Lecture Notes: Canadian Health Care Policy PDF

Lecture Notes Tags Last edited @September 14, 2024 12:01 PM Status In progress Introduction - Canadian Health Care Policy https://prod-files-secure.s3.us-west-2.amazonaws.com/2eeb8c2c-730c-4...

Lecture Notes Tags Last edited @September 14, 2024 12:01 PM Status In progress Introduction - Canadian Health Care Policy https://prod-files-secure.s3.us-west-2.amazonaws.com/2eeb8c2c-730c-4 273-848a-d4ff5640cb49/e58273ac-af25-4313-97b6-d842194137b8/510-2 024-IntroToPolicy-LIVE.pdf Economics in training - undergrad, masters, and doctoral focus on pharmaceutical policy Equitable access to medicines in Canada and abroad: research, advice, advocacy Also work globally with WHO - pharmaceutical innovation policy OECD - host an annual meeting of managers of systems Policy network & theories - policy takers Advocate with patient groups, unions, etc. Politics - left of the centre Will see him three sources: SPHA 511, and co-teach SPHA 501 About the course Credible insight into Canadian health care system Name the 5 principles of the Canada Health Act There is an in-class quiz!! - similar shouldn’t be too stressful Lecture Notes 1  This course focuses on health care - (there are others in public health, occupational/environmental health, population health and promotion) Canada’s Constitution Act: a colonial act of British parliament Roots of colonialism and anti-Indigenous racism Public Policy when is policy decision was just a reaction vs direction of how we proceed Public polices address public problems Only certain people have the legitimate power to make policies - Cabinet ministers Logical Policy Analysis Three main components of a public: Problems, goals, and instruments The logic of a policy Table Task = Agenda Setting 1. Identify one persistent health care system problem that warrants a public policy response. 2. Frame the problem in a way that suggest its cause Example: Long wait times; fame - unequal distribution of resources; lack of incentive to stay in family practice or other specialty Recruitment & retention - health human resources - cost of living; increase public awareness; burnout; compensation Wait times that are unmeasured - primary mental health care services Policy advocacy at some level is to play down complexity and play up a focus on one part of the problem Report: In Plain Sight Spectrum of instruments Public provisions is a highest coercion Lecture Notes 2  Not a four letter word! there is a role of government in many sectors “Political will is perhaps the strongest determinants of health.” Peddy Fry? longest standing woman standing MP All these things (SDOH) require (to meet those needs) you need public policies > political will (they have the power to make these things) Policy is shaped by far more than just evidence! Brutal reality is that - only way to do something is to win elections there are so many influences on policy processes that all the stars have to align for policy to have the incentive and a winning policy. To get votes, retain votes, to influence government Stone’s book The Market vs The Polis 💡 A polis is a community with collective ideas, will, and effort. It is constantly changing, shaped primarily by competing ideas, alliances, and influences within. - So, it’s like a bee hive... but not really like a bee hive at all. reminder that we live in a social world; influences on us as human beings; ties to our family 3 I’s Framework Categorization of different things poli scientist look to why government did or did not do something Lecture Notes 3  Policy is not done in isolation 💡 Institutions: established laws, practices, or customs that regulate behaviour of actors in a system. - also include informal norms and conventions that affect how actors behave (e.g., what we are accustomed to). Traditional institutionalism: how formal institutions –the laws and policies that define the government’s roles, responsibilities, and accountability –can influence policymaking processes. The Constitution Act - is a massive impediment to rational policy development? “One million people get out of bed every day and go to work in the health care system, and they largely want to do exactly what they did the day before.” – Michael Decter Lecture Notes 4  Habituated behaviours - change is hard; we get comfortable - these are informal conventions - Change management is very difficult E.g., Most doctors in Canada provide services within independent, private practices. 💡 Interests: actors and groups that have (or believe they have) a stake in a policy problem, solution, or both Stakeholders DOES NOT have a stake in both the problem and the solution Taxpayers among the most powerful interests - the 1%; any expense for public expenditures will cost them more than market value Corporate interest will promote policies that interest them -not moral issue Public interest - as a society as a whole Why do members of the public “mobilize” around some health care issues but not others? 