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The Sustainability of Health Care Spending in Canada

Health care is the single largest budget item for every province in Canada, ranging from 34.5 percent of total program spending in Quebec to 44.6 percent in Nova Scotia in 2015. Any changes in the amount spent on health care can have a significant impact on a government’s fiscal balance (deficits or surpluses), the resources available for other programs such as education and social services, and/or tax competitiveness.

It is therefore vital that we routinely assess historical, current, and expected trends in health care spending in order to determine if such spending is sustainable.

While a number of indicators can help determine the sustainability of changes to health care spending, the most common and informative of these indicators are the share of program spending represented by health care and the ratio of health care spending relative to the size of the economy (GDP). An increase in the former may result in the crowding-out of other spending while an increase in the latter may require a change in the current tax system or deficits.

An examination of these two indicators of health care spending, that is health care spending as a share of program spending and health care spending as a share of the economy, shows clearly that the recent period of 1998 to 2015 saw provincial governments increase health care spending at an unsustainable pace. During this period, the share of program spending represented by health care for the provinces in total grew from 34.4 percent to 40.6 percent. Further, while provincial health care spending (in total) represented only about 5.8 percent of Canada’s GDP in 1998, it had grown to represent 7.3 percent by 2015.

The pressing question today, however, is what can we reasonably expect to occur in the near future in the absence of any significant shift in government policy?

In order to answer this question, this paper presents the results of two scenarios based on a model for projecting health care spending in the future based on demographic factors (population growth and aging), inflation (general and health-specific inflation), and other factors (which may include factors related to government policy, income elasticity, developments in technology, etc.).

The first scenario is based on reasonable expectations of general inflation and demographic trends in the future, as well as assumptions regarding health-specific inflation, and other factors based on trends observed between 1998 and 2013. Under this scenario, health care spending is projected to grow at about 6.3 percent per annum on average between 2015 and 2030. As a result, health care spending is expected to consume an increasing portion of total program spending—growing from 40.6 percent in 2015 to 47.6 percent in 2030. The range of results for specific provinces is a low of 36.6 percent in Quebec to a high of 54.2 percent in Prince Edward Island in 2030. Indeed, the projections calculated indicate that five provinces (PEI, Nova Scotia, New Brunswick, Ontario, and British Columbia) will see health care spending grow close to (or exceed) 50 percent of total program spending by 2030. As well, health spending in total is expected to grow from 7.3 percent of the economy in 2015 to 10.7 percent in 2030.

In the second scenario, the assumptions regarding health-specific inflation and other factors are altered to reflect trends between the shorter and more recent period between 2008 and 2013. Under this scenario, health care spending is projected to grow at about 4.6 percent per annum on average between 2015 and 2030. As a result, it is expected consume a larger portion of total program spending—growing from 40.6 percent in 2015 to 45.3 percent in 2030. As well, health spending can be expected to grow from 7.3 percent of the economy in 2015 to 8.3 percent of the economy in 2030.

It is clear that under either scenario, the current ratio of health care spending to other program spending will be surpassed, as will be the current ratio of program spending to GDP. The rate of increase expected in health care expenditures will thus necessitate changes in other policies—either reductions in other spending to accommodate the increases in health care spending, or higher taxation, higher deficits and debt, or some combination of these three. Simply put, this paper shows that the current health care arrangements, which result in the level of spending observed and expected, do not seem sustainable over the next 15 years from today’s vantage point.

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Duty to Consult with Aboriginal Peoples

Section 35 of the Canadian Constitution states that “the existing aboriginal and treaty rights of the aboriginal peoples of Canada are hereby recognized and affirmed”. In an attempt to provide greater clarity the constitution defines “treaty rights” as rights that now exist by way of “land claim agreements or may be so acquired”. It is through this constitutional provision that the duty to consult has been constructed by Canadian courts. The department of Indigenous and Northern Affairs Canada estimates that the legal duty to consult is triggered for some provinces over 100,000 times per year and for the federal government over 5,000 times per year.

Over the past decade, the Supreme Court of Canada has attempted to define how provincial and federal governments are to put into practice their duty to consult with First Nations. They have done this through various judgments including: Haida Nation v. British Columbia, Taku River Tlingit First Nation v. British Columbia, Mikisew Cree First Nation v. Canada, and Tsilhqot’in Nation v. Canada. In an effort to address the Crown’s legal obligation to consult with aboriginal groups, provinces have created consultation guides for their departments and project proponents. However, these guidelines are vastly different depending on which jurisdiction a project is in. This creates a patchwork of consultation policies across the country.

