make to the economy has long been recognized in Canada, at least whenever an official enquiry is conducted.
Appointed in 1937, the (Rowell-Sirois) Royal Commission on Dominion-Provincial Relations "emphasized the chaotic financial results on business if some provinces, acting independently on health insurance, levied taxes on employers that placed them in a less competitive position with respect to business in provinces that did not."6 This Royal Commission was just as concerned that employees would seek out provinces that offered better health plans and thus disrupt more efficient job search strategies. Although the Commission recognized that health care is a provincial responsibility, its investigation of these economic consequences led to the conclusion that "The balance of advantage lies in some degree of uniformity throughout Canada, and, therefore, in the collection of contributions by the Dominion."7 In other words, the Commission concluded that the kind of differences that would be produced by approaches such as the proposed social union would undermine the economic advantage of public care.
More recently, the World Competitiveness Report identified public health care as a major factor in Canada's competitive advantage.8 This advantage is obvious when employer payroll taxes in Canada and the United States are compared. Canadian employer contributions for benefits are significantly lower primarily because we have a national health system that spreads the costs among employers and citizens in a manner that benefits them all relatively equally. Less visible, but nonetheless important, is the advantage gained from a healthier workforce; a workforce that not only has access to care when it is required but also has to worry less about paying the bills from high cost medical care and less about which employers offer health benefits. In addition to reducing employer costs, the publicly-funded system provides important employment opportunities. This is particularly the case for women, who make up 80% of this highly educated workforce9. With a public health system, labour force strategies can be organized across a province or territory in ways that ensure both stability and efficiency. In British Columbia, for instance, the Employment Security Agreement that the provincial government signed with the three health care unions representing the majority of employees in the health sector assists in the relocation of workers displaced by restructuring . 10 Equally important, secure employment promotes a healthier, more loyal and productive workforce that pays taxes, and spends money, in Canada.
The five principles of the Canada Health Act
The health care system has these benefits primarily because it is based on five nationally determined principles designed to ensure reasonable equity and conditions for patients, providers and employers. These five principles set out very simply in the Canada Health Act are mutually reinforcing, in ways that help promote a healthy economy.
1. Portability
The Canada Health Act requires that citizens be eligible for coverage in all provinces. This means that employees can follow job opportunities without fear of losing their insurance coverage. The portability requirement also means that provinces without the resources to provide certain kinds of very specialized treatment can purchase these services in other parts of the country and thus ensure coverage for their citizens while efficiently using resources. Because coverage is paid for the service rather than for the patient, Canadian health insurance is also portable from service to service and from workplace to workplace. This kind of portability is particularly important with employers demanding an increasingly flexible workforce and with employees required to move from job to job or even hold two jobs at once. Employees and employers do not have to consider health care coverage as a barrier to this mobility. Indeed, portability is central to the "freedom of choice" that the (Hall) Royal Commission on Health Services made a basis of the Health Charter and that has made medicare so popular in Canada.11
2. Public Administration
A second principle in the Canada Health Act requires that the tax-funded insurance be publicly administered. Public administration allows governments to distribute services effectively across their territories, in the process more efficiently allocating resources. Equally important, it allows for public debate and public planning as well as for stability. Integration and continuity are also more possible to emphasize in a publicly-administered system. This contrasts sharply with the disruptions, discontinuities, and secrecy involved in private and for-profit care in the United States. For example, Oxford Health Plans Inc. has announced it intends to close Medicare HMO operations covering 17% of its Medicare members and other American Managed Care organizations have indicated they will follow suit.12
Under the Canada Health Act, "private insurance is implicitly or explicitly forbidden and there is no opting out of paying taxes for the public system".13 The combination of this stable financing and prohibition against for-profit coverage for medically necessary services significantly reduces the need for bureaucratic controls, excessive record keeping and extensive contracts that need both regular re-negotiation and constant surveillance. At the same time, it permits the development of systematic coverage in equitable ways. The result, as study after study has shown, is reduced costs compared to a largely for-profit system.
