|
BP-300E
THE CANADIAN
AND AMERICAN
HEALTH CARE SYSTEMS
Prepared by:
Odette Madore
Economics Division
June 1992
TABLE
OF CONTENTS
INTRODUCTION
THE
ROLE OF GOVERNMENT AND PRIVATE SECTOR
IN
HEALTH CARE
HEALTH
CARE SYSTEMS IN PROFILE
A.
Access to Health Care Services
B.
Financial Barriers to Care
C.
Extent of Benefits
D.
Administration
COST
CONTAINMENT
A.
Level and Rate of Growth of Health Care Costs
B.
A Single Payer May Lower Costs
RATIONING
AND QUALITY OF CARE
CONCLUSION
SELECTED
REFERENCES
THE CANADIAN AND
AMERICAN
HEALTH CARE SYSTEMS
INTRODUCTION
The United States is currently
studying various proposals to reform its health care system and that of
Canada is often cited as a possible model. Curiously, Canadians sometimes
look to the United States for ways to improve their system. This search
for improved health care has led to abundant but conflicting documentation
about the relative merits of the two systems. The available literature
emphasizes the relative efficiencies of public versus private intervention.
While many maintain that Canadas public system is both better and
cheaper, still many others contend that the privately-oriented American
system provides more efficient and better quality services.
This paper presents a comparative
description of the Canadian and American health care systems and reviews
the most recent literature. The first part briefly examines the reasons
for and against government involvement in health care; the second part
compares both systems in terms of access, financial barriers to care,
extent of benefits, and administration; the third section deals with cost
containment. Finally comparisons are made in terms of the quality of care.
THE
ROLE OF GOVERNMENT AND PRIVATE SECTOR
IN
HEALTH CARE
Both Canada and the United
States devote a high proportion of their national wealth to health care.
Estimates for 1990 show that Canada spent more than 9% of its GDP, or
$60 billion dollars on health care,(1)
while the United States contributed $660 billion or 12% of its GDP.(2)
The health care system in Canada is characterized by strong government
intervention. As can be seen in Table 1, of total health care spending
in Canada, 72% was funded through federal, provincial and local governments.
Canadians spend out of pocket only for services not covered by their provincial
government insurance plan; this amounts to 21% of total health care expenditures.
By contrast, the health care system in the United States relies heavily
on the private sector; American individuals and their private insurance
companies contributed more than half of total health care expenditures,
while the federal, state and local governments accounted for 43%.
TABLE 1
HEALTH CARE FINANCING BY SOURCE OF FUNDS, 1990
|
Canada
|
United
States
|
Percentage
of Total
|
Federal
Government |
28
|
30
|
Provincial/State
and Local Governments |
44
|
13
|
Out-of-Pocket
Spending and Private Insurance |
27
|
52
|
Others |
1
|
5
|
Total |
100 |
100 |
Source: Standing Committee
on Health and Welfare, Social Affairs, Seniors and the Status of Women,
The Health Care System in Canada and Its Funding: No Easy Solutions,
Ottawa, June 1991, p. 7; Julie Kosterlitz, "A Sick System,"
National Journal, 15 February 1992, p. 383.
Government intervention
in the health care field is a source of controversy, with solidly based
arguments both for and against. In Canada, health care is treated as a
public service, which Canadians believe should not be subject to the laws
of the marketplace and the mechanism of price and profit. By contrast,
Americans favour limiting government assistance to those in need and allowing
the private sector to have a great portion of the market. They contend
that market mechanisms, the motive force of classical economics, can ensure
cost control, efficiency, and top-quality services through effective competition.
Canadian government intervention
in health care is generally explained with reference to certain market
failures. In the private sector, resources are generally allocated according
to the law of supply and demand. The resulting price levels ensure optimal
allocation of resources, provided certain conditions relating to supply
and demand are met. These conditions do not always prevail in the area
of health care, however. First, it is difficult for the market system
to ensure an adequate supply of health services because the very nature
of these services implies costs and benefits that the market system does
not take into account. Furthermore, consumers cannot make informed decisions,
because there is always uncertainty about illness and the future state
of ones health. Consumers are often unable to determine for themselves
the type of health services they need and must delegate the decision-making
process to those who provide the health services. Government involvement
in health care is also justified by reference to social fairness and economic
inequality. In a free market system, low-income people with health problems
pay the same as high-income people, so that the economically disadvantaged
pay a relatively larger share of their income for health costs. For these
reasons, federal and provincial governments in Canada have preferred a
public system providing health insurance to all residents, regardless
of their ability to pay.