There are some principles that all jurisdictions share, such as the Crown’s taking responsibility for the duty to consult; and yet there are other principles that differ dramatically depending on the province in which a project is located. For example, British Columbia, Manitoba, and Quebec are the only jurisdictions that do not state in their policies that aboriginal communities are required to participate in the consultation process. British Columbia, Manitoba, Ontario, and Quebec also all still have “draft” aboriginal consultation policies. In the case of Ontario, their policy has been in draft form since 2006. The consultation process could be improved for project proponents and First Nation communities across the country.

Recommendations

  • British Columbia, Manitoba, Ontario, and Quebec could provide additional certainty to First Nations and project proponents by finalizing their “draft” consultation guidelines.
  • British Columbia, Manitoba, and Quebec could outline the roles and responsibilities of First Nations during the consultation process. The rest of the jurisdictions analyzed for this paper have clear expectations of engagement from First Nations communities.
  • Timelines around the consultation process to ensure the duty to consult is implemented in a timely way is another improvement jurisdictions could adopt. Timelines will help guide project proponents who are undertaking procedural aspects of the duty to consult and it will also provide First Nations a clear indication of how long they have to engage in the consultation process. First Nations’ capacity to engage in the consultation process should be taken into consideration when developing timelines.
  • Manitoba could improve their process by including clear offloading provisions in their duty-to-consult policy and highlighting what, if any, procedural duties can be offloaded to project proponents in the consultation process.
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Report Card on Alberta’s Elementary Schools 2016

The Report Card on Alberta’s Elementary Schools 2016 reports a variety of relevant, objective indicators of school performance. These indicators are used to calculate an overall rating for each school. On the basis of this rating, the schools are ranked. The Report Card brings all of this information together in one easily accessible public document so that anyone can analyze and compare the performance of individual schools. By doing so, the Report Card assists parents when they choose a school for their children and encourages and assists all those seeking to improve their school.

In Alberta, many parents enjoy considerable choice regarding the school in which they will enroll their children. Where choice is available, the Report Card provides a valuable decision-making tool. Because it makes comparisons easy, the Report Card alerts parents to nearby schools that appear to have more effective academic programs. Further, parents can determine whether schools of interest are improving over time. By first studying the Report Card, parents will be better prepared to ask relevant question when they interview the principal and teachers at the schools they are considering.

The Report Card provides a detailed picture of each school’s academic outcomes that is not easily available elsewhere. Naturally, a sound academic program should be complemented by effective programs in areas of school activity not measured by the Report Card.

Certainly, the act of publicly rating and ranking schools attracts attention. Schools that perform well or show consistent improvement are applauded. The results of poorly performing schools generate concern, as do those of schools whose performance is deteriorating. This inevitable attention provides an incentive for all those connected with a school to focus on student results.

However, the Report Card offers more than incentive: it includes a variety of indicators, each of which reports results for an aspect of school performance that might be improved. School administrators who are dedicated to improvement accept the Report Card as another source of opportunities for positive change.

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Moving Targets: Re-estimating Federal Deficits and Debt-to-GDP

The federal government has repeatedly shifted the goal posts on its own “fiscal anchors.” This bulletin examines the robustness of the current “fiscal anchor” to reduce the debt-to-GDP ratio by the government’s first mandate.

The 2016 federal budget confirmed the government’s plan to run long-term deficits–$113.2 billion over the five-year plan. Budget 2016 increases program spending by 7.6% in 2016/17, following a 6.7% increase in 2015/16.

A closer look at the government’s spending plan reveals a major slowdown in spending growth during the last three years. Specifically, the federal government is proposing to reduce spending as a share of the economy and per-person spending (inflation-adjusted) from 2017/18 to 2020/21. Decreasing the size of the federal government does not square with the government’s view that government spending drives economic growth.

Using three alternative spending scenarios from 2017/18 to 2020/21, we estimate the potential impact on the five-year deficit plan and debt-to-GDP assuming:

  • Program spending increases at the rate of population growth plus inflation
  • Program spending increases at the rate of economic growth
  • Program spending increases by 6.0% annually (the average growth rate of first two years of the 5-year budget plan)

We estimate that over the course of the government’s fiscal plan the cumulative federal deficit could reach up to $196.0 billion. We find that the debt-to-GDP ratio under three different spending scenarios would be greater in 2020/21 than in 2015/16. The federal government is therefore unlikely to meet its latest target of reducing the federal debt-to- GDP by the end of its first mandate.

