Health insurers are increasingly dependent on government programs and subsidies for their growth. Source: Geyman J. The publicly administered VA has come under attack by many conservatives as they try to expand privatization of the VA based on the unproven ideology that veterans would have more choice and better care.
He said that, rather than cut health care, a Conservative government would make "record high transfers to the provinces to ensure every Canadian can benefit from free, high-quality health care. He also said he also wouldn't stand in the way of provinces working with the private sector to make changes to how care is delivered. I trust the premiers to do what is best for patients in their provinces. Because it gives Canadians more choice. The more choices Canadians have in health care, the better.
He said private, for-profit services could help alleviate the pressure on publicly run facilities, reduce wait times and save money. Critics of privatization claim it threatens to undermine the current system, where access to health care is not dictated by an individual's ability to pay.
The Conservatives also announced on Tuesday a plan to protect access to pensions when companies go through bankruptcy or restructuring. The proposal would bar executives from receiving bonuses during that process unless their workers' pension plan was fully funded. The plan would also force companies to disclose the funding status of pensions, which the Conservatives say will increase transparency.
O'Toole's health-care comments came a day after Liberal candidate Chrystia Freeland posted to Twitter a selectively edited clip of O'Toole speaking about health care. Others claim that increased private financing will free public funds to improve access for patients in the public system, but critics argue that it will instead reduce access by undermining support for public financing.
Although the BC Supreme Court recently ruled to uphold the BC Medicare Protection Act Government of British Columbia , it is possible that the plaintiffs may move to have the case heard by the Supreme Court of Canada, and the outcome may have the potential to impact healthcare delivery in Canada.
Canada's healthcare system is unique in that guaranteed access to core physician and hospital services is provided, while other important areas of healthcare are left open to ad hoc public coverage, which varies between provinces CIHI Despite this, many Canadians perceive Canada's healthcare system as overwhelmingly publicly funded.
In some provinces, the decline was even steeper. The framing of the healthcare financing debate in Canada is unfortunate because it equates sustainability and quality with public or private financing. A better alternative is to discuss healthcare financing in the context of the values that Canadians want to see in their healthcare system. In a free market equilibrium, demand and supply balance each other; however, healthcare is not a typical market good. In a free healthcare market, wealthier people would have the ability to access more and expedited healthcare, whereas poor people would make do with less and wait longer.
During the Great Depression of the early s Struthers , many people lacked the means to purchase even basic healthcare, and social conscience led Canada's leaders to make healthcare a public instead of a private good by introducing elements of universal health insurance and eventually creating the CHA.
The CHA embodies the core values of universality, comprehensiveness, portability, public administration and accessibility Health Canada A public good is one that is open for all to use, and consumption by one party does not deter another party's ability to use it; however, if demand outstrips supply, as is the case in healthcare, this can lead to market failure.
Regulation or public policy can work to alleviate market failure. Canada's medicare relies on supply-side control where supply e. Some contend that supply control without demand control is unsustainable, and when demand exceeds supply, implicit rationing results in long wait times and compromises access to and quality of care.
Some countries also allow for the purchase of private insurance to cover the copayments — as is done in France. However, opponents are concerned that this disadvantages some groups lower income groups, extremes of age, immigrants, etc. Others propose increased private financing to fill the supply "shortfall" Kaczorowski ; critics argue that because only the wealthy can afford private healthcare, this will create a two-tiered healthcare system that compromises medicare's core values Flood and Choudhry and could undermine public support for medicare.
Moreover, evidence suggests that access e. Here, we examine the experiences of other countries, via health indices, to explore how increased private financing may impact widely accepted values in our healthcare system, overall health system performance, health outcomes and growth in health expenditures. Our analysis of private financing includes both private for-profit insurance and private out-of-pocket financing.
Discussion of private services refers to those provided in both private for-profit and private not-for-profit modalities. We analyzed the potential impact of increased private financing in Canadian healthcare by searching for and examining published health indices for associations between private health-spending share in a country and the country's ranking for two core CHA principles universality and accessibility and two values expressed during the Romanow Commission equity and quality; Romanow , as well as overall health system performance and health outcomes.
The remaining three principles of the CHA public administration, portability and comprehensiveness were not selected for analysis as they are not included in international health system rankings. Therefore, universality and accessibility were the two CHA principles included in the analysis.
The impact of increased private financing on health expenditure growth HEG was assessed by analyzing HEG rates in a group of high-income countries representing a broad range of private financing within their health systems.
We used the IHME SDG Universal Health Coverage Index that examines childhood vaccination, antenatal care, in-facility delivery rate, antiretroviral therapy and risk-standardized death rates from causes amenable to healthcare to assess the impact of private financing on universality.
We used the CWF Equity sub-index that examines timeliness, financial barriers to care and patient-centred care and the EIU Equity of Access sub-index that examines access to appropriate health services to assess the effect of private financing on health equity EIU ; Schneider et al. We used the CWF Access sub-index that evaluates affordability and timeliness and the EIU Accessibility sub-index that examines access to child and maternal health services, infectious diseases care, non-communicable diseases care, medicines and equity of access to assess the impact of private financing on accessibility EIU ; Schneider et al.
We used the IHME HAQ that is based on risk-standardized mortality rates from causes that, in the presence of high-quality healthcare, should not result in death — also known as amenable mortality to assess the impact of private financing on access and quality of the healthcare system Barber et al.