By contrast, the market-oriented
health insurance system of the United States is based on choice rather
than on ability to pay. In recognition of the fact that specific groups
need public protection, Medicare and Medicaid provide for the poor and
the elderly. This reflects government action to resolve some market failures.
The American system is based on the assumption that the vast majority
of people are perfectly capable of providing protection for themselves
against illness and its consequences and that most of the population are
not denied care for financial reasons. Under the market approach, the
consumer is free to choose the extent and form of insurance protection.
Some may choose an appropriate level of coverage, while others may choose
to be inadequately covered or not covered at all. When deciding how to
insure themselves against costs of health services, people consider how
they value health services compared to other things, given their level
of income and their willingness to pay. Although Americans can choose
the type of health insurance they want to buy, the use of health services
requires specialized knowledge, so that doctors remain providers of information
and advice. Thus, in a fee-for-service scheme, physicians could be in
a conflict of interest. Most Americans contend, however, that an effective
competition between doctors and hospitals ensures good quality medical
care at a reasonable price.
In summary, there is no
unanimity on the basic principles that should underlie the health care
system. Social arguments seem to favour government intervention, while
other considerations, such as freedom to choose and the efficiency of
the interaction between demand and supply, call for the involvement of
the private sector. These different philosophies have resulted in a relatively
simply structured system in Canada and a very complex system in the United
States.
HEALTH
CARE SYSTEMS IN PROFILE
Canada provides universal
insurance coverage to all its residents through provincial health insurance
plans jointly financed by the federal and provincial or territorial authorities.
Although private insurance companies exist, they are not allowed to cover
services provided under provincial plans. In each province, only one public
insurance entity is responsible for reimbursing hospitals and physicians.
Patients are free to choose their physicians, but they do not reimburse
these physicians or hospitals for insured health care services. Most physicians
are in private practice and are paid on a fee-for-service basis. Most
hospitals are private, non-profit organizations financed by provincial
governments overall budgeting.
Similarly, American providers
of care, including physicians and hospitals, are largely private. The
majority of patients receive care on a fee-for-service basis and are generally
free to choose their own providers. However, the United States provides
health insurance through a combination of public programs and private
initiatives, including employer-provided arrangements and the individual
market.
U.S. employers may provide
their employees with self-insurance plans or insurance plans contracted
out with third-party insurers. Self-insured employers usually operate
and administer their own health plans; a few of them even run their own
health care facilities. In addition to commercial plans, third-party insurers
include Health Maintenance Organizations (HMOs), which both insure and
deliver health care services, and Preferred Provider Organizations (PPOs),
which offer health insurance plans but allow patients to choose from among
a specific group of medical care providers. It is recognized that HMOs,
PPOs and employer-sponsored plans somewhat restrict patients choice
among health care providers.(3)
Individuals who do not have access to employer-based coverage may obtain
health insurance coverage by purchasing it directly from commercial insurers
or HMOs.
Access to health care for
particularly needy population groups is provided through public programs.
Medicare is a national, federally administered program with uniform eligibility
and benefit protection serving the elderly and disabled persons. It covers
hospital and physician services and is financed by a combination of enrolled
premiums and general revenues. It also incorporates user charges such
as deductibles and co-insurance. Medicaid is a medical assistance program
for low-income groups. Under this program, the U.S. federal government
provides matching funds to state governments, which operate and administer
Medicaid within federal guidelines, although eligibility requirements,
benefit levels, and provider reimbursement schemes vary greatly from state
to state. Other federal and state government programs target specific
population subgroups such as pregnant women, native Americans, and people
suffering from renal disease and cancer.
A.