💡 Ideas: what various actors in society know or believe about a policy problem, solution, or both. - include misinformation, whether innocent or nefarious - also include values “Ideas are the stuff of politics. People fight about ideas … and people fight with ideas.” Values determine what people will mobilize over … and how people will vote. Normative belief that what is right and what is wrong - There are external shocks, outside the policy system that causes disruption Lecture Notes 5  (E.g., pandemics) Create windows of opportunity to do things which it cannot be done before Affordable Care Act (ACA) signed by Obama in 2019 Ideas has been around for a while Financial crisis in 2008 (did not hit Canada directly, but indirectly with trading partners) > changes public ideation on government intervention and financial “Never let a crisis go to waste. It’s an opportunity to do things once thought impossible.” - Robert Emmanuel (by Churchill) Which “i” is arguably the main reason your persistent health care problem is yet unsolved? Institutions & interests Welfare & The Right to Health https://prod-files-secure.s3.us-west-2.amazonaws.com/2eeb8c2c-730c-4 273-848a-d4ff5640cb49/a2f304f3-79b0-47af-8ee0-08cc3ebacf90/510-2 024-WelfareRightToHealth-LIVE.pdf Governments seek (ostensibly) objective standards that define needs Would be easy to govern theoretically … and thereby (ostensibly) objective standards that define the scope of public responsibility for social welfare … but objective standards of needs do not exist in a polis! Need is probably the most fundamental political claim A “want” is not a powerful political claim Lecture Notes 6  Few people would be against satisfying basic, material needs for survival. Except perhaps because just doing that might be absurd Stone’s Dimensions of Needs (categorization of debates about needs) Material vs symbolic needs Intrinsic vs instrumental value Volatility vs security Quantity vs quality Individual vs relational needs Absolute vs relative welfare 💡 Intrinsic value is the value of something in and of itself, for its own sake. - Value of the THING, not for what it does Does health care have intrinsic value to its consumers? - The procedures have no intrinsic value, in it of itself - there are no procedures that are zero risk - Unless I need it, I don’t want health care - The value of health care is instrumental value but not intrinsic When systems provide more care than the people need it, it harms more than heal - it’s an intrinsic BAD Some services that patients seek seem like traditional good - like to see doctors for just the socialization (but are still meeting a need) Paradoxically, progress can both satisfy and create needs Your wellbeing is always relative to others - e.g., the richer your neighbour get, the worse you become Lecture Notes 7  Technology can do this kind of paradox - progress can both satisfy needs that were unmet but also create new needs Once there is something that can work, you’re putting in a position that there is a need for that Failure to provide treatment is causing harm Pricing of new treatments are similar to ransom Moral failure of technological advancement (e.g., COVID vaccination) - compulsory licences so that poor countries can use them to save lives 💡 Moral hazard: insurance against loss may result in reduced caution or increased risk-taking and, thus, increased losses. “if we have free health care, people will abuse the system” Nearly half of the population do not use the health care system Sickest 20% of the population 80% of the health system Sickest 5% of the pop using 50% of the health care systems They are not abusing the system There are documented risky shifts when there are protections - e.g., seatbelts → drove faster; PrEP/condoms → increase promiscuity - but these increases are not that bad From welfare to rights to obligations Michael E? - leader of liberal party, lost majority government to Harper In defining certain needs as legitimate public responsibilities to be met through public policy, a society defines itself and what it means to live with dignity within it. There are some things we need to do for people It was the atrocities of WWII that drove allied nations to consider human rights as matters of global concern Lecture Notes 8  Human rights frameworks shift narrative from seeing people as ‘objects of charity’ to seeing people as ‘subjects of rights’ … and, thus, to identifying collective obligations and duties. Elena Rosevelt 1948 - Universal Declaration of Human Rights (of the things we need for human rights, but not the things we need to do) 1966 - International Covenants on (1) Civil and Political Rights; and (2) Economic, Social, & Cultural Rights (Canada ratified these in 1976) The right to health is the right to the highest attainable standard of physical and mental health … given available technologies and resources of a country it is not just a right to be healthy - for some it’s not determine by anything the society can do Rights framework is to all people residing in their borders (not just citizens) States are Obligated To… Respect the right to health (by not causing harm) Protect the right to health (by preventing harm) Promote the right to health (by promoting health) “The RTH is inclusive” → State obligations are broad The ambitious are so broad that it can be too much (This is a slight change for alliteration) Countries must ensure health care is universally… Available, in sufficient quantity and quality Accessible, physically and financially Acceptable, ethically and culturally Appropriate, scientifically and medically Lecture Notes 9  Progressive Realization: Resource-constrained countries can meet some RTH obligations progressively provided they are actively working to fulfil those obligations. But all countries must meet core minimum obligations, including provision of essential medicines, without delay. Core minimum obligations - e.g., universal access to primary care/maternity care, access to essential medicines Poor countries can take time but there are some standards NEED TO BE DOING DEMONSTRABLE FACTS TO BE DOING THESE Discussion 1. Can you think of any ways Canada fails to fulfil its basic health care obligations under the UN’s RTH framework? We do not have universal access to at least essential access to medicines (about 20% struggle with accessing medicine) Access to primary health care - limited by unique geographical challenges; access to rural community is WAY BEHIND Western medicine - lack of cultural appropriateness Structure impediments - implicit and explicit racism We can right an appeal to UN’s RTH framework but won’t do much 2. Can the Canadian government use the concept of progressive realization as an excuse? No - Canada is one of the richest countries in the world - we are the “richest 1%” When pointing out these problems, we are not appealing to the international court or global state, we are appealing to the public court - public embarrassment of Canada we are the only country that occur universal health care that do not have universal pharmacare Shame is a powerful motivator! Lecture Notes 10  💡 Discrimination: is any distinction or restriction with the effect or purpose of limiting the exercise of human rights Non-discrimination: in RTH recognizes obligation to all and specific responsibilities to population subgroups Obligations to meet the needs of everyone but have specific actions needs for specific subgroups (equity seeking groups) For starters, meeting RTH obligations in a non-discriminatory way requires acknowledging and serving differences in health needs across population groups. - e.g., Women’s and Children Hospital Non-discrimination also requires making care culturally safe, acceptable, and accessible - you cannot just say “everyone is welcome” In Plain Sight: Comprehensive changes are needed to address systematic racism in BC’s health care system, beginning with respecting the rights of Indigenous peoples. UNDRIP and health care: Indigenous peoples have the right to access, without discrimination, all health services and the right to traditional medicines and health practices and the right to self-determination in health policy Discussion: Table Task = Medically Necessary What 2 or 3 characteristics must be true for something to be considered “medically necessary”? (patient or the service) Benefits out way the risks Irreversible damage to your formal way of being Survival / life perseving Non-futility Protective Lecture Notes 11  Deprivation or a risk of deprivation Scientific evidence that the intervention will improve their status When there is no intervention, these are not medically necessary South Centre in Alaska - Indigenous owned World famous for primary health care and community health care “Clinicians identified these clinical targets for patients, and we think of patients as darts, we don’t think of patients as darts, think about them as birds. Think of them how they want to shift” - Eby The Constitution and Pre-Medicare Health Care Policy Quiz - will not ask dates or nuances! But there are three examples in this lecture to understand why did something happen in history and how is it more likely to not happen or happen again. https://prod-files-secure.s3.us-west-2.amazonaws.com/2eeb8c2c-730c-4 273-848a-d4ff5640cb49/dd3e9c42-e47e-4ba9-bce7-f6f1f6b832bb/510-2 024-History1-ConstitutionAndPreMedicare-LIVE.pdf When we talk about our “Constitution” → the 1867 British North America Act → 1982 Constitution Act (Canadian version) - essentially the same Both court decisions and constitutional conventions concerning the law is interpreted In 1867 → motives behind creating the confederation - were on trade and securing (taking/colonizing) land Colony of BC did not join the confederated back in 1867 Lecture Notes 12  Population at the time was 3.7 million people Smallest province that represent the confederation is only 8% As compared to other federation in the world - don’t see the level of devolution of responsibility to the state or provincial government - a lot more responsibility at the common wealth or federal government Most health care was provided by charities and municipalities (religious organizations) This is the dawn of modern medicine both industrial and technological evolution - beginning of science-based medicine (and others) 1870 until now (Long Century) Well-being of the poor has increased in both poor and rich countries 💡 In general, the BNA assigned only truly national matters (citizenship, defense, trade, finance, etc.) to the federal government. Virtually everything else was to be a provincial responsibility. The Brits gave India similar division of power The Feds also get public health - in some sense a bit like defense (communicable disease do not know borders) Says very little about health care!!! The only explicit clauses about health care in the BNA: Federal: “Quarantine and … Marine Hospitals” Provincial: “Hospitals, Asylums, … [and] Charities” Clauses implicitly related to health care in the BNA: Federal: “Indians” “Regulation of commerce” and “Patents” There is that clause there is a good argument that the government is responsible for Indigenous health care Health care is so reliant of patents and federal protection Lecture Notes 13  Provincial: “Matters of a merely local or private Nature” and “Shop, Saloon, Tavern, Auctioneer, and other Licences” Catch up phrase - this could also involve health care - for your illness (it’s private and just you) The words of the constitution are not clear - not explicit Revenue generating powers Provinces can only raise taxes locally - related to these licenses Health care licenses are also responsibility of the region Imbalance would become clear over time Per capita expenditure on health care (in today’s dollars) 1900 = $20 → 2024 = $9,000 Silly logic that health care is the sole responsibility of the provincial gov’t Today, provincial populations range by a factor of 90, from 170,000 in PEI to 15 million in Ontario. Challenge of governance in a a small population - a large responsibility Today, provincial GDP per capita ranges nearly two-fold, from $54K in Nova Scotia to $103K in Alberta Wealth distribution across provinces - SK and AB GDP per capita have $100k or more; Atlantic provinces have $60k or less Asking the provinces/territories to govern themselves with this range of population and wealth distribution → INSANE! No rational person would write Canada’s constitution like this today; yet, amending it is all but politically impossible. History Conscriptionists needed the votes from the parliament to pass through Lecture Notes 14  Federal government must provide veterans for health care While health care is provincial responsibility, we’ve carved out a group of people that feds take care of Feds still did not create a federal system; used expenditure power for local systems to fund or create programs for veterans Feds do not do direct service delivery (not like others, even the US) In early 1930s, provinces wanted help with their fledgling health insurance programs but Conservative Prime Minister R.B. Bennett was opposed. Provinces were asking the feds for help In 1935, Bennett promised Canadians a Roosevelt-style “New Deal” – including national health insurance–if re-elected; and offered unemployment insurance to start Political incentive - completely opposite of what he was opposing Passed an unemployment insurance act Mackenzie King won the 1935 (won it back), promise to implement “New Deal” - PM until 1948 - LONGEST SERVING PRIME MINISTER In 1936, the Supreme Court struck down Bennett’s unemployment insurance scheme, ruling it ultra vires (out of jurisdiction) Report of the Royal Commission on Dominion-Provincial Relations (1937 to 1940) Most important Commission that no one has heard of “… undertake a re-examination of the economic and financial basis of Confederation and of the distribution of legislative powers in the light of the economic and social developments of the last seventy years.” - it’s such a big deal! First royal commission to go from coast to coast (talking to the elites and having town halls, etc.) Lecture Notes 15  Need a national income security - this idea makes great economic sense - unemployment insurance on a country level. Insurance is about pooling risks (the bigger the pool, the