We used the CWF Health Care System Performance index that examines care process performance, access, administrative efficiency, equity and healthcare outcomes and the EIU Healthcare System sub-index that examines measures enabling conditions to provide access to healthcare services, including population coverage, political will, healthcare infrastructure and efficiency and innovation mechanisms to assess the impact of private financing on overall health system performance EIU ; Schneider et al.
In the CWF Health Care System Performance index, health systems with more private services were associated with poorer overall health system performance, but the relationship was not statistically significant. Finally, we used the CWF Health Care Outcomes sub-index that examines population health factors, mortality amenable to healthcare and disease-specific outcomes and the BGH that examines life expectancy, causes of death and health risks to assess the effect of private financing on health outcomes Lu and Del Giudice Our analysis shows that health systems with more private services were not significantly associated with health expenditure growth rates.
Our findings provide further evidence that systems with higher rates of private financing are negatively associated with universality, equity, accessibility and quality of care, as has previously been found in international literature reviews Alkhamis ; Bambra et al.
We did not find an association between private financing and improved health outcomes. Health outcomes may be affected more by socio-economic determinants of health Dutton et al. Canada's unique health system lacks comprehensiveness because it covers unlimited demand to a narrow range of services physicians and hospitals , leaving other important areas of healthcare e. This is a concern because lack of comprehensiveness e. In contrast, many other OECD nations publicly fund access to a broader range of basic healthcare services; however, they control demand by requiring top-up private insurance for added services Schoen et al.
It should be noted, however, that copays deter the poor and extremes of age from accessing care. Moreover, they represent no deterrent to the rich and may reduce both medically unnecessary and medically necessary care, meaning direct patient payment would require a thoughtful and deliberate policy setting Evans et al.
If private financing was expanded in Canada, the resulting impact on health system values would depend on the design and regulation of the private system. If it is designed to provide enhanced access and services based on willingness to pay, it will certainly reduce equity. If, on the other hand, regulations that restrict a parallel system based on willingness to pay are introduced, then the core values of medicare may not be at risk, although there is a lack of precedents to provide evidence for this.
BOX 1. An adapted summary of health financing models Model Description Beveridge Public health insurance funded by general government revenues i. Private health insurance can take on different forms — it can duplicate, complement or supplement public health coverage. Duplicate private insurance competes with public health insurance and is common in systems with separation between publicly and privately funded providers.
Complementary private insurance provides coverage for out-of-pocket payments that may be required by public systems. Supplementary insurance already exists in Canada, so any further changes to the private financing of healthcare in Canada may include expansion into complementary or duplicate insurance.
Clearly, duplicate private insurance can easily lend itself to a "two-tier" system that goes against Canadians' values for medicare, whereas progressive tax policies can mitigate the impact of the cost of complementary or supplementary plans.
Additional considerations are whether private insurance companies will be allowed to risk rate or cherry-pick and exclude enrollees, whether they are for-profit or non-profit and whether physicians will be mandated to work a specified number of hours in the public system before they are able to operate in the private system.
Consequently, regulations and public policy governing private financing may temper the degree to which medicare values are impacted and will need careful consideration. Sustainability, or the ability to maintain the healthcare system both fiscally and operationally, is crucial. The key to sustainability, however, is not private versus public funding models, but rather controlling the annual HEG, also known as health inflation. The reasons for HEG include population growth, aging, inefficiency, labour and drug price inflation and technological change, among others CIHI A Canadian Institute for Health Information report indicates that demographic factors such as population growth and aging contribute only modestly to HEG, although that may change as the proportion of the seniors in the population rapidly grows CIHI If HEG consistently exceeds the growth rate of the economy, the system is unsustainable irrespective of private or public financing as health costs will increasingly consume available resources and squeeze out other forms of consumption Dodge and Dion Although some may argue that healthcare is only as sustainable as we wish it to be, one must acknowledge that we do not have limitless public resources to spend on healthcare, and if HEG continues to exceed the growth rate of the economy, it will either lead to a reduction in spending on other public domains, or continually increase tax burdens.
Canada's HEG has exceeded economic growth by an average of 1. Other countries have similar experiences, including the US, where HEG has exceeded economic growth by an average of 2.
Our results show no relationship between HEG and private financing in a healthcare system; therefore, increased private financing neither improves nor worsens sustainability of the healthcare system. More government involvement in healthcare and more provision of state insurance would make the system much stronger as this brings the system a bit closer to the French healthcare system. Just through a few tweaks in the US healthcare system, the US could compete against one of the best healthcare systems around the world.
Medicare does provide state insurance to some of the citizens; however, the US healthcare system would only improve through the expansion of Medicare to the general populous as the French example shows.
The expansion of Medicare and increased state-insurance would make people feel much safer in case of medical emergencies. Moreover, an increase in government involvement and the subsidization of merit goods such as incremental care could help the healthcare system improve tremendously.
However, the payback for allocating resources towards incremental care and increasing government involvement in healthcare would outweigh any such costs. With increased government involvement, we only stand to benefit. Most countries fall somewhere between these three.
Britain, Italy, Spain and Sweden essentially use the first system. Everyone is enrolled in a national government-run health system, most health care is paid for by the government, usually free of charge, and most doctors work for the public health service. But there are also some private doctors and hospitals, and private insurers offering supplemental plans for those who can afford them.
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