3. Universality
The third principle of the Canada Health Act requires that everyone be covered for health care. Universal coverage is not only more democratic. It is also cheaper and more efficient. The Hall Commission, the Royal Commission that led to Medicare, considered a two-tier system requiring means testing for eligibility and user fees for those able to pay.
The Commission rejected these alternatives on the grounds that up to three-quarters of the population would be eligible for subsidy, depending on the income cut-off thresholds, and the costs to administrate such a program would outweigh the benefits.14 This has certainly proved to be the case in the United States, where the administrative costs of sorting out the deserving from the undeserving provides a major part of the explanation for why U.S. governments spend almost as much of their GDP on health care as Canadian governments do, but only manage to cover the very old, the very poor, the very disabled and the military for some of their health care needs.15 In U.S. hospitals, administration costs are nearly twice those in Canada and administrative expenditures are highest in the for-profit ones.16 Most of the explanation for the difference in expenditures between Canada and the United States can be found in the amounts going to profits and to extra expenses, and waste, caused by competition.
4. Accessibility
The Canada Health Act does more than require universal coverage. It also says that these services must be provided under uniform terms and conditions. It thus explicitly forbids a two-tiered system, user fees or other means of providing differential or preferred access or different facilities linked to different payment needs. The Hall Royal Commission rejected differential treatment primarily on the "pragmatic tests of administrative and financial feasibility."17
But Canadians have come to value this principle because it is more equitable and more effective to base access on need rather than on ability to pay.
Accessibility means providing 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."18 With access to services, citizens can use services when the need arises, instead of delaying to avoid the expense (Table 2). Early treatment and preventative action are thus more likely with such access. The consequence is better health, as well as the avoidance of long-term care costs, especially for the elderly.
It is important to note that the Canada Health Act also includes "reasonable compensation for all ensured services" as an integral part of accessibility.19 In other words, the Act recognizes that decent pay is essential for those providing services in order to ensure not only quality and stability but also fairness. While only doctors and dentists are mentioned specifically in the list of providers, the Act refers to reasonable compensation for hospitals and those hospital services include the services of all who work there.
5. Comprehensiveness
Comprehensiveness, the final principle, is defined to include insured services provided by hospitals, physicians and dentists. In addition, the Act provides for federal compensation to provinces allowing other practitioners to perform similar services. The Hall Royal Commission recommended that the plan cover prescription drug services, optical services, prosthetic services and home care services, in order to allow for the provision of care at the most appropriate level and to insure necessary care was covered. But the Canada Health Act does not go this far.
As well, the Act specifically excludes nursing homes, residential care services and institutions for the mentally ill. Although the Canada Health Act does not extend much beyond medically necessary care provided by doctors and hospitals, the coverage for these services initially included virtually everything that was required within these confines.
The rationale is simple. If the services are necessary they should be covered, including food, housekeeping services, drugs and laboratory or other tests. It would cost more to sort out the payments for some services, it would define care too narrowly given the determinants of health, and it would limit access.
In sum, the principles provided for a national system that was and remains more efficient and effective than a for-profit, non-public scheme while ensuring more equitable and fair treatment for patients, providers and employers. At the same time, the principles provided enough flexibility to allow provinces to develop their own way of delivering care. As the Hall Royal Commission put it, "We do not suggest that the various provincial programs be required to conform to any rigid pattern, but to qualify for federal support they need to provide, in whatever manner may be chosen, universal coverage in the province regardless of age or condition, or ability to pay, upon uniform terms and conditions, and to adhere to the basic inclusive features of each of the programs recommended". These principles are responsible for our firm support for, and strong identification with, public health care.