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Rates of Return for the Canada Pension Plan

There is confusion regarding the rates of return earned by the Canada Pension Plan Investment Board (CPPIB), which manages the investable funds of the Canada Pension Plan (CPP) with the returns received by individual Canadian workers in the form of CPP retirement benefits.

The returns of the CPPIB do not in any direct way influence the CPP retirement benefits received by individual Canadian workers. CPP retirement benefits are basically determined by the number of years a person works, their earnings in each year (relative to the maximum under the CPP), and the age at which they retire.

The returns to the CPPIB, however, do benefit workers and retirees indirectly. Specifically, the returns earned by the CPPIB can reduce the need for higher contribution rates. In addition, sustained over-performance by the CPPIB over time could allow for a reduction in the contribution rate and/ or an increase in the benefits paid. However, the opposite is also plausible, whereby under-performance by the CPPIB could necessitate higher contribution rates and/or reduced benefits.

Based on the model employed in this paper (which assumes workers retire at age 65), the real rates of return enjoyed by Canadian workers from their CPP retirement benefits ranged from an incredible 45.5 percent in 1969 to just 3.6 percent in 2015.

Specifically, there was an initial steep decline from the 45.5 percent real rate of return observed for retirees in 1969 to less than one-third that rate in 1989 (12.6 percent). By 2003, the real rate of return for CPP retirees was halved to 6.3 percent. By 2015, the real rate of return for CPP retirees had declined to 3.6 percent.

The projected real rates of return for the CPP continue to fall to 2.1 percent for those retiring in 2037, stabilizing thereafter. In other words, Canadian workers retiring after 2036 (people born in or after 1972) can expect a real rate of return of 2.1 percent from the CPP.

The rates of return noted above are further reduced if certain assumptions are changed. For example, making maximum contributions over the entire course of one’s working life (ages 18–65)—rather than assuming zero contributions for the first eight years (which are exempted from the retirement benefit calculation), as done in the first set of calculations—reduces the real rate of return to 1.7 percent for workers retiring in 2037 or later (compared to 2.1 percent).

A different way to think about the returns received by Canadian workers from their CPP retirement benefits, particularly those borne after 1971, is to compare the expected rate of return (2.1 percent real rate of return) with the required real rate of return for the CPPIB of 4.0 percent. In other words, Canadian workers born after 1971 pay into a fund that must generate a 4.0 percent real rate of return to meet its obligations, a fund which provides a 2.1 real rate of return in the form of CPP retirement benefits.

There are two principal reasons for the decline in the rates of return. The first is the difference in the periods of contribution for Canadian workers, particularly in the early years of the CPP. For instance, in the initial years of the plan, only ten years of maximum contributions were required to receive a full CPP benefit. That period is currently 39 years.

The second principal reason for the decline in the rates of return is the increasing contribution rate to the CPP (i.e., the tax rate). The CPP was launched in 1966 with a contribution rate of 3.6 percent. The CPP contribution rate climbed steadily beginning in 1987, and stabilized at 9.9 percent in 2003. It’s worth noting that the stabilized CPP contribution rate is nearly three times higher than the original contribution rate of 3.6 percent.

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Child Care in Canada: Examining the Status Quo in 2015

Governments in Canada have decided that it is good public policy to help subsidize the cost of raising children, especially for children in low-income households. This paper presents the existing array of programs in Canada (as of the fall of 2015) and examines their nature (targeted or universal), function, and costs. The federal government is, by far, the major actor in this regard.

The Canada Child Tax Benefit (CCTB) directs tax-free funds (about $122 per month per child in 2015) to low and middle income families with children under 18. The National Child Benefit Supplement (NTBS) adds additional funds (about $190 per month per child in 2015) to qualifying low income families. Combined, these two federal programs cost taxpayers about $14 billion in 2015. In addition, there are 3 other federal programs of significance.

The Universal Child Care Benefit is a taxable cash grant to families with children and is designed to “help families cover the cost of child care.” The basic grant at the beginning of 2015 was $100 per month for any child under 6. However, during 2015, the program was expanded and now provides $160 per month per child under 6 and $60 for children between ages 6 and 17. This program cost approximately $2.7 billion in 2014 but about $.4 billion of that was recovered through the tax system. With the enhancements, the estimated cost of the UCCB program will be about $7 billion in 2016 with at least $1 billion recovered in taxes.