Access to Health Care Services
In Canada, the health care
system is characterized by its universal access. All residents of a province
are entitled to the insured health services provided for by the public
health insurance plan on uniform terms and conditions. In addition, health
care provided to someone who is temporarily visiting another province
is reimbursed under the insurance plan of the patients home province.
Canadians moving from one province to another continue to be covered for
insured health services by their home province during any waiting period
(not to exceed three months) imposed by their new province of residence.
By contrast, there is no
universal public health insurance in the United States and access primarily
depends on the type and extent of coverage. As shown in Table 2,
Americans have varying degrees of health insurance coverage, from comprehensive
to none at all. In 1991, almost 62% of Americans were covered under private
health insurance plans; public health insurance plans covered 25% and
14% had no insurance.
TABLE 2
HEALTH INSURANCE COVERAGE IN THE UNITED STATES, 1991
Type of Coverage
|
Number of Persons
|
|
(millions)
|
Covered
by privately operated medical insurance plan |
156
|
Covered under
Medicare
|
35
|
Covered under
Medicaid
|
27
|
No coverage at
all
|
35
|
Total U.S. Population
|
253
|
Source: William Lowther,
"Medicare to the Rescue," Macleans, Vol. 105,
13 January 1992, p. 33-34.
B.
Financial Barriers to Care
There is no financial barrier
to care in Canada. All Canadians have insured access to medically necessary
hospital and physician services under their provincial government health
insurance plan. Under the Canada Health Act, the provinces must
not permit user fees for publicly insured services, except for extended
care for those with chronic illness living in hospitals, nursing homes
and similar institutions. If they permit such charges, provinces are subject
to dollar-for-dollar deductions from the federal cash contributions provided
to them under the Established Programs Financing (EPF) as well as any
other federal cash transfers. This ensures that individuals are not forced
to forgo needed care because of expense. Canadians spend out of their
own pocket, or purchase private insurance, only for services such as dental
care, cosmetic surgery, and additional hospital-room amenities that are
not covered by their provincial plan.
In the United States, access
to health care is often limited by financial barriers, such as the high
cost of private insurance, inadequacies in public programs and user charges.
On the whole, Americans who can afford to pay are able to purchase medical
care that is better or more readily available than that open to people
who are less well off. Although U.S. federal and state governments help
reduce the effect of individual financial constraints through Medicaid,
Medicare and state assistance programs, millions of Americans still lack
either public or private health insurance coverage. Indeed, Medicare and
Medicaid do exclude many Americans. These uninsured must either pay out-of-pocket
or rely on public hospitals, or clinics offering free or subsidized care.
In recent years, the large number of patients without insurance has resulted
in an increase in "uncompensated care."(4)
C.
Extent of Benefits
Under the principle of comprehensiveness
underlying the Canada Health Act, provincial health insurance plans
must cover all medically necessary hospital services, physicians
services, and certain surgical dental procedures. Provincial governments
also have considerable flexibility in terms of the range of services they
may provide. They may and do include other benefits, such as prescription
drugs for the poor and the elderly that are not required under the federal
guidelines. There are no dollar limits to the amount of "necessary"
medical care that individuals may receive. Private health insurance covers
uninsured services.
The extent of benefits in
the United States varies widely among insurers. Most insurance sold by
private companies is regulated by the state, and therefore must provide
state-mandated minimum benefits. Self-insured employer plans, which do
not fall under the jurisdiction of state insurance laws, cover about half
of insured workers. Employment does not, however, guarantee coverage.
As a matter of fact, among the 35 million Americans without any insurance,
25 million are in families where at least one member has a full-time
job.(5) Some firms, particularly
small businesses, do not offer health insurance to their employees. This
presents a potentially significant impediment to moving from one job to
another a situation not found in Canada. Furthermore, when working
people retire, they lose the health insurance benefits provided by the
employer, and, as we have seen, Medicare provides standard benefits to
only some Americans.
D.
Administration
In Canada, the health insurance
plan is administered in each province by a public agency which operates
on a non-profit basis and is responsible to the provincial government.
Provincial governments determine overall increases in hospital budgets
and physicians fees and regulate the acquisition of major equipment
and facilities. While most physicians in private practice are paid on
a fee-for-service basis, most hospital-based physicians are salaried employees
of the hospital. Most hospitals receive funds under a global budgeting
system negotiated with the provincial government. On the whole, government
is the sole payer for all insured health services.