This is not to suggest that all is perfect with the Canadian health care system. It is forever evolving to address new political realities, medical and technological advances, and organizational change. It still fails to serve all of us equally well, as the research on health and Aboriginal peoples in particular makes clear.20 There is, then, always room for improvement in the health care system that a majority of Canadians see as "a basic fundamental tenet of being Canadian".21 However, as the National Forum found in group after group interviewed for their report, "many see 'health reform' as a code for withdrawal of services and, consequently, there is concern about the viability of the system in the future."22
The federal role in undermining the Canada Health Act
Much of this rising concern can be traced back to the federal government, which has contributed to the undermining of the five principles, and thus of both the health care system and public support for it, in at least two significant ways.
First, the federal government has dramatically reduced the cash transfers to the provinces. These cash transfers not only provide necessary financial support. They also provide the sole means by which the federal government can enforce the five principles of the Canada Health Act. The provincial access to funds made available through the transfer of tax points neither compensates for the decrease in federal cash nor provides an alternative means of federal enforcement of the principles. With federal cash transfers now collapsed into the Canada Health and Social Transfer that lumps together health, education and welfare funding, it has indeed become impossible to determine just how large the federal cash contribution is. All we can assert is that because the total CHST is so much smaller than that of its former components, federal health spending has declined sharply.
The provinces have responded by reducing hospital budgets significantly, by delisting some services, by failing to cover new therapies and services, and by offloading responsibility for some other services to municipalities and to private providers. Hospitals have been redefined to provide only the most acute care, and the definition of medically necessary care has been made more restrictive. These new definitions threaten the protection accorded by the five principles, because the further care is moved from hospitals and doctors, the further it is moved out from under the umbrella of the Canada Health Act. Even in areas clearly covered by the Act, governments are shifting responsibility for some payments to individuals, employers and insurance companies, and responsibility for care provision to for-profit firms and to individuals in their homes. The federal government has done little to stop this privatization of care.
The impact is clearly reflected in the data. The share of health care paid for privately has risen from 23.3% in 1983 gradually to 25.6% in 1991 and then sharply to an estimated 31.3% in 1997.23 The number of hospital beds has declined by 20% over the last ten years, while the population has of course grown appreciably.24 Part of this decline in beds can be explained by new techniques and drugs that make it possible for patients to be sent home quickly, although these patients still often require considerable care. And part of the rapid decline can be explained by the removal from hospitals of all but the very acutely ill in order to meet the major cutbacks in hospital funding.25 The discharged have not found spaces in residential care, however, given that there are also fewer beds in facilities for the aged, the developmentally delayed, emotionally disturbed children and those with addictions.26
Many of those discharged early, sent home after day surgery or out-patient care and of those released with chronic health problems are also discharged from coverage by the public system. Home care work and home care costs for drugs, tests, equipment and care have increased enormously. Much of the care work is being done by women who are untrained for the task, unpaid for the work and often unable to combine care provision with their paid jobs in ways that allow them to remain productive. Such caregivers are just some of the people who told the National Forum that they did not want to be "conscripted into care giving."27 Equally important, these caregivers are replacing the more than 60,000 highly trained health care workers who used to be paid to do the work. Most of those losing their paid jobs, as well as most of those conscripted into care giving at home, are women. When women are paid to do care work in the home, they seldom receive the same kind of pay or protections provided for those employed in institutions.
It is for these reasons that the national consultation on home care concluded that the shift out of hospitals and institutions must be accompanied by new legislation that will ensure health care remains universal, comprehensive, accessible, publicly administered and portable beyond the walls of hospitals and doctors offices. Such coverage should also be accompanied by stable financing for hospitals, to slow the rush to discharge patients and transfer the costs of care. By covering both hospitals and home care, the government would be following through on the Hall Royal Commission's recommendation designed to ensure the appropriate location and level of care for all Canadians. Equally important, care by for-profit firms must be prohibited in order to allocate all the tax dollars to care, rather than to profit, and to guarantee continuity as well as integration of health care services.