The Canada Education Savings Grant (CESG) tops up any parental contribution to their child’s RESP of up to $2,500 per year with a cash grant of 20 percent of the parental contribution. This plan is designed to provide an incentive for parents to save for their child’s post-secondary education. In 2014, the CESG program cost taxpayers about $800 million.

The Child Care Expense Deduction allows one parent (usually the lower income parent if both parents are employed) to deduct expenses for children under 16 so that a parent could earn income, go to school, or conduct research. The cost of this program in 2015 is estimated to be about $900 million.

There are a number of much smaller programs that provide modest assistance for children’s fitness and for families with disabled children. All together, the federal programs that direct cash benefits to families with children will cost about $24 billion this year.

Each province in Canada has programs designed to help families with children as well. Most of the provincial programs are income tested so that the benefits flow mainly to lower-income families. The Quebec day care program stands out both for its uniqueness and scope. While there is no accessible information about program costs, waiting lists, and usage by class, it is a much discussed and much studied program. For lower-income families with pre-school children, the program subsidizes daycare in eligible facilities so that families only pay $7.30 per child per day. Even that low fee is waived in cases where the family is in very straightened circumstances. For families with incomes above $155,000 per annum, the fee is modulated up to a maximum of $20 per child per day.

The paper examines the case of a single parent with a pre-school child on social assistance and the federal and provincial benefits that would flow to that family. In nine of the 10 provinces, the child-specific cash benefits provided by various levels of government amount to between 30 and 38 percent of total family income. For Quebec, however, government benefits are about 50 percent of the family’s income. And this excludes the Quebec daycare program, which not all single-parent families use. Again, the Quebec government stands out in terms of their decision to direct significantly more public funds to families with children.

The paper examines a second case, one that focuses on a middle income family, but it compares only Ontario and Quebec. In this case, once the higher taxes that Quebecers pay are considered, Ontario families with two children (ages 4 and 8) are somewhat better off. While Quebec provides more benefits, including heavily subsidized daycare, it also has much higher taxes.

The paper’s final section provides an overview of the research on the effects of daycare programs on children’s cognitive and noncognitive outcomes. Four conclusions can be drawn from that research. They are:

  • First, that the quality of parenting and home life is the most important determinant of a child’s intellectual and emotional development;
  • Second, good quality daycare (similar to good quality primary education) may be able to help offset some of the deleterious effects of a bad home environment;
  • Third, for children who have a positive home environment, there is no consistent evidence that daycare has a positive, lasting impact on cognitive development; and
  • Fourth, the results of smaller scale, high quality programs cannot be used to support the case for universal, publicly funded programs.

Finally, the most recent evaluation of the Quebec subsidized daycare program, that by Haeck et. al (2015), suggests that while the plan has led to increased labour force participation by mothers, it was “mainly driven by highly educated mothers.” As well, the policy “did not improve school readiness and may even have had negative impacts on children from low-income families.”

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Measuring Personal Income Tax Complexity in Canada

Canadian families and businesses incur significant costs complying with the tax system. Those costs include direct spending on items such as accountants, lawyers, and computer software, as well as the financial cost of the time it takes to compile the materials and complete the forms. Governments also incur costs to administer and collect taxes. These costs are driven in part by the complexity of the tax system.

This study measures the evolution of tax complexity in Canada’s personal income tax system. It uses three broad categories of empirical measurements: tax expenditures, tax legislation, and administrative tax documents. According to various specific indicators, the system has become more complex over time.

For instance, from 1981 to 2014, the number of federal personal income tax expenditures (which are credits, deductions, exemptions, exclusions, and other preferences) increased from 101 to 128—an increase of 27 percent. The number of tax expenditures was essentially flat up to 2001, after which there was a marked increase. In fact, since 2006, every federal budget has included a new tax credit for specific activities or eligible groups.

For perspective, in 2014, the value of these tax expenditures ($165.0 billion) exceeded total federal personal income tax revenue ($135.7 billion). Indeed, tax expenditures cost the federal government more than it collects in personal income tax revenue.

