Medicare () is an unofficial designation used to refer to the publicly funded single-payer healthcare system of Canada. The system consists of ten provincial and three territorial health insurance plans, which provide universal healthcare coverage to Canadian citizens, permanent residents and, depending on the province or territory, certain temporary residents. The systems are individually administered on a provincial or territorial basis, within guidelines set by the federal government. The formal terminology for the insurance system is provided by the 1984 Canada Health Act () and the health insurance legislation of the individual provinces and territories.
The name is a contraction of medical and care and has been used in the United States for health care programs since at least 1953,Oxford English Dictionary, s.v. "Medicare". with Medicare becoming that nation’s official national health insurance program.
Under the terms of the Canada Health Act, all "insured persons" are entitled to receive "insured services" without copayment. Such services are defined as medically necessary services if provided in hospital or by practitioners (usually physicians). Approximately 70 percent of expenditures for healthcare in Canada come from public sources, with the rest paid privately (through both private insurance and out-of-pocket payments). The extent of public financing varies considerably across services. For example, approximately 99 percent of physician services and 90 percent of hospital care are paid by publicly funded sources, but almost all dental care is paid for privately. Most physicians are self-employed private entities that enjoy coverage under each province's respective healthcare plans.
Services of non-physicians working within hospitals are covered; conversely, provinces have the option to cover services by non-physicians if they are provided outside hospitals. Changing the site of treatment may thus change coverage. For example, pharmaceuticals, nursing care, and physical therapy must be covered for inpatients, but there is considerable variation from province to province in the extent to which they are covered for patients discharged to the community such as after day surgery. The need to modernize coverage was pointed out in 2002 by both the Romanow Commission and the Kirby committee of the Canadian Senate (see External links below). Similarly, the extent to which non-physician providers of primary care are funded varies. For example, Quebec offers primary health care teams through its CLSC system.
History
Prior to World War II, health care in Canada was privately funded and delivered, with the exception of services provided to the sick poor that were financed by local governments. The traumatic experience of the 1930s left many Canadians in challenging financial situations. As personal financial situations deteriorated, the municipal governments were overwhelmed. Though the provinces provided relief payments for food, clothing, and shelter, additional medical costs were beyond the capacity of most of the provincial budgets. Many Canadians were not receiving adequate medical care, and those that did were overwhelmed with the associated costs. As such, preventable diseases and deaths were still common occurrences.Taylor, Malcolm G. (1978). Health Insurance and Canadian Public Policy, McGill-Queen's University Press, Montreal.
Ten years of economic depression, followed by six years of worldwide war, formed the social context of ambitious federal Green Book proposals. In a bid for unprecedented cooperation between the federal and provincial governments, these initiatives formed the foundations of a national program for social security, including provisions for health insurance. However, the failure to come to a consensus on the required allocation of tax resources at the Dominion-Provincial Conference in August 1945 precluded adoption and delayed subsequent action. Although the Green Book proposals were not adopted, they effectively created an appetite for government-funded health services.Canadian Museum of Civilization (2010). Making Medicare: The history of health care in Canada, 1914–2007.
Following the Green Book proposals, Saskatchewan in 1947 and Alberta in 1950, under provincial governments led by the Co-operative Commonwealth Federation (CCF) and the Social Credit party respectively, led initiatives to implement publicly funded health care at the provincial level. The first implementation of public health care at the federal level came about with the Hospital Insurance and Diagnostic Services Act (HIDS), which was passed by the Liberal majority government of Louis St. Laurent in 1957, and was adopted by all provinces by 1961. The HIDS implemented a high degree of federal regulation of the provincial health systems.Canadian Museum of History – Making Medicare: "Achieving National Standards for Hospital Insurance".
The fight for a broad publicly funded system began at the provincial level, and was originally led by Saskatchewan Premier Tommy Douglas and the CCF,Canadian Museum of History – Making Medicare: "Saskatchewan Leads the Way". who won the 1960 Saskatchewan general election on a campaign promise of publicly funded health care, over the opposition of the medical profession.Canadian Museum of History – Making Medicare: "Medical Opposition in 1960". When Douglas resigned to become the leader of the new federal New Democratic Party (NDP) in 1961, the task of implementing Medicare fell to Woodrow Stanley Lloyd, who succeeded Douglas as premier.Canadian Museum of History – Making Medicare: "Conflict and Compromise". Lloyd overcame considerable public opposition to the plan, including a strike by the province's doctors, who withdrew their services from the public in opposition to the proposed medicare plan.Canadian Museum of History – Making Medicare: "The 1962 Doctors’ Strike" The resolution of the dispute was assisted by mediation by a British Labour peer, Lord Taylor, who had been involved in the development of the National Health Service in Britain.Canadian Museum of History – Making Medicare: "Mediation through Shuttle Diplomacy".