This leads to a second way in which the federal government has contributed to the undermining of the five Canada Health Act principles. It has done very little to stem the marketization of health care. Indeed, federal policies often serve to promote it. Yet such marketization has been rejected as inefficient and ineffective by every government commission and task force that has reported, and has been found to be unacceptable to a majority of Canadians in every opinion poll that has been conducted since medicare became fully established a quarter century ago. The federal government's failure to prevent marketization is no surprise given its commitment to "getting government right"28 by embracing both partnerships with the for-profit sector and the adoption of managerial practices developed in the for-profit sector. In the process, the federal government is undermining the principles of its own Canada Health Act.
The designation of food and drug manufacturers as the "clients" of the Health Protection Branch, a Branch whose budget has been halved and many of whose in-house laboratories have been closed, is only the most obvious example. Federal support for health care (and other) research is increasingly conditional on the establishment of partnerships with the private sector. At the same time, the government's own direct investment in health care research has dropped, forcing researchers to seek funds from the private sector. As the National Forum points out, the offloading of research costs to the private sector "will be a major obstacle to improving effective management of research needs and priorities" and can lead to a distortion of the research agenda.29
Health information technologies provide another example. The development of health information technologies was located, not with Health Canada, but with Industry Canada, where it was assumed that these technologies should be designed, constructed and delivered by for-profit firms. The technologies were assumed to be market goods. With private partners, governments may be pressured to keep confidential decisions about such vital health issues as what information is to be collected by whom, in what way for what means, beyond the reach of public input and scrutiny, in order to respect the commercial interests of their partners. And tax dollars may go to profits in health information technologies that we may not need, or that the public may decide we can do without. Yet health information technologies are integral to an effective public system for providing health care. They should be developed in ways that support the principles of the Canada Health Act. Public accountability is critical, not just in terms of privacy issues but also in terms of the design, collection and analysis of the data that are produced.
Like their federal counterparts, most provinces and the health providers they fund are contracting out managerial decision-making, along with a vast range of the activities involved in actually delivering health care, to for-profit firms. And many of these firms are foreign-owned. As a result, tax dollars are leaving the country along with jobs and public accountability. In the process, the system is becoming less efficient and less effective.
The National Forum made it abundantly clear that: an over-reliance on private health care financing tends to inflate health expenditures, thereby crowding out other worthwhile expenditures in other sectors. Within the health sector, private health care financing can distort resource allocation by creating excess capacity, and by skewing resources toward high-tech services and administrative machinery.30
Privatization, then, is more than simply against the wishes of most Canadians. It is also an inefficient way to allocate resources, one with negative effects reverberating throughout the economy. As the National Forum put it, "Public financing promotes system integrity, cost-control and access based on need."31
Ensuring medicare's future
There are a number of federal initiatives that are necessary if Canadians are to sustain their best loved social program and their efficient approach to care. The initiatives suggested here build on the past, including the recommendations of various Royal Commissions, and on the evidence from experience and from comparisons with the United States.
Ensuring the Five Principles:
1. Cost-sharing raised to 25%
First, the federal government needs to once again play a central role in the financing of care in order to maintain the right to enforce the five principles of the Canada Health Act and to encourage the kind of stability necessary for both planning and for employment. To do this, the federal government should establish a National Health Care Fund instead of rolling welfare, education and health funds into the Canada Health and Social Transfer (CHST). As was the case in the past, such a strategy would help ensure a standard of equity for patients, providers and employers across the country. At the same time, because it is principles rather than services that would be national, the strategy would allow provinces to determine precisely how health care is delivered. This strategy would address the concerns that have led to demands for a social union. With federal funding stable and adequate, the only reason to demand more provincial control would be to abandon the five principles of the Canada Health Act. The separation of health funds into a distinct envelope would also allow Canadians to learn the size of the federal contribution, and to hold the federal and provincial governments accountable for their funding decisions.