The study also measures the text area occupied by the Income Tax Act and regulations from 1971 to 2014. The text area is the number of pages multiplied by page size, which measures the area that the legislation would take up were we to lay out all the pages side by side. Over this period, the area of the tax legislation increased 355 percent, from 345,948 cm² to 1,575,537 cm². It is important to measure text area because not only did the number of pages in the Income Tax Act increase, but so did page size. Together, both changes have the effect of magnifying the growth in text area.  In standard letter paper format (8.5x11 inches), the space occupied by the tax code represents an increase from 573 to 2,612 pages over the period.

Finally, an analysis of provincial administrative documents (examining the number of documents, pages, and total lines in the tax forms) also points to growing tax complexity. Consider the results for the total number of lines, arguably the most appropriate indicator of complexity since governments can reduce the number of documents simply by combining them, and cut the number of pages by reorganizing blank spaces, and so on—without reducing the complexity of calculations linked to the personal income tax system. From 2000 to 2015, the average number of total lines in tax forms for the provinces (excluding Quebec) increased from 52 to 172.

While Canada’s personal tax system would benefit from simplification, the country does not have the equivalent of the United Kingdom’s Office of Tax Simplification (either federally or provincially). That means there is no systematic work being done to measure, let alone reduce, tax complexity in Canada. This study is part of an ongoing research program at the Fraser Institute that attempts to help fill that void.

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Learning from the Saskatchewan Surgical Initiative to Improve Wait Times in Canada

Wait times for elective surgery are long in Canada relative to other OECD countries and Saskatchewan has historically had among the longest of all the provinces. In 2010, the Saskatchewan government announced the Saskatchewan Surgical Initiative (SSI) to tackle wait times and promised that by 2014 no patient would wait more than three months for surgery. Today Saskatchewan’s wait times for elective surgery are among the shortest in Canada. What explains Canada’s long waiting lists, what prompted governments to tackle them, and why was Saskatchewan successful in reducing them?

Canada’s long waiting lists are related to the funding and structure of Medicare. Governments’ reluctance to change Medicare’s funding and structure helps to explain their slow response to wait times. Also, waiting lists primarily affected patients: as reports on health care demonstrated, the health care system was dominated by those providing care and was not centred on patients.

Pressure to act came in the 1990s when the Fraser Institute began tracking Cana-da’s growing waiting lists and patients went public with stories about their suffering while waiting for treatment. The Supreme Court’s 2005 decision in the Chaoulli case also put pressure on governments: its main message was that, if governments impose a monopoly on medical services, then they have to deliver those services in a timely way.

In developing the SSI, Saskatchewan worked with, and learned from, other prov-inces—belying the image of a fragmented health-care system in which leadership must come from the federal government—and built upon previous Saskatchewan initiatives to reduce waiting lists. The SSI changed the way waiting lists were managed and organized, but it also fundamentally changed the culture and decision-making process in health care.

The 2015 Report of the Advisory Panel on Healthcare Innovation written for Health Canada cited three factors that drive innovation in health care and all three were central to the SSI. One factor was leadership: in setting a firm and specific target to reduce wait times the government provided the leadership and vision that drove the SSI. The second factor was the engagement of front-line staff in embracing change, which was achieved in the SSI by developing a more collaborative and inclusive decision-making process. The third factor was the SSI’s patient-centred focus, a fundamental change in a system that had historically been dominated by providers. Effective communications with the public was also a central feature of the SSI and a major reason for its success.

Effective communications also helps to explain the success of the most controversial aspect of the SSI, the use of private, for-profit clinics to deliver day-surgery procedures. Health-care unions and self-styled defenders of Medicare warned the public that the private clinics would threaten the core values of Medicare. The transparency and ac-countability in the process of selecting the companies to run the clinics and regulating their operations were important in blunting criticisms. Also, though the government saved money by having procedures performed in the clinics rather than in hospitals, this fact was downplayed in the communications, which focused on the patients and their need for timely care. Most important, however, was the message that the clinics would help to reduce wait times. After years of living with long waits for treatment, people in Saskatchewan were prepared to set aside ideology and willing to judge the clinics on their results.

The SSI was successful within a specific context. It only improved wait times for elective surgery; long waits remain in other areas. It also involved increasing capacity, which meant pouring more money into an already expensive health-care system. Finally, it did not tackle the structural problems of Medicare that foster long wait times. The SSI treated the symptom—the waiting lists—rather than the root problem: Medicare’s structure and funding. But, it was not designed to fix Medicare. Its goal was to relieve the suffering of patients who were waiting far too long for surgery. In that it succeeded.