In the United States, responsibility
for administering and controlling the health care system is diffused,
and involves private insurers, employers, and federal, state and local
governments. With the variety of reimbursement systems, U.S. providers
are often paid different amount for the same services, depending on the
consumers insurance carrier. Furthermore, co-payments and deductibles
are common, and it is not unusual for health care providers to bill the
patient for charges in excess of the standard insurance reimbursement.
No authority has responsibility for the condition of the system as a whole.
COST
CONTAINMENT
Two major issues arise when
comparing health care spending in Canada and the United States. The first
is the level and rate of growth of health care costs; the second is governments
ability to control health care expenditures.
A.
Level and Rate of Growth of Health Care Costs
Health care expenditures
expressed as a percentage of GNP or in per capita terms take into account
the different sizes of the Canadian and American economies. As shown in
Table 3, since the early 1970s Canada has spent a smaller proportion
of its total economic output on health care than has the United States;
Canadian spending has also been lower on a per capita basis. Furthermore,
the rate of growth in health care expenditures as a percentage of GNP
has been lower than the comparable U.S. rate. For these reasons, many
studies conclude that Canada, with its public health care system, is doing
better than the United States: it provides coverage to all Canadians,
spends less on health care and is more successful in containing costs.
For example, the U.S. General Accounting Office (GAO) notes that:
Canadas relative
success in containing costs is evidenced by its slower rate of growth
in health care expenditures since 1971, the year publicly funded health
insurance was implemented in all provinces. As a result, health care
expenditures per capita and as a proportion of gross national product
(GNP) remain significantly less than the Unites States. This gap is
due to differences in how the two countries finance and deliver health
care as well as socio-demographic differences.(6)
Other analysts argue that
these comparisons between Canada and the United States are simplistic
and misleading. They suggest that comparisons of the two nations
health spending as a proportion of GNP exaggerate Canadas success
in containing health costs. They argue that faster GNP when growth, rather
than lower health spending, explains why healths share of GNP has
stayed lower in Canada.(7)
Furthermore, they show that when the real rates of growth of per capita
spending are compared, the average rate of growth over a twenty-year period
is slightly lower in the United States. From that perspective, Neuschler
concludes that "Given very similar growth rate of per capita health
spending, the country that expands economic output more rapidly will spend
a smaller proportion of that output on health care."(8)
However, another study shows that faster GNP growth in the United States
would indeed have led to an even higher level of health care expenditures:
"If U.S. income had grown as fast as Canadas, health spending
would have increased more and per capita spending would have been even
higher than the current U.S. levels."(9)
TABLE 3
TOTAL HEALTH CARE EXPENDITURES
AS A PERCENTAGE OF GROSS NATIONAL PRODUCT
AND IN PER CAPITA TERMS
|
Canada |
United
States
|
Percent
of GNP |
Dollars
Per Capita |
Percent
of GNP
|
Dollars
Per Capita
|
1960
|
5.5
|
120
|
5.2
|
149
|
1965
|
6.0
|
174
|
5.9
|
206
|
1970
|
7.1
|
293
|
7.4
|
349
|
1975
|
7.3
|
540
|
8.3
|
591
|
1980
|
7.5
|
943
|
9.1
|
1,055
|
1985
|
8.7
|
1,605
|
10.3
|
1,696
|
1990
|
9.5
|
2,321
|
12.2
|
2,566
|
Source: Health and
Welfare Canada, National Health Expenditures in Canada 1975-1987,
Ottawa, 1990, p. 27 and 137. Preliminary figures for 1990 were provided
by the Department in May 1992.
Another indicator of the
effectiveness of health care cost controls used in the literature is the
ratio of per capita spending in Canada as a percentage of per capita U.S.
spending. In his study, Neuschler shows that this percentage has fluctuated
in a very narrow range (approximately 75%) over the past three decades.