more risk you an spread) Shocks to economy affects the provinces differently: pool those risks on a national level - so it’ll balance it all out Economic and social argument to support equalization and national standards that are until provincial jurisdiction 💡 Equalization payments are federal payments to ensure that provincial governments have sufficient revenues to provide reasonably comparable levels of public services at reasonably comparable levels of taxation. Federal money paid out to provincial government to provide reasonably comparable levels of public services and taxation Lecture Notes 16  The commission also argued for (even though they were not allowed to recommend) a universal, federally-funded health insurance program. During/Post WWII, King acting on some recommendations 1940: Federal Unemployment Insurance Act (constitutional amendment) 1942: Wartime Tax Rental Agreement Also the first time to ask for a Constitution Amendment British Colony needed Canada’s assistance; King used this opportunity to get the Unemployment Insurance Act approved Tax Rental Agreement - Feds held all the money and “acts of charity” to give the provinces an agreed upon formula of money Canada Hosts 1941 Atlantic Conference Global conversations about a post-war era 1942 the Brits publish the “Beveridge Report” on Social Insurance and Allied Services - Landmark study on what does a welfare system look like (post-war) Sold a million copies in the US - influential! Identified - universal, publicly-publiced national health care insrance Blueprint for the NHS In 1943, Canada would have two reports similar to the Brits: Marsh on Social Security, and Heagertyon Health Insurance So, a universal, comprehensive, public health insurance program was recommended repeatedly from 1935 to 1945. Post-War Health Care Policy... In Stages Lecture Notes 17  https://prod-files-secure.s3.us-west-2.amazonaws.com/2eeb8c2c-730c-4 273-848a-d4ff5640cb49/e54083f3-64fa-4e47-b6cc-77679b89565b/510- 2024-History2-PostWarFirstStages-LIVE.pdf A 1944 Gallup poll found 80% of Canadians supported a national health insurance plan. But, in post-war planning, some provinces (e.g., QC) disagreed with the rapid introduction of a comprehensive, national health insurance plan By 1946 - implementing national health insurance “in stages” Feds are still collecting money at this time Tommy Douglas Baptist minister → politician Post-depression era democratic socialist MP with CCF in 1930s; leader of NDP in 1962. Premier of Saskatchewan (1944 to 1961) Wildly popular: “Tommy Douglas doesn't have to kiss babies…” “Father of Canadian Medicare” Was premier and health minister when he took office in 1944. Also… First bill of rights in North America. Eliminated Saskatchewan’s provincial debt. CBC’s “Greatest Canadian” (2004) 1947 Saskatchewan Hospital Services Insurance Plan Universal, public insurance for hospital care Lecture Notes 18  During the 1945-1946 Dominion-Provincial Conferences on Reconstruction, Douglas fought for a Canadian system similar to what the British would soon implement. Yet, in 1947, he implemented the SK hospital plan instead. Why would he compromise like that? The compromise was only for hospital plan CMA (medical community) supported the report! and enough support to do more The federal discussion - policy “in stages” - doing these incrementally The federal still had all the money at the time - have all the revenue power Provincial did start to collective their own taxation but it was tiny They had to work with the federal government 3 I’s Framework External forces → SK economy Institutions → Wartime tax agreement Interests → popular policy, not much opposition at the time, no big private insurance company Lecture Notes 19  Ideas → Canadian Medicare “in stages” The first stage of Canadian Medicare 1957 Hospital Insurance & Diagnostic Services Act (10 years!!) 1st stage of the Canadian “medicare” system Federal legislation offering 50% of costs of provincial programs meeting national standards Standards based on SK hospital insurance model Funding started Canada Day 1958, by 1961 all provinces had compliant insurance programs A really fast time scale! Because of federal election cycles and changes in ideation SK was funding their own program 100% on their own (and some BC) 1961 Saskatchewan Medical Care Insurance Act Universal public insurance for medical care Promised by Douglas in 1960 SK election (which would be his 5th consecutive majority win) It was a critical moment in Canadian health care policy. Douglas had to wait until the feds are on board before he has extra cash to use SK doctors went on strike - fueled by resources and personnel in other provinces and from the US medical association US - having similar national debate; same place as Canada; also fear of communism; the fear of socialize