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Too often, an underlying assumption in the income inequality debate is that low- and high-income Canadians are the same people year in and year out. In reality, however, Canadians are not permanently stuck in certain income groups. Over the course of their lives, the overwhelming majority move up and down the income ladder.

Fluctuation in our income is a part of the natural cycle of our lives. People typically start off with relatively low income early on when they are young, new to the workforce, and lack work and life experience. Once they acquire education, job-related skills, and experience, their income tends to increase until it peaks in middle age and then drops again as they retire (income may fall, perhaps temporarily, if someone exits the workforce or changes jobs).

Using data obtained from Statistics Canada, this study tracks nearly 1 million Canadians starting in 1993 to measure how their income changes after five years (1993-1998), ten years (1993-2003), and 19 years (1993-2012).

The people covered in the study were divided into five groups based on their initial income (defined as wages and salaries before taxes). The groups are referred to as: the bottom 20% (the lowest income group), the second, third, fourth, and the top 20% (the highest income group). If someone starts in the lowest income group in one year, but moves to a higher group after several years, he or she has experienced upward relative income mobility. Conversely, if someone ends up in a lower income group than the one they started in, he or she has experienced downward relative mobility.

The study finds considerable upward relative mobility over all time periods, particularly for the bottom 20%. In just five years, 79% of Canadians who started in the bottom 20% in 1993 had moved to a higher income group by 1998. After 10 years (1993 to 2003), 88% in the lowest income group moved up at least one income group. The 19-year period (1993 to 2012) similarly had nearly nine of every 10 individuals (89%) in the lowest income group moving up. The results show being in the lowest income group is generally a temporary experience and that upward mobility occurs fairly quickly in one’s life.

The results also show that many of those initially in the bottom 20% climbed high up the income ladder reaching the top income groups. Remarkably, nearly one in four (24%) of the bottom 20% in 1993 had reached the top 20% by 2012, and nearly half (46%) ended up in the top two income groups.

Some Canadians also moved down the income ladder over time, particularly those who were initially in the top 20%. Specifically, 35% of individuals in the top 20% in 1993 moved down at least one income group by 2012.

The study also examines absolute mobility, which is the change in average income of the same people over time (after accounting for inflation). In 1993, the average income earned through wages and salaries of Canadians in the bottom 20% was $5,800. However, the average income of those same individuals increased dramatically to $51,100 by 2012 (all income in 2012 dollars). The $45,300 increase in average income translates into an impressive 781% gain.

By comparison, those that began the 19-year period in the top 20% had an average income of $82,600 in 1993, which increased to $106,100 by 2012. That is an increase of $23,500 or just 28%. In absolute terms, individuals in the bottom 20% in 1993 experienced by far the largest income gains of any group.

Another telling figure emerges from the data: in 1993, the average income of individuals in the top 20% was 14 times greater than those in the bottom 20%. By 2012, those who were in the top 20% in 1993 now had an average income that was only twice as high as those who were initially in the bottom 20% in 1993. In other words, in a comparison of income of the same group of people over time, income inequality declined significantly. This is because people’s incomes were mobile—some moved up while others moved down.

This study provides compelling evidence that the rich and poor do not remain stuck in their respective income groups year after year. In any measure of income inequality, it is misleading to rely solely on comparisons of “snapshots” of the income distribution at any two points in time because doing so does not capture the fact that Canadians are mobile.

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Private Cost of Public Queues for Medically Necessary Care, 2016

One measure of the privately borne cost of wait times is the value of time that is lost while waiting for treatment.

Valuing only hours lost during the average work week, the estimated cost of waiting for care in Canada for patients who were in the queue in 2015 was almost $1.2 billion. This works out to an average of about $1,304 for each of the estimated 894,449 Canadians waiting for treatment in 2015.

This is a conservative estimate that places no intrinsic value on the time individuals spend waiting in a reduced capacity outside of the work week. Valuing all hours of the week, including evenings and weekends but excluding eight hours of sleep per night, would increase the estimated cost of waiting to $3.5 billion, or about $3,951 per person.

This estimate only counts costs that are borne by the individual waiting for treatment. The costs of care provided by family members (the time spent caring for the individual waiting for treatment) and their lost productivity due to difficulty or mental anguish are not valued in this estimate. Moreover, non-monetary medical costs, such as increased risk of mortality or adverse events that result directly from long delays for treatment, are not included in this estimate.

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