Running head: UNIVERSAL MEDICARE IN CANADA

The Three Dimensions of Universal Medicare in Canada

HLST 2020 3.0

Health Policy: Power and Politics

UNIVERSAL MEDICARE IN CANADA

Overview of the Problem

The eventual fate of Medicare in Canada has been accepted to be secure, however, being
tested in the courts by numerous anti-Medicare doctors and their patients propose that such beliefs
might no longer hold. According to Section 7 of the Canadian Charter of Rights and Freedoms, the
anti-supporters of Medicare argue that the right to life, liberty and security of the person is being
disrupted (Marchildon, 2014). Thus, it is important to re-evaluate the five key components of
Canadas Health Act (1984) to see if they require systematic alterations. Although, these
components have their own debates, universality has been the mainly opposed policy feature of
Canadian-style Medicare. For this reason it is necessary to thoroughly assess how universality
plays a role in the Canadian Health Care system by following The three dimension of universal
health coverage model proposed by the World Health Organization in 2010 (WHO, 2010).
No matter where you look for the definition of universal, you will generally find
something similar to this, being able to access medical and health services when people desire
with minimal or no cost at all (Marchildon, 2014). Even though such a definition is generally
accepted and shared by many Canadians, it is currently not the way the health care system of
Canada functions.
To understand this issue further it requires us to address three key aspects of the project: 1)
who is being covered; 2) what proportion of costs are covered; and 3) what health services are
covered (WHO, 2010). Although no country has been able to achieve all three aspects of
universality by this time, it is important to make strategic developments toward such a goal.
Canada, along with some other high-wage countries have been able to tackle down the first
dimension of universality mainly because of the evolution of the problem throughout history and

UNIVERSAL MEDICARE IN CANADA

because it is the aspect that is most prioritized by governments all around the world (Marchildon,
2014).
United States, on the other hand is an example of a country that still has not been able to
cover all of its participants (Maioni, 1997). According to a recent study, an estimated 25 million
citizens would still remain uninsured even after certain policies take place in the future. United
States argue that it is not necessary for everyone to be insured in an identical fashion under the
same terms and conditions, but essential to be insured by some type of basic coverage (Marchildon,
2014).
The type of insurance coverage has also been an issue when deciding who is being covered,
for example, there is one-tier, two-tier and multi-tier systems that differentiate people and countries
from accessing health care (Flood, 2006). The strongest version has been the one-tier system where
everyone is insured and treated equally, as opposed to the two-tier systems where individuals are
given the ability to choose between private and public coverage. A more advanced multi-tier
system comes in to play when there exists differing benefit packages and pricing for individuals
to purchase from (Marchildon, 2014).
The last two dimensions in Canada have rather been obscured by the fact that they are no
longer available for modification. The coverage is considered to be narrow because of the limited
services covered (such as hospital and physician services), and deep because free access at the
point of those services are provided (Marchildon, 2014). The second dimension looks at how direct
costs comes in between a patient and doctor or more importantly the patient and their health.
Unless the individual owns full financial coverage, there may be user charges at the point of service,
including extra-billing by the physician, co-payments and insurance deductibles. When the patient
is unable to meet these expenditures, their health may be at risk (Maioni, 1997). Lastly, the third

UNIVERSAL MEDICARE IN CANADA

dimension of universality involves the extent to which health services are covered. What is
incorporated in the universal basket shifts extensively from nation to nation, and in Canada it was
constrained to hospital and physician services (Marchildon, 2014).
History of the Problem
Before looking at these three dimensions separately, it is significant to understand how the
history of Medicare took place. More importantly, analyzing the two distinct phases in the
Canadian timeline allows us to get a better understanding of how these decisions were made and
by whom (Maioni, 1997).
In 1947, Saskatchewan became the first province in Canada to publicly insure hospital
services, however, without a leadership role by the federal government, there would have been no
subsequent implementation in other provinces. The availability of cash incentives, federal Grantsin-Aid (1948), a cost-share transfer, and national standards through the Hospital Insurance and
Diagnostic Services Act of 1957 allowed provincial governments to act accordingly in coming up
with a proper health care system for their provinces (Marchildon, 2014).
The second phase would then begin when Saskatchewan implemented their own program
to promote universal medical care insurance in 1962. While they might have been the successors,
the federal government acted as the backbone by providing another cost-share transfer to the
provinces and broad national standards through the Medical Care Act of 1966. By the end of 1972,
Medicare systems that cover their citizens for essential hospital and physician services were
brought in to place by all provinces and territories in Canada. Finally in 1984, Canada Health Act
was passed by the federal government in order to diminish the practice of facility user fees and
physician extra-billing (Marchildon, 2014).