medicine If SK could do it, it could spread everywhere The professional associations that do not always speak for all of its members - tensions between “free-market” professionals The SK doctors’ strike was nasty but it didn’t work. People in SK loved the plan. Even most doctors preferred it. Lecture Notes 20  The federal policy response to SK Medicare was tactical. With an unanticipated twist. John Diefenbaker, Canada’s first Progressive Conservative PM called for a commission! To figure out if it is worth it Appoint a conversative commissioner! SK has run for MP against Douglas; give him three reports One party’s bad luck is another party’s good fortune 1963 New, Liberal minority government 1964 Hall Commission Report arrives (extremely comprehensive report) Recommends universal, comprehensive public health insurance system across Canada First: nationalize SK’s medical care insurance model Then, other essential services “in stages” Next would be been pharmaceutical, dental care, etc. To everyone’s surprise that Hall said there are very compelling and ethical and economic reasons to do this! Investing in the health of the Canadians, it is investing in the economic benefits Tommy Douglas was the balance of power - encourage Pearson to be bold Powerful tool to Pearson’s government 2024 Jugmeet Singh couldn’t been the Tommy Douglas to Justin Trudeau The second stage of Canadian Medicare 1966 Medical Care Act 2nd Stage of Canadian medicare system Federal law. (Passed in Parliament 177 to 2) 50% of costs subject to standards based on SK model 4 principles: Universal, public, portable and comprehensive Lecture Notes 21  Funding delayed to 1968, but by 1971 all of provinces have qualifying systems in place. There was opposition from MPs so delayed the funding Maximal point was just under 50% of Canadians having private insurance (many are cooporative systems, physician run, they are not for-profit) Physician has guaranteed bill payment Stage 1 - barely did anything; Stage 2 - SK’s act didn’t change nationally, the passage of the legislative really made the shift It grew again in the 1970s to cover those that are not covered in the national medicare program Public payment (insurance) and private practice (services delivery) Health authority - working for a quasi-health organizations Hospital; private non-profit organization; more like NGOs - e.g., PHC has contracts with health authority, chain of command but Board has fiduciary responsibility with the Minister? If health authority, paid by the ministry → public sector employee Most medical clinics are private practice - this is about physician services Lecture Notes 22  The 1970s and the EPFA https://prod-files-secure.s3.us-west-2.amazonaws.com/2eeb8c2c-730c-4 273-848a-d4ff5640cb49/3ce1ac7a-3aed-40d5-af88-f3334490e674/510-2 024-History3-1970sAndEPFA-LIVE.pdf What “stage” was added to Canadian Medicare in the 1970s? No stage was added?! generalized agreement 3 I’s Framework - reasons why nothing was added 1970: Florence Bird delivered the report of the Royal Commission on the Status of Women to parliament. (gov’t did nothing) 1973: Nisga’a chief Frank Calder won a landmark Supreme Court case ruling Aboriginal title to traditional lands predates colonial law (gov’t did nothing) October Crisis of 1970: the FLQ (Front de libérationdu Québec) kidnap a British diplomat, then kidnap and kill the Deputy Premier. Started this decade off with tension and drama 1976: Rene Levesque’s Parti Quebecois wins QC election in a landslide on the promise of Quebec sovereignty via referendum. Lavesque - gradual moving towards sovereignty 1973: Arab members of OPEC launch an embargo against the United States, sparking a global economic crisis –the “Oil Crisis.” 1973 to 1975: Canada and other countries experience “stagflation.” Demands for unemployment insurance, social assistance, and health care would rise while the economy was contracting. Have a period of simultaneous high inflation and high unemployment - if both; traditional tools makes them better makes them worse (e.g., increase interest rate, which increase unemployment) Lecture Notes 23  Oil crisis got worse and worse and got right into the 80s Ideation- Also, 1974: Health Minister, Marc Lalonde, releases landmark report claiming health care is just one determinant of health. Why? A health minister is saying that health care is not the only determinants of health! This could also be a political and policy tactic? Take the heat off the conversation of not putting all the attention in health care - do things outside the areas of these expectations The EPFA (Established Programs Financing Act) The first two stages of Canadian medicare based on a 50% cost-sharing formula - any drawbacks to that funding formula? Lack of autonomy (greater incentive for P/Ts to send on that program) but they might