He concludes that Canada has not really been more successful than the
United States in containing health care costs and hence: "The factors
leading to different levels of health care spending in the two countries,
therefore, must be more basic than the difference in health care financing
arrangements."(10)
Overall, comparisons show
that health care costs are lower in Canada than in the United States but
there is no unanimity as to whether cost containment is better achieved
in this country.(11) Although
both countries are facing financial pressures, these pressures are exerted
differently. As the study of the GAO indicates,
In both Canada and the
United States, health care is limited by financial resources. However,
each country approaches access to health care services in a different
way. In Canada, financial constraints are applied to the entire system,
but not directly to an individuals utilization. In the United
States, financial constraints are placed directly on individuals
utilization - ability to pay is an important factor in obtaining access
and amount of care not on the system as a whole.(12)
In summary, the burden of
health care expenditures is shared collectively in Canada, while it is
borne by the individual in the United States. In the former country, payment
is made indirectly but equitably through the tax system; in the latter,
most of it is paid directly by consumers. On the whole, however, the systems
are similar in the sense that individuals ultimately pay for them; one
can thus conclude that the burden of health care costs is less for Canadians
than for Americans.
B.
A Single Payer May Lower Costs
Although there is no consensus
on government impact on health care, some studies indicate that the Canadian
system, by concentrating financial responsibility in a single payer, permits
more efficient administration and results in better control over health
care costs. As shown in Table 4, Canadian spending on health was,
in 1987, some $450 per person less than in the United States. The GAO
study indicates that most of the difference between U.S. and Canadian
per capita spending on health care comes from administrative costs and
physicians and hospital services.
TABLE 4
HEALTH CARE EXPENDITURES PER CAPITA BY SECTOR, 1987
(IN 1987 U.S. $)
|
Canada
|
U.S.
|
Hospital and Construction
|
659
|
802
|
Physicians
Services
|
241
|
369
|
Insurance Overhead
|
18
|
95
|
Other Professionals
|
20
|
84
|
Dentists
Services
|
82
|
108
|
Research
|
13
|
36
|
Other Health care
|
42
|
49
|
Other Institutions
|
156
|
158
|
Public Health
|
67
|
58
|
Drugs and Appliances
|
209
|
196
|
Total
|
1,507
|
1,955
|
Source: United States
General Accounting Office, Canadian Health Insurance: Lessons for the
United States, Report to the Chairman, Committee on Government Operations,
House of Representatives, June 1991, p. 29.
In 1987, Canadas per
capita spending on insurance administration was only one-fifth that of
the United States. Accordingly, the GAO points out that Canadas
publicly financed single-payer system eliminates the costs associated
with the marketing of competitive health insurance policies, billing for
and collecting premiums, and evaluating insurance risks.(13)
Danzon believes, however, that overhead costs in Canada would tend to
be higher than comparable costs in the United States, if hidden costs
were taken into account. She argues that a public insurer has fewer incentives
than private insurers to take into account all the costs for patients
and providers.(14)
Canada also exhibits lower
physician and hospital costs than the United States. The GAO argues that,
since Canadian provincial governments are the sole payer for insured medical
services, they are able to negotiate physicians fee schedules and
hospital budgets from a position of strength. Within the U.S. system,
hospitals and physicians are reimbursed by numerous payers using widely
differing procedures and coverage. According to the GAO, the fact that
no single entity is managing the U.S. system results in piecemeal measures
to control costs.(15)
Other health experts also
believe that government regulation in Canada does not necessarily reduce
the quality and quantity of health care services. For example, Conklin
recognizes that the control of physicians fees has in real terms
kept physicians incomes below the levels they would otherwise have
reached, but he believes that this has not resulted in poorer health care
in Canada. He contends that the higher expenditures in the United States
do not necessarily indicate the delivery of more health care, and explains
that higher U.S. spending only represents higher incomes for health care
workers.(16) He also believes
that limits placed by provincial governments on hospital budgets are cost-effective.
For instance, hospitals must compete for the right to adopt a new technology
and they do so by presenting convincing arguments to the provincial government.