The CHST has served to camouflage real cuts to health care. If health care is to be restored as a strong national program, the federal government should not only clearly identify health funding but also increase the share of total health care funding represented by federal cash transfers to the provinces. Initially, the federal government paid half of insured health care costs. Now it pays just over 10%, according to the best estimates, and the period of most rapid decline is the last decade. Some health care savings have been realized through health reform strategies but many of these strategies intended to compensate for reductions in federal contributions have served to undermine public care, reducing both access and comprehensiveness. More federal funding is necessary to maintain and improve the public system. And more federal cash is necessary if the government is to have the power to enforce the principles of the Canada Health Act. Therefore, we are recommending that the government bring overall federal contributions back to at least 25% of total funding, a level last reached in 1989. The federal allocation for the National Health Care Fund would be $4.6 billion per year (See Appendix 1).
Provinces have rightly complained not only about the reductions in federal funds but also about the unreliability of federal financing. Governments at the federal level keep changing the formula, making it difficult for provinces to plan for care. To allow long-term planning for integration and continuity at all levels, the federal government should guarantee stability in federal direct and cash transfer funding for health care. A five-year formula that requires two years notice before changes can take effect would promote a rational distribution of resources and good will in federal-provincial relations.
Ensuring Universal Access to Care:
2. Home Care
Second, the federal government should extend the public system to accommodate the shift to care outside hospitals. The federal conference on home care -- a conference that brought together providers, patients, employers and experts -- concluded that this could best be done by developing separate legislation mandating federal participation in the funding of a national home care program. The participants agreed that the Canada Health Act should not be extended to cover this care, primarily because they feared that powerful forces pushing for privatization would fundamentally weaken the Act. Basically, the conference recommended the same strategy used for public hospital insurance and medical insurance. Parallel to the Canada Health Act, this new legislation would set out the principles provinces must follow to be eligible for federal contributions. This would allow for provincial variations in programme design and delivery while ensuring the kind of uniformity in access that the Hall Royal Commission said was essential for both employers and employees. A key condition for funding would be a prohibition against the use of public funds to pay for-profit firms to provide home care. The prohibition is necessary in order to ensure continuity, and to avoid both higher administrative costs and public money going to profits rather than to care. It is also necessary in order to prevent both tax money going to foreign firms and new obligations being created under free trade agreements. With an annual additional transfer of $2 billion, the federal government would be in a position to ensure compliance with these principles.
3. Pharmacare
In addition to extending coverage to home care, the federal government should take the initiative in addressing the rising drug costs that individuals are facing as a result of de-hospitalization, de-institutionalization and price increases. Sent home quicker and sicker, people are also sent out of the drug coverage provided under the public system. In order to ensure both the appropriate level of care and of public coverage, the government should do what the Hall Royal Commission recommended long ago -- develop a public drug plan. It should phase in a National Drug Program based on single-payer, first dollar coverage. The goals guiding a national drug program would be:
- equity of access;
- improved prescribing appropriateness; and
- cost-containment.
In this way, the federal-provincial health insurance system could move to integrate prescription drugs as a fully funded component of medicare.
The first step towards a national drug program is the implementation of comprehensive and publicly run population-based drug information systems. The second step is the centralization of drug purchasing in one agency for federal and provincial governments. This measure involves what the National Forum calls the "de-commodification" of drugs. 32
Just as hospitals and physicians are not encouraged to "market" their services, drug marketing and promotion should be actively discouraged, including a stricter prohibition on advertising. A central purchasing agency could also contract with Canadian pharmaceutical companies to supply generic copies of brand name drugs for non-commercial distribution. The public procurement of generic medicine for this purpose is permitted in international trade law. Some of these practices are already underway in various provinces and, as was the case with medicare, they can serve as an example and as evidence for developing a public plan.
By integrating home care and pharmacare into the system, the federal government would not only be ensuring access to necessary care - the stated commitment in the Canada Health Act - it would also promote the allocation of patients to the appropriate level of care. Care needs, rather than cost, would be the basis for decision-making. The result, as the Hall Commission made clear, is likely to be lower cost and better care in the long-term.