also spend more money in those areas Equalization - can incentivize what provinces choose to invest on Budget uncertainty (WILL ASK ON THE QUIZ!) For the federal government, they don’t know what the costs would be from the provinces - will be terrible during an economic crisis Lecture Notes 24  Incentives for (in)efficiency How much incentive has the province to control costs? Exactly half of the incentive as they want to have Concern this level of government makes the decision, and the other level of government pays for the costs P/Ts were keeping the physicians happy by essentially stuffing their mouth with money - incentives for salary increases, etc. Regional inequities Feeding the rich Administrative (and political) complexity Creates tension b/t two levels of government The Feds auditing their books and disagreements about what was and what was not a legitimate costs What was the biggest drawback to 50-50 cost-sharing for medical and hospital insurance in the 1970s? Budget certainty & efficiency Pierre Elliott Trudeau threatened to scrap federal funding … in order to get provinces to negotiating table. Performative (would be political suicide) 1977 Established Programs Financing Act Replaced 50/50 cost sharing with a per capita block transfer Transfer would include cash and “tax-points” (13.5% income tax, 1% corporate tax) The feds are still collecting most of the tax Provinces do not have much of the revenue power - they have started but the feds never let go of their centralized revenue power Hypothetical Lecture Notes 25  Lower the federal tax by 13% - no longer take that 13% so that provincial level and you have total sovereignty over it Tax payer doesn’t know the difference Some of the money we give you for health care is the value of the transfer here Worked out to be 25% of the health care First year of EPFA - total value of the tax power of the tax transfer + cash would be the same 50% contribution Can the federal government take tax points back? NO!! You can’t take back the revenue tools that it’s in the hands of another It’s gone as a tool of enforcement AB has often threatened to tear up principles of the medicare act Always been dominated by Conversative Leadership Giving freedom to provinces, but also weaken the enforcement of the feds for the standards of medicare Why give provinces tax points? Lecture Notes 26  Give freedom but using a tool that you cannot give back - stupid idea economically but politically beacuse of the threats of soverignty - showing QC we’re giving your province back Total Transfer: (cash + value of tax points in the particular province) equalized on per capita basis across provinces Rich province → less cash; poor province → more cash Poor provinces under EPFA, all included an equalization payment in same way embedded into the health financing transfer Growth of the transfer would be controlled by Ottawa Liability is fixed at that number - set up for 3-5 horizon; could never differ Not that you can set at the 50% of whatever the province would ask her Have fiscal control Transfer would be for health insurance and education Why did the federal government bundle transfers for health insurance and education in the EPFA? Ostensible argument: letting the provinces decide how they spend the money - more universities or hospital - they allows provinces to think rationally and efficiency Actual reason: The very motivation for the federation is to slow its liability for the expensive health insurance programs Budget pressure in place by squeezing education; total envelop may start to look bigger, but it’s a blame deferral strategy - provinces have to make tough decisions Makes the cut of closing hospital or education at the local government The EPFA even to this day, all the tax points transferred in 1977 never happened - we need to get back into the world where federal gov’t to cover 50% Tainted with mixed some logic - continues to haunt us to this day What’s the “fair share”? They don’t understand those tax points transfer Lecture Notes 27  13% of personal income tax - is an enormous revenue power Latter 1980s, gov’t cut taxes (global movement) Providers also increasing fees they charge patients, extra user fees, as the response to the squeeze of this response Health System Models Chung’s paper is a nice summary, with flaws Household money (virtually all the money comes from) > Lecture Notes 28  Very little money from direct household to providers Lecture Notes 29  Worst performing - health outcomes (per dollar spent), equity and distribution justice Bohm et al (2013) There are a lot of countries …but not that many governance models. 