Since hospitals have freedom in resource allocation within their budgets,
this process encourages cost minimization.(17)
Although government control
may lower costs, the GAO suggests that this can also reduce the potential
to manage costs as effectively. "For example, Canadian hospitals
have been described by physicians as having underdeveloped information
systems. Unlike the U.S. reimbursement system, the global budgeting approach
provides hospitals with fewer incentives for careful tracking of costs
per patient day or costs per case."(18)
Furthermore, some believe that Canada is limited in the development of
innovative approaches (such as HMOs) to health care financing and delivery.(19)
Finally, it has been argued that government control in the health care
sector in Canada has resulted in rationing and declining quality.(20)
RATIONING
AND QUALITY OF CARE
A number of weaknesses have
been identified in the management of both the Canadian and American health
care systems. One common problem relates to health care rationing. This
is defined as a limitation on the availability of beneficial interventions
whereby some persons are permanently or temporarily denied useful services.(21)
Canada tries to provide
uniform standard care to the entire population according to relative medical
needs. There is no price rationing based on the ability to pay. However,
non-price rationing does take place and results in waiting lists for selected
surgical and diagnostic procedures. Some ill people may thus have to wait
for treatment and risk the possibility of seeing their condition deteriorate.
Some Canadian patients experiencing delays in obtaining specialized medical
services have even crossed the border to seek care in the United States.(22)
By contrast, in the United
States rationing is based on the ability to pay. Such price rationing
comes about because some individuals have inadequate coverage, or are
deterred by user charges from using services. As a result, access to and
quality of care vary significantly among the U.S. population; the poor
and the poorly insured experience long waiting periods and substandard
facilities, if they receive care at all. Some aspects of American medical
care, such as limited immunization, a large number of pregnant women without
regular medical attention, and risk of bankruptcy through illness, are
the direct result of price rationing and would probably be considered
intolerable in Canada. Furthermore, non-price rationing exists even in
federal and state government programs. Although the poor, the elderly
and the disabled receive free treatment for most major illnesses and many
routine services, the availability of high-quality treatment is constrained
by the escalating cost of Medicaid and Medicare.
Critics of the Canadian
health care system suggest that the rationing of services results from
government constraints placed on hospital budgets and the number of facilities
used for specified high-technology services. It is true that Canada has
less expensive technological equipment per capita than has the United
States (see Table 5) and that some expensive facilities are not as
available in this country. Many critics view the slower diffusion and
limited use of some new technologies as evidence of lower quality of care.
If high quality is defined as more high-technology services regardless
of relative effectiveness, then the United States indeed offers higher
quality medical care. If, on the other hand, quality is defined by health
outcomes, there is no evidence of a Canadian disadvantage. Specifically,
Marmor maintains that if life expectancy and infant mortality measure
the quality of a health care system, Canada has a definite advantage.(23)
As can be seen in Table 6, Canadian indices of population health
status are superior to American. Nevertheless, some claim that there is
no definite link between medical care outcomes and the functioning of
the health care system.(24)
TABLE 5
AVAILABILITY OF SELECTED MEDICAL TECHNOLOGIES
(Units per Million of Population)
|
Canada
|
United States
|
Open-Heart
Surgery |
1.23
|
3.26
|
Cardiac
Catheterization |
1.50
|
5.06
|
Organ
Transplantation |
1.08
|
1.31
|
Radiation
Therapy |
0.54
|
3.97
|
Lithotripsy |
0.16
|
0.94
|
Magnetic
Resonance Imaging |
0.46
|
3.69
|
Source: Beth C. Fuchs
and Joan Sokolovsky, "The Canadian Health Care System," CRS
Report for Congress, Congressional Research Service, Library of Congress,
20 February 1990, p. 9.
TABLE 6
HEALTH STATUS INDICATORS
|
Canada
|
United
States
|
Infant Mortality
Rate
(per 1,000 live births, 1985)
|
7.9
|
10.5
|
Maternal Mortality
Rate
(per 100,000 live births, 1984)
|
3.2
|
8.0
|
Life Expectancy
at Birth
(men, 1985)
|
71.9
|
71.2
|
Life Expectancy
at Birth
(women, 1985)
|
79.0
|
78.2
|
Source: Beth C. Fuchs
and Joan Sokolovsky, "The Canadian Health Care System," CRS
Report for Congress, Congressional Research Service, Library of Congress,
20 February 1990, p. 13.
CONCLUSION
An overview of the recent
literature reveals that the health care systems in Canada and the United
States both have problems and limitations. Moreover, much of the debate
reflects different philosophical attitudes to government involvement in
health care; it will always be difficult to reconcile a market orientation
with the belief that health care should be provided on the basis of medical
need rather than ability to pay. Comparing the Canadian and U.S. health
care systems should, however, highlight both the strengths and drawbacks
of each and help find solutions best suited to each approach.
