Tommy Douglas was the Premier of Saskatchewan who introduced North America's first public health insurance plan in 1962, covering all residents for hospital services free of charge. This helped establish the principle of universal public health care that eventually spread across Canada.

1. Introduction to
Health Care in Canada
HLTH 405 / Canadian Health Policy
Winter 2012
School of Kinesiology and Health Studies
Course Instructor:
Alex Mayer, MPA

2. Introductions
• Instructor:
o Alex Mayer, MPA (Health Policy)
• About me
• Office Hours: Tuesdays, 12pm – 5pm (KHS 301B), or by appointment
• Contact info: alex.mayer@queensu.ca
• TAs:
o Jenna Brady
• 0jb4@queensu.ca
o Catalina Medina
• 9cm56@queensu.ca
o Adele Pontone
• 11ap29@queensu.ca

3. Class Business…
• Course Textbook
o “Health Care in Canada: A Citizen‟s Guide to Policy and Politics”
• By Katherine Fierlbeck
o Available on Amazon for $25
o It will also be available for free on the Queen‟s E-brary
• To register for an ebrary account, go to:
http://library.queensu.ca/research/databases/record/5298

4. Class Business…
• You will need an iClicker
o Available for purchase at the Campus Bookstore
o Be sure to register your iClicker on Moodle (under “My Clickers”) before next Monday
o We will be using it regularly, so always bring it to class

5. Class Business…
• Our Facebook Group: “HLTH 405 – Canadian Health Policy”
o Join it to access the Course Syllabus, Schedule, Lecture Slides, Class Announcements
o Etiquette: “I like you, but please don‟t friend me.”
o Privacy: If you have privacy concerns, check your privacy settings.
**Joining the group will not give others access to your profile information, unless
they are your friends and/or your settings allow anyone to see your profile.**

6. Evaluation Schedule
• iClicker Quizzes (30%)
o Every week, except Week 1 and Week 7
o 10 questions, 10 minutes; Open-book
o Quiz will be a review of weekly readings
• i.e. if the lecture is about Wait Times, you will be quizzed on readings about Wait
Times.
o Your 8 best scores out of 10 possible quizzes will determine 30% of your final grade
• 2% bonus for attempting every quiz.
• Assignment 1: Briefing Note (20% + 0%)
o Due Monday Feb 27th (Week 7)
o Presentations: Week 7 tutorial (Feb 28th)
• Assignment 2: Policy Options Paper (40% + 10%)
o Due Monday April 9th (Week “13”)
o Presentations: April 3rd tutorial (Week 12)
• Participation
o Possibility of raising your final mark by one letter grade (e.g. B to B+)
o Passion for course material; evidence of preparedness; ability to enhance the
educational experience for others

7. Questions?

8. Introduction to
Canadian Health Care
• Key points on Canadian health care
o Intergovernmental relations are defined by fiscal federalism
• Health care system is the domain of the provinces/territories
• The Federal Government lends fiscal support ($)
o The Canada Health Act (1984) sets out rules and a national „minimum
standard‟ for provincial/territorial insurance plans
• The result is 13 public single-payer insurance
schemes that are distinct but similar.
o Together, these provincial/territorial plans pay for ~70% of health care
costs incurred in Canada (Marchildon, 2005).

9. Fiscal Federalism
• The 1867 Constitution did not specify what level of
government has constitutional authority over the
health care system.
• It did state that the federal government was responsible for maintaining
„Peace, Order and Good Governance‟ (POGG).
• Roles of the Federation and Provinces have thus
been clarified through a series of court rulings.
o Judicial interpretation of POGG: Federal government is responsible for…
• 1) food, pharmaceutical, consumer product, and health technology
regulations and standards (Health Canada)
• 2) the maintenance of a national health information database (CIHI)
• 3) public health and infectious disease surveillance (PHAC)
o Court decisions by the Judicial Committee of the Privy Council set
precedents that gradually cemented the autonomy of the provinces in
the administration and organization of the health care system.

10. Fiscal Federalism
• The Federal Government has a largely fiscal
role, due to its spending power
o Health accords are negotiated every 10 years to determine its
financial contribution to the provinces
o Has historically included cash transfers and/or giving provinces
„tax room‟
o The 2004 Health Accord under Paul Martin built in an annual 6%
escalator in the Canada Health Transfer ($)
• CHT funds from the Feds are contingent on
provinces adhering to the Canada Health Act
o The CHA sets out a few general rules
o Maintains a national „minimum standard‟ of medically necessary services
that must be insured under provincial health insurance plans

11. The Canada Health Act (1984)
• Latest in a series of legal statutes affecting health
care funding in Canada
• Preceded by the Hospital Insurance and Diagnostic Services
Act (1957)
o a formal 50/50 cost-sharing agreement between Feds and Provinces
for hospital care.
o HIDS Act was the first to set out the 5 criteria found in the CHA.