Ensuring Federal Responsibilities:
4. Health Information Technologies
Third, the federal government should defend the public interest in the field of health information technologies. This could be done by allocating money from the Health Transition Fund to develop Social Partner Councils. Made up of community groups, provider organizations and employer organizations, these Councils would supervise the development and implementation of new health information technologies. There would be three Councils, one in each of the following areas of technologies:
- clinical/patient data;
- outcomes measures/population data;
- employment/management data.
Dis-aggregating the technology decisions in this manner would help ensure public participation in appropriate areas and make the process more transparent.
5. Health Protection Branch
In addition, the government has to once again take an active role in health protection. In order to ensure the safety of our food and drug supply, in-house food and drug research laboratories, research budgets and scientific personnel should be re-established. The recommendations set out in the Krever Inquiry on blood safety should be applied across the entire Health Protection Branch. This would require a number of initiatives.
To start with, the Branch must be independent. As Krever made clear, "...an active regulator does not rely on, or defer to, manufacturers for information, expertise, and judgment but seeks its own information...". Equally important, the emphasis should be on protection of the public. A key tenet in the philosophy of public health is "action to reduce risk should not await scientific certainty" and this should be the basic tenet of the Branch. Moreover, the Health Protection Branch should adopt a policy of active, not passive, regulation of food, drugs, medical devices, air quality, water quality, and radiation. Cost-recovery revenues would not be applied to core budgets of safety programs but would be applied to expanding basic scientific research. In addition, emerging areas of risk should be financed with new money; not by cutting traditional areas like food and drugs.
Other initiatives are necessary to ensure that the researchers in the Branch can act independently, based on their scientific judgement, without pressure from managers or industries. To support this principle, an investigation into the non-performance of duty under the Food and Drugs Act should be conducted. Officials in Health Canada and industry who engage or have engaged in wrong-doing or negligence should be brought to justice. The budget of the Branch should be restored to 1993/94 levels.
6. Health Research
The federal government should also be active in the support of independent health research that would investigate all aspects of care. This would involve increasing health care research funding to 1 per cent of total health funding. A significant proportion of this increased funding should come from the pharmaceutical industry. As the National Forum points out, at the time Bill C-91 was enacted this industry made a commitment to increase its funding of research. The National Forum's recommends that this commitment "be converted into specific, required contributions to a fund for health research broadly defined at full arms-length from the industry, to be administered by the national research granting agencies and allocated through the normal peer-reviewed granting process."33
7. Aboriginal Health Services
Steps need to be taken in order to address issues of unequal access for a variety of groups. In particular, the government should implement the Royal Commission on Aboriginal Peoples' recommendations on health; namely: a) reorganize Aboriginal health services under Aboriginal control; b) train Aboriginal people to provide these services; c) adapt mainstream services to make them culturally appropriate; and d) promote the infra- structural development of Aboriginal communities, particularly in the areas of housing, clean water and waste management.
Ensuring Democracy
Finally, the government should establish a permanent Canadian Council on Health to guard and guide the public health system. The Council would monitor health care reforms. It would report to Canadians on how consistent the reforms are with the five principles of the Canada Health Act and on how the reforms contribute to the meeting of national health goals. This would include a strategy to protect health care services as public goods, delivered by the non-profit sector. The establishment of the Canadian Council on health would begin with a National Summit on health care.
Endnotes
1. National Forum on Health, "Values Working Group Synthesis Report," Canada Health Action: Building on the Leg acy. Volume II, Synthesis Reports and Issues Papers (Ottawa: Minister of Public Works and Government Services, 1997), p. 5.
2. Economist Intelligence Unit, Healthcare International (First Quarter, 1998), Chap. 4, "Canadian Healthcare Strug gles with its Five Pillars," Fig 4.5, citing Ekos Research Associates data. In 1995, public satisfaction with health care was reported at 61%, while for the next two most highly rated (consumer protection and crime) it stood at 42%.
3. Mohammed Adam, "Health-care ills can rip Canada apart, pollster Reid predicts," Ottawa Citizen (23 April 1998), p. A4, quoting Angus Reid.