The next stage in the development of Medicare was the Royal Commission on Health Services, 1961 to 1964,Royal Commission on Health Services, 1961 to 1964 often cited as the Hall Commission, after its chair, Supreme Court Justice Emmett Hall. The commission was created by another Saskatchewanian, Prime Minister John G. Diefenbaker, who appointed Hall, also from Saskatchewan, to chair the commission. Both Diefenbaker and Hall were Progressive Conservatives, unlike the CCF government of Saskatchewan.Canadian Museum of History – Making Medicare: "The Royal Commission on Health Services". In 1964, after intensive study and public consultations, the Hall Commission released the first volume of its report, calling for federal funding for a national medicare plan.Canadian Museum of History – Making Medicare: "Canada’s First Health Charter".
By the time the Hall Commission made its report, the Diefenbaker government had been defeated in the 1963 federal election. The new prime minister, Lester Pearson, had campaigned on establishing a national health care system. He began to work towards implementing a plan. His first Minister of Health, Judy LaMarsh, continued internal reviews and consultations with her provincial counterparts to implement the proposals. Pearson also consulted with the provincial premiers, and encountered provincial opposition.Canadian Museum of History – Making Medicare: "Creating Medicare: National Politics". Alberta,Canadian Museum of History – Making Medicare:Provincial Reactions". Quebec,Canadian Museum of History – Making Medicare: "Autonomy in La Belle Province". and OntarioCanadian Museum of History – Making Medicare: "Opposition from Ontario". all opposed the initial federal proposals, suggesting that each province should develop its own plan. Following his initial consultations, Pearson and his government developed a new, more decentralised plan. Relying on the advice of Al Johnson, the federal Deputy Minister of Finance and former Deputy Provincial Treasurer in Saskatchewan during the development of Medicare, the new plan set out four requirements. To be eligible for federal funding, a province would have to have (1) a publicly administered funding system, (2) providing universal coverage to residents, (3) for medically necessary services, (4) with portability when people moved.Canadian Museum of History – Making Medicare: "The Federal Proposal". Although the provincial premiers were surprised that the proposal lacked central regulation of health care, continuing to leave the operation of the health systems to the provinces, some premiers such as Premier Manning of Alberta continued to oppose the federal proposal.
In the 1965 federal election, the Liberals campaigned on implementing their proposal. Although they were re-elected, it was with a minority, meaning that they would need at least some opposition support to have their proposed plan passed by Parliament. A split now developed in the Liberal Cabinet and caucus. The new Minister of Health and Welfare, Allan MacEachen, pushed for the enactment of the proposals, introducing the Medical Care Act, 1966 into Parliament. Although opposed by the MPs for Progressive Conservative Party and Social Credit, the bill received support from the New Democratic Party, led by Tommy Douglas. It passed first reading in the House of Commons.Canadian Museum of History – Making Medicare: "The Medical Care Act, 1966".
However, when Prime Minister Pearson left the country to attend a Commonwealth conference, the Acting Prime Minister and Minister of Finance, Mitchell Sharp, stated that the government might not be able to afford the new program, in light of the financial state of the country, and called to defer passage.Canadian Museum of History – Making Medicare: The Next Stage of the Battle". The proposed policy shift almost triggered MacEachen's resignation, and generated internal debates in the Liberal party. As word of the split within the Liberals became public, the PC and Social Credit MPs began to put greater pressure on the government to stop the bill in the Commons. The bill eventually passed second and third readings with NDP support, after contentious debates. The government agreed to defer implementation of the Act for one year, coming in force on July 1, 1968.
In 1984, the Canada Health Act was passed, amalgamating the 1966 Medical Care Act and the 1957 Hospital Insurance and Diagnostic Services Act. The Canada Health Act affirmed and clarified five founding principles: (a) public administration on a non-profit basis by a public authority; (b) comprehensiveness – provincial health plans must insure all services that are medically necessary; (c) universality – a guarantee that all residents in Canada must have access to public healthcare and insured services on uniform terms and conditions; (d) portability – residents must be covered while temporarily absent from their province of residence or from Canada; and (e) accessibility – insured persons must have reasonable and uniform access to insured health services, free of financial or other barriers. These five conditions prevent provinces from radical innovation, but many small differences do exist between the provinces.
Eligibility Each province and territory can establish residency requirements for eligibility for coverage. For example, to qualify for enrollment in Ontario, one must, among other requirements, "be physically present in Ontario for 153 days in any 12-month period; and be physically present in Ontario for at least 153 days of the first 183 days immediately after establishing residency in the province."
Funding