Overall, one must recognize
that Canada has achieved a balance between cost, quality and access. It
must now build upon its strengths and make the system more cost-effective.
The United States still has to make its system more efficient, less expensive
and more inclusive. Deber summarizes the issues now facing the two countries:
[In Canada], the old agenda
looked at accessibility and universality, asking questions such as:
What services are available? Where? At what cost to the patient? The
new agenda has had a different focus - on efficiency, outcome and the
appropriate role for government.(...) The United States, in contrast,
has not yet reached that point; much argument is still focused on how
care can be provided for those with poor (or no) access to it.(25)
On the whole, improving
Canadas health care system may not depend on putting greater reliance
on the private sector. Likewise, it may not be feasible for the United
States system to accept greater government involvement. It may be better
for each country to develop its own systems strengths and, where
appropriate, to incorporate features from that of the neighbouring country.
SELECTED
REFERENCES
Butler, Stuart. "Freeing
Health Care." National Review, 22 December 1989, p. 34-36.
Congressional Research Service.
Health Insurance and the Uninsured: Background Data and Analysis.
Library of Congress, May 1988, 172 p.
Conklin, David W. "Why
Canadas System is Better and Cheaper." Policy Options,
May 1990, p. 15-18.
Conklin, David W. "Health
Care: What Can the United States and Canada Learn From Each Other?"
Canada-U.S. Outlook. National Planning Association, Vol. 2, No.
4, September 1991, p. 3-19.
Danzon, Patricia M. "Other
Models and Hidden Costs." The American Enterprise, Vol. 3,
No. 1, January-February 1992, p. 71-75.
Deber, Raisa B. "Philosophical
Underpinnings of Canadas Health Care System." Canada-U.S.
Outlook. National Planning Association, Vol. 2, No. 4, September 1991,
p. 20-45.
Fuchs, Beth C. and Sokolovsky,
Joan. "The Canadian Health Care System." CRS Report for Congress.
Congressional Research Service, Library of Congress, 20 February 1990,
p. 14.
Haislmaier, Edmund F. "Northern
Discomfort: The Ills of the Canadian Health System." Policy Review,
Fall 1991, p. 32-37.
Kosterlitz, Julie. "A
Sick System." National Journal, 15 February 1992, p. 376-388.
Lowther, William. "Medicare
to the Rescue." Macleans, Vol. 105, 13 January 1992,
p. 32-39.
Marmor, Theodore R., "National
Health Care: Is Canada the Model System?" Current, No. 341,
March-April 1992, p. 12-16.
McCready, Douglas J. "Dont
Copy Canadas Health Care System." Policy Options, October
1991, p. 8-10.
Naylor, David. The Canadian
Health Care System: an Overview and Some Comparisons with America.
University of Toronto, Department of Medicine, 1991, p. 31.
Neuschler, Edward. "Is
Canadian-Style Government Health Insurance the Answer for the United States
Health Care Cost and Access Woes?" Canada-U.S. Outlook, National
Planning Association, Vol. 2, No. 4, September 1991, p. 46-73.
Pfaff, Martin. "Differences
in Health Care Spending Across Countries: Statistical Evidence."
Journal of Health Politics, Policy and Law, Vol. 15, No. 1, Spring
1990, p. 1-69.
Santerre, Rexford E., Stephen
G. Grubaugh and Andrew J. Stollar, "Government Intervention in Health
Care Markets and Health Care Outcomes: Some International Evidence."
The Cato Journal, Vol. 11, No. 1, Spring/Summer 1991, p. 1-12.
United States General Accounting
Office. Canadian Health Insurance: Lessons for the United States.
Report to the Chairman, Committee on Government Operations. House of Representatives,
June 1991, p. 85.