UNIVERSAL MEDICARE IN CANADA

First Dimension of Universality

Even after Saskatchewan first came up with their plan, not all provinces fully agreed upon
health coverage for all people under the same terms and conditions (Marchildon, 2013). Alberta
being the opposing group, introduced an insurance plan that was decentralized which gave choices
for both local governments and their individuals. British Columbia who followed the footsteps of
Saskatchewan, and along with other provinces who believed in universal care, put pressure on the
federal government to cost-share only for those provinces. Alberta was shortly cut, however, it
didnt stop them from finding loop holes in the universal care system. One such instance was the
23-days doctors strike in Saskatoon that eventually granted the right of doctors to opt out and
extra-bill patients (Marchildon, 2014).
The Premier of Alberta, Ernest Manning continued to fight against Tommy Douglas of
Saskatchewan who had moved from CCF to NDP at the time. Manning argued that the
Saskatchewan system should not be the template for any future cost-share plans that the federal
government may decide to offer because it arose disruptions among physicians inside and outside
the province. With the help of private health insurance industry and the Alberta Medical
Association, Manningcare was introduced to allow government subsidies to individuals to
purchase private medical care insurance with a public plan for those who were not able to afford
insurance, or because they were incapacitated to make decisions or be eligible (Marchildon, 2014).
This phase of care only lasted until Lester B. Pearson come to be the Prime Minister of
Canada (Marchildon, 2013). While confronting weight from the desires brought up in the Hall
Commission report (Privy Council Office, 1965) and the dynamic support of universality from the
federal NDP, Pearson and his minority government were forced to outline the four minimum
conditions, one of which was universality. As Pearson later explained, Since the basic reason for

UNIVERSAL MEDICARE IN CANADA

a federal contribution is to make Medicare possible for all Canadians, it is hardly logical to bring
a federal contribution into play for plans not aimed at universal coverage (Privy Council Office,
1965).
Second Dimension of Universality
Having no user charges or co-payments was key in recognizing a full functional universal
health care system, however some provincial governments disagreed by stating that it is necessary
to have some modest patient payments at the point of service mainly to prevent the overuse of
these services. The CCF of Saskatchewan and other governments opposed it by saying that any
amount of extra expenditure by the patient is a potential barrier to their access (Marchildon, 2014).
The first ever program in Saskatchewan didnt involve user fees, and they even refused to
distinguish between basic users and heavy users (people who took up a bed for a long time versus
who left in a day or two). At that time, they fully relied on prepaid premiums such as poll taxes as
well as general public taxations (Marchildon, 2014). Later on, the terms for what is essential and
what are needless services were debated for a long to see if they should charge a modest fee for
one but not the other. As this got out of hand, The Government of Canada stepped in to say that
they would deduct any amount of direct charge to patients from its transfer to the province. After
the federal government introduced a block transfer known as Establish Programs Financing (EPF)
and held the growth in the health transfer to the rate of economic growth, the amount charged by
the user and extra-billing by the physicians became even more noticeable in the country as a way
of fighting back (Marchildon, 2014).
The Trudeau government was tasked in to ending practice of user fees and extra-billing,
thus resulting in bringing the final component of Canadas Health Act, accessibility. The CHA
allowed the deductions from provincial governments to be refunded if those above mentioned

UNIVERSAL MEDICARE IN CANADA

charges were eliminated by the year of 1987 (Marchildon, 2014). By the end of 1999, the provinces
involved realized that their user charges were declined by a total of $8.2 million. Although the
amount of deductions have fallen dramatically in the next few years, the fact that some deductions
are being made every year (averaging less than $100,000/year) is still progress (Marchildon, 2014).
While this may imply that the practice has just about been quenched in Canada, it could likewise
imply that the national government has been less vigilant in checking and punishing those areas
allowing hospitals, clinics and doctors from imposing user charges.
Third Dimension of Universality
This last dimension deals with the breadth of coverage, in other words to what extent the
services are being covered universally. Despite the opponents of Medicare who had hoped that the
policies would change, the Chaoullis case that was decided by the Supreme Court of Canada in
2005 stand as evidence to why it would not (Flood, 2006). Nonetheless, the coverage of services
in Canada is not consistent with the priorities set out in the beginning of Medicare. Pharmacare
(prescription drugs) and home care have been advised to be part of the basket of universal Medicare
services for decades, however, this idea of modifying the CHA have been either ignored or
abandoned (Romanow, 2002).
In conclusion, analyzing the three dimensions of universality are key in improving
Medicare system in Canada. It shows us how the policy has changed in favour of certain parties to
be able cover citizens universally. After the election of 2006, Stephen Harper has redefined and
limited its role in health care. In light of the administration's perspective of the restricted role of
the state and, specifically, the more constrained role of the government in regions of provincial
jurisdiction, it is unrealistic to expect any activity that would extend the realm of Medicare. In any
case, the Harper government has additionally decided not to disassemble the Canada Health Act

UNIVERSAL MEDICARE IN CANADA

or remove the Canada Health Transfer despite opposing advice (Marchildon, 2014). For Canada
to improve their point of service and in reducing co-payments, it is required to lose self-interest
and focus upon covering every single citizen with health care as they need, rather than ability to
pay for service.

UNIVERSAL MEDICARE IN CANADA

References
Flood, C. (2006). Chaoulli's Legacy for the Future of Canadian Health Care Policy. Osgoode
Hall Law Journal, 44(2), 273-310.
Maioni, A. (1997). Parting at the crossroads: The development of health insurance in Canada and
the United States. Comparative Politics, 29(4), 411-431.
Marchildon, G. P. (2013). Canada: Health system review. Health Systems in Transition, 15(1), 1179.
Marchildon, G. P. (2014). The three dimensions of universal Medicare in Canada. Canadian
Public Administration, 57(3), 362-382.
Privy Council Office. (1965). Proceedings of the Federal-Provincial Conference. Ottawa, ON:
Queens Printer for Privy Council Office.
Romanow, R. J. (2002). Building on Values: The Future of Health Care in Canada. Saskatoon,
SK: Commission on the Future of Health Care in Canada.
WHO. (2010). The World health report - Health Systems Financing: The Path to Universal
Coverage. Geneva, Canton: World Health Organization.