12. The Canada Health Act (1984)
Under Premier Woodrow Lloyd, Saskatchewan takes advantage of
its influx of HIDS funds to begin insuring physician services too (1962).
Physicians are livid; they strike for 3 weeks.
But Lloyd‟s idea catches on; the Medical Care Act (1968) is passed
• Amends cost-sharing agreement between Feds and
Provinces to include non-hospital physician services
• Maintains that 5 criteria be met for the receipt of federal $$$

13. The Canada Health Act (1984)
• But physicians soon find a way to increase their
earnings beyond provincial reimbursement rates
o Extra-billing: Additional service charges tacked onto
provincial reimbursement claims by physicians, in an effort
to recoup what they were previously earning under the
higher rates paid out in their provincial medical association
fee schedule.
o User fees: Charging patients for the difference between
the new provincial reimbursement rates and the old
provincial medical association fee schedule.
• In 1984, the Canada Medicare Act is amended to
address these practices and include 2 more
provisions. It is renamed the Canada Health Act.

14. The Canada Health Act (1984)
• In total, the Canada Health Act contains
o 5 program criteria (S.8-12)
• Public Administration
• Comprehensiveness
• Universality
• Portability
• Accessibility
o 2 conditions (S.13)
• Formal recognition is given to the Federal Government in all health
publications
• The federal Health Minister has a right to provincial health system
information
o 2 provisions banning extra-billing and user fees for publicly-insured services
(S.20)

15. The Canada Health Act (1984)
• Despite the recommendations of the Hall Report to expand
the list of insured services in Canada, to include…
o Pharmaceutical drug coverage
o Prosthetic services
o Home care
o Eye care
o Dental care for children and welfare recipients
… “Comprehensiveness” in the CHA continues to refer only
to “medically necessary services” provided in hospitals
or by physicians. It is “narrow but deep” coverage,
• In all fairness, Canada was in a mountain of debt by 1984.
Trudeau had to resign as PM before the CHA was even
passed!

16. “Narrow but Deep”
Insurance Coverage
• All “Medically necessary” services
(diagnostic imaging, treatments,
pharmaceuticals, hotel costs)
provided in a hospital.
• All “Medically necessary” services
provided by a physician.

17. “Narrow but Deep”
Insurance Coverage
• This leaves many essential health goods
and services uninsured (i.e. “privatized”)
o Pharmaceutical drugs
o Medical devices
o Outpatient services not provided by a physician
• Eye care
• Dental care
• Physiotherapy
• Home care
o List goes on and on!

18. “Similar but Distinct”
• Therefore, provincial plans typically insure many
additional services beyond their CHA-mandated
coverage.
• Some municipalities will also work with regional
health care providers to subsidize specific health
services.

19. “Similar but Distinct”
• In Ontario, for example, OHIP will offer selective
coverage for:
o Ambulatory Services
• Partial subsidy (patients are billed a copayment fee of $45, compared
to $500-$1000 for basic ambulatory life support services in U.S.
jurisdictions).
o Pharmaceuticals
• Ontario Drug Benefit offers complete drug subsidy for ODSP recipients
and seniors; partial subsidy of catastrophic drug costs for every
Ontarian; special outpatient coverage of pharmaceutical costs for
specific conditions.
o Dental
• Complete subsidy of select services (e.g. check-ups, basic cleaning)
for youth, seniors, and ODSP recipients.
o Eye Care
• Complete subsidy of select services (e.g. check-ups) for youth, seniors,
ODSP recipients, and individuals with diagnosed eye conditions.

20. Recap
• Important concepts to understand:
o Fiscal Federalism
o Health Accords
o The 5 Criteria of the Canada Health Act
• what do they refer to?
o What „narrow but deep‟ Medicare coverage refers to
• Food for Thought:
How do these concepts relate to the following news stories:
“A Canada With No Health Accord? Provinces Grapple With The Possibilities”
http://ca.news.yahoo.com/canada-no-health-accord-provinces-grapple-possibilities-164300843.html
“Seniors Prefer Hospitals Over Long-Term Care Homes”
http://www.cbc.ca/news/canada/windsor/story/2012/01/05/wdr-long-term-care-beds.html
• Fill-in-the-blank:
o Who is Tommy Douglas and what was his role in Canadian health care?