(1)
House of Commons, Standing Committee on Health and Welfare, Social Affairs,
Seniors and the Status of Women, The Health Care System in Canada and
its Funding: No Easy Solutions, Ottawa, June 1991, p. 2.
(2)
Julie Kosterlitz, "A Sick System," National Journal,
15 February 1992, p. 383.
(3)
David W. Conklin, "Why Canadas System is Better and Cheaper,"
Policy Options, May 1990, p. 18.
(4)
"Uncompensated care" consists of services for which the hospital
or physician receives partial payment or no payment. See Congressional
Research Service, Health Insurance and the Uninsured: Background Data
and Analysis, Library of Congress, May 1988, p. 148-150.
(5)
William Lowther, "Medicare to the Rescue," Macleans,
Vol. 105, 13 January 1992, p. 34.
(6)
United States General Accounting Office, Canadian Health Insurance:
Lessons for the United States, Report to the Chairman, committee on
Government Operations, House of Representatives, June 1991, p. 13.
(7)
Edward Neuschler, "Is Canadian-Style Government Health Insurance
the Answer for the United States Health Care Cost and Access Woes?"
Canada-U.S. Outlook, National Planning Association, Vol. 2, No. 4,
September 1991, p. 49. A similar argument is presented by Edmund F. Haislmaier
in "Northern Discomfort: The Ills of the Canadian Health System,"
Policy Review, Fall 1991, p. 34.
(8)
Neuschler, (1991), p. 55.
(9)
United States General Accounting Office (1991), p. 16.
(10)
Neuschler (1991), p. 53.
(11)
Clearly, there is not unanimity among empirical works on the impact of
government involvement in the health care market. For example, in an extensive
study on differences in health care expenditures among the OECD countries,
Pfaff show that health care systems relying on some form of government
control of spending generally exhibit lower health care expenditures than
those relying on market mechanisms. A study by Santerre et al.,
however, also using OECD data, reaches an opposite conclusion. Specifically,
this regression analysis shows that government financing does not necessarily
lead to lower total health care spending. For further details, see Martin
Pfaff, "Differences in Health Care Spending Across Countries: Statistical
Evidence," Journal of Health Politics, Policy and Law, Vol.
15, No. 1, Spring 1990, p. 20-21, and Rexford E. Santerre, Stephen
G. Grubaugh and Andrew J. Stollar, "Government Intervention in Health
Care Markets and Health Care Outcomes: some International Evidence,"
The Cato Journal, Vol. 11, No. 1, Spring/Summer 1991, p. 1-12.
(12)
United States General Accounting Office (1991), p. 21.
(13)
Ibid., p. 29.
(14)
Patricia M. Danzon, "Other Models and Hidden Costs," The
American Enterprise, Vol. 3, No. 1, January-February 1992, p. 71.
(15)
United States Federal Accounting Office (1991), p. 27.
(16)
David W. Conklin, "Health Care: What Can the United States and Canada
Learn From Each Other?" Canada-U.S. Outlook, National Planning
Association, Vol. 2, No. 4, September 1991, p. 8.
(17)
Ibid., p. 6.
(18)
United States General Accounting Office (1991), p. 33.
(19)
Stuart Butler, "Freeing Health Care," National Review,
22 December 1989, p. 35.
(20)
Neuschler (1991), p. 65-66; Beth C. Fuchs and Joan Sokolovsky, "The
Canadian Health Care System," CRS Report for Congress, Congressional
Research Service, Library of Congress, 20 February 1990, p. 11.
(21)
David Naylor, The Canadian Health Care System: an Overview and Some
Comparisons with America, University of Toronto, Department of Medicine,
1991, p. 14-16.
(22)
Douglas J. McCready, "Dont Copy Canadas Health Care System,"
Policy Options, October 1991, p. 9-10.
(23)
Theodore R. Marmor, "National Health Care: Is Canada the Model System?"
Current, No. 341, March-April 1992, p. 13.
(24)
Conklin (1991), p. 7.
(25)
Raisa B. Deber, "Philosophical Underpinnings of Canadas Health
Care System," Canada-U.S. Outlook, National Planning Association,
Vol. 2, No. 4, September 1991, p. 42.
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