4. Ekos Research Associates, "Tracking Beliefs Surrounding Two-Tier Health Care," (1998). In 1996, 55% expressed opposition to two-tier care while 34% supported it. In 1997, opposition had grown to 67% and support had dwindled to 23%.
5. Environics Research Group, "Ontarians' Attitudes regarding Funding and Organization of Nursing Services," prepared for the Registered Nurses Association of Ontario (March 1998), p. 11.
6. Quoted in Malcolm Taylor, Health Insurance and Canadian Public Policy (Kingston: McGill-Queen's University Press, 1978), p. 7.
7. Taylor, Health Insurance and Canadian Public Policy, p. 7.
8. World Economics Forum. World Competitiveness Report 1991 (Lausanne, Switzerland: Institut pour l'Etude des Methodes de Direction de l'Entreprise, 1992).
9. Pat Armstrong "Unravelling the Safety Net: Transformations in Health Care and Their Impact on Women". Pp. 129 - 150 in Janine Brodie (ed:) Women and Canadian Public Policy Toronto: Harcourt Brace, 1996.
10. Health Canada, Health Reform Database Ottawa: Health Canada, 1998-99.
11. Quoted in Taylor, Health Insurance and Canadian Public Policy, p. 343.
12. Globe and Mail (October 5, 1998), p. B12.
13. National Forum, "Striking a Balance Working Group Synthesis Report," Canada Health Action: Building on the Legacy. Volume II, Synthesis Reports and Issues Papers (Ottawa: Minister of Public Works and Government Services), p. 16.
14. Taylor, Health Insurance and Canadian Public Policy, p. 346.
15. In 1995, public spending on health accounted for 6.9% of the Canadian GDP and 6.6% of the U.S. GDP, according to the OECD measure cited in Pat Armstrong and Hugh Armstrong with Claudia Fegan, Universal Health Care: What the United States Can Learn from the Canadian Experience (New York: The New Press, 1998), Table 6.4. On comparative administrative costs and personnel, see for example David U. Himmelstein et al., "Who Administers? Who Cares? Medical Administrative and Clinical Employment in the United States and Canada," American Journal of Public Health 86:2 (February 1996).
16. Steffie Woolhandler and David Himmelstein "Costs of Care and Administration at For-Profit and Other Hospitals in the United States" New England Journal of Medicine 336:769-774, March 13, 1997.
17. Taylor, Health Insurance and Canadian Public Policy, p. 345.
18. Canada, Canada Health Act 1984, c.6.s.l. 12(i) (a).
19. Canada, Canada Health Act 1984, c.6.s.l. 12 (a).
20. See for example National Forum on Health, "The Need for an Aboriginal Health Institute in Canada," Canada Health Action: Building on the Legacy. Volume II, Synthesis Reports and Issues Papers (Ottawa: Minister of Public Works and Government Services, 1997).
21. National Forum, "Values Working Group Synthesis Report," p. 8.
22. National Forum, "Values Working Group Synthesis Report," p. 8.
23. Calculated from Canadian Institute for Health Information website, totprov1.htm and prvtpro1.htm at www.cihi.ca, October 1998.
24. Barbara Wickens, "When Hospitals Lose Beds" Maclean's (June 15, 1998), p.21.
25. Jane Coutts, "Hospital Stays Show Decline," Globe and Mail (June 7, 1998), p.A4.
26. Wickens, "When Hospital Lose Beds," p.21.
27. National Forum, "Values Working Group Synthesis Report," p.19.
28. This term is to be found in the pivotal 1995 Budget Speech by Finance Minister Paul Martin (27 February 1995) and in a host of subsequent government pronouncements.
29. National Forum, "Values Working Group Synthesis Report," p.30.
30. National Forum, "Striking a Balance Working Group Synthesis Report," p. 14.
31. National Forum, "Striking a Balance Working Group Synthesis R