💡 Financing concerns the mechanisms used to collect, pool, and allocate funding for health care It is about who pays for care and to whom they pay E.g., how much of the money is going to just the paper work; can the system make matters worse or possibly alleviate those services 💡 Delivery concerns the people, organizations, and resources used to provide health care. It is about who provides care and to whom they provide it Lecture Notes 30  💡 Governance (regulation) concerns the processes through which decisions are made and authority is exercised. It is about who makes key decisions and to whom they are accountable State actors include government and public sector organizations They are accountable to the public or to elected officials they serve Societal actors include non-governmental organizations established to represent particular interests (e.g., unions, industries, etc.) They are accountable to the members or constituencies they represent Corporatism (political constructs) - government partnerships societal organizations that represent different interests - control agenda, etc. Private actors include individuals, households, and private corporations. They are accountable to themselves or their owners (which may be themselves). If there are 3 dimensions to health systems with 3 possible actors in each, there are a lot of possible models. Fortunately, there is a hierarchy that limits the number of systems in reality Lecture Notes 31  Statutory model does not have key constituents at the table FR gone from a country from many health insurance fund (sickness fund, non-profit regulated insurance care), now to just a few (two) - one for agricultural workers and everyone’s else Essentially FR, being Canadian model No country in the world that is truly free market US spend more public money for health care than Canadians per capita - ton of people that cannot be insured through the private insurance and expensive private Lecture Notes 32  No country has a monolithic, comprehensive health care system with a single set of decision-making institutions and processes. Countries have mixes of systems, typically stratified by population and/or type of care. E.g., dental care, vision care, mental health - mixed models depending on social groups (e.g., children, Indigenous, etc.) Bohm and colleagues classify the governance (regulation) dimension of health systems based on what type of actor makes most decisions concerning each of three key relationships: 1. Between beneficiaries and financing agencies: e.g., who decides who is covered and how it is financed? 2. Between financing agencies and service providers: e.g., who decides which providers are remunerated and how? 3. Between service providers and beneficiaries: e.g., who decides which providers patients access and which services are provided? When it comes to acute hospital care in Canada… 1. Beneficiaries and financing: who decides who is covered and how it is financed? State actors 2. Financing and providers: who decides which providers are remunerated and how? Depending health authorities, it might be state actors (made by government) 3. Providers and beneficiaries: who decides where patients access care and which services are provided? Government does influence the capacity of the hospitals Lecture Notes 33  Not easy - not black and white - part private (patients can go to a particular hospital or private actor of their referring physicians) What about prescription drugs in Canada…? Beneficiaries and financing: Argue no body? 60% are will with private sector money or patients voluntary get insurance from their workplace Voluntary private insurance Financing and providers: government does that for particular population subgroups - that are covered by some subgroups Or at the catastrophic covers Majority is the private actors Same with providers and beneficiaries READ THE TAPIC PAPER!!! 💡 Good health system governance skews decisions toward the objectives of universal, equitable access to quality, sustainable health care (goals of the UN’s Right to Health framework). Transparency about the nature, process, and rationale behind decisions. Accountability requiring decision makers to inform, explain, and be subject to sanction. Good governance requires consequences Participation of affected parties to improve legitimacy, information, and ownership/uptake. Engaging in constituencies Integrity via clarity, consistency, and reasonableness of decision-making rules and processes. Lecture Notes 34  Capacity to develop policy that is aligned with goals, to turn a political idea into a thought-out proposal for implementation or recommendation about risk. Investment in public decision making is not wasted money - leads to high functioning governance “Death by a 1000 cuts” - shame when you undermine public sector organizations to make good decisions and to turn ideas into well thought- out programs, etc. Group Briefing Note Ask prodding question or two Presentation - short Whole class will see the briefing note Lecture Notes 35