canadian health care system

Summary

• The dominant role played by government financing in Canada’s single-payer health care system has led to an oversight related to demographics: senior migration.
• Health care spending is skewed towards the first year of life and after retirement. The average amount spent on health care by governments in a person’s first year of life is $10,800. For those between the ages of 65 to 69, that amount is $6,424, but it rises to $13,797 for those over 70.
• Taxes, on the other hand, start out quite low and then climb steadily to one’s prime earning years (56-63), before beginning to decline as one nears and then enters retirement.
• When a senior migrates from one province to another, they are likely to have paid the bulk of their lifetime taxes in one province but will consume the majority of their health care in another.
• Six provinces experienced a net inflow of seniors between 1980 and 2016: BC, AB, ON, NB, NS, and PEI. The remaining four provinces (SK, MB, QC, and NL) experienced a net outflow of seniors. British Columbia recorded the greatest inflow (40,512), while Quebec experienced the greatest outflow (37,305).
• Based on average annual health care costs by age, British Columbia had the largest cost at $7.2 billion (in 2017 dollars) while Quebec had the largest savings at $6.0 billion.
• A partial analysis of potential tax revenues provided by migrating seniors suggests that BC’s costs could have been mitigated by as much as 36.3 percent while Quebec’s savings could have been reduced by as much as 19.2 percent.

Comparing the performance of different countries’ health-care systems provides an opportunity for policy makers and the general public to determine how well Canada’s health-care system is performing relative to its international peers. Overall, the data examined suggest that, although Canada’s is among the most expensive universal-access health-care systems in the OECD, its performance is modest to poor.

This study uses a “value for money approach” to compare the cost and performance of 29 universal health-care systems in high-income countries. The level of health-care expenditure is measured using two indicators, while the performance of each country’s health-care system is measured using 42 indicators, representing the four broad categories: [1] availability of resources; [2] use of resources; [3] access to resources; [4] quality and clinical performance.

Five measures of the overall health status of the population are also included. However, these indicators can be influenced to a large degree by non-medical determinants of health that lie outside the purview of a country’s health-care system and policies.

Expenditure on health care
Canada spends more on health care than the majority of high-income OECD countries with universal health-care systems. After adjustment for “age”, the percentage of the population over 65, it ranks third highest for expenditure on health care as a percentage of GDP and eleventh highest for health-care expenditure per capita.

Availability of resources
The availability of medical resources is perhaps one of the most basic requirements for a properly functioning health-care system. Data suggests that Canada has substantially fewer human and capital medical resources than many peer jurisdictions that spend comparable amounts of money on health care. After adjustment for age, it has significantly fewer physicians, acute-care beds, and psychiatric beds per capita compared to the average of OECD countries included in the study (it ranks close to the average for nurses). While Canada has the most Gamma cameras (per million population), it has fewer other medical technologies than the average high-income OECD country with universal health care for which comparable inventory data is available.

Use of resources
Medical resources are of little use if their services are not being consumed by those with health-care demands. Data suggests that Canada’s performance is mixed in terms of use of resources, performing at higher rates than the average OECD country on about half the indicators examined (for example, consultations with a doctor, CT scans, and cataract surgery), and average to lower rates on the rest. Canada reports the least degree of hospital activity (as measured by discharge rates) in the group of countries studied.

Access to resources
While both the level of medical resources available and their use can provide insight into accessibility, it is also beneficial to measure accessibility more directly by examining measures of timeliness of care and cost-related barriers to access. Canada ranked worst on four of the five indicators of timeliness of care, and performed worse than the 10-country average on the indicator measuring the percentage of patients who reported that cost was a barrier to access.

Quality and clinical performance
When assessing indicators of availability of, access to, and use of resources, it is of critical importance to include as well some measure of quality and clinical performance in the areas of primary care, acute care, mental health care, cancer care, and patient safety. While Canada does well on four indicators of clinical performance and quality (such as rates of survival for breast and colorectal cancer), its performance on the seven others examined in this study are either no different from the average or in some cases—particularly obstetric traumas and diabetes-related amputations—worse.

The data examined in this report suggests that there is an imbalance between the value Canadians receive and the relatively high amount of money they spend on their health-care system. Although Canada ranks among the most expensive universal-access health-care systems in the OECD, its performance for availability and access to resources is generally below that of the average OECD country, while its performance for use of resources and quality and clinical performance is mixed.

Health care is the single largest budget item for every province in Canada, ranging from 34.3 percent of total program spending in Quebec to 43.2 percent in Ontario in 2016. 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 is 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 last 15 years (ie., between 2001 to 2016) saw provincial governments increase health care spending at an unsustainable pace. Indeed, during this period, health care spending grew by 116.4 percent, outpacing growth in other program spending (94.6 percent) and GDP (77.4 percent). It is therefore unsurprising that during the same period, the share of program spending represented by health care for the provinces in total grew from 37.6 percent to 40.1 percent. Further, while provincial health care spending (in total) represented only about 6.0 percent of Canada’s GDP in 2001, it had grown to represent 7.3 percent by 2016. However, growth in spending has not followed a consistent trend over this 15-year period. Notably, the average annual growth in health spending (6.7 percent) during the first 10 years between 2001-2011 was much higher than the average annual growth during the past 5 years (2.6 percent) between 2011-2016.

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 (long-term trend model) 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 2001 and 2016. Under this scenario, health care spending is projected to grow at about 5.3 percent per annum on average between 2016 and 2031. As a result, health care spending is expected to consume a slightly larger portion of total program spending—growing from 40.1 percent in 2016 to 42.6 percent in 2031. The range of results for specific provinces is a low of 34.2 percent in Quebec to a high of 47.2 percent in British Columbia in 2031. As well, health spending in total is expected to grow from 7.3 percent of the economy in 2016 to 9.3 percent in 2031. Health care spending in four provinces (British Columbia, Prince Edward Island, Ontario and Nova Scotia) is projected to consume over 45 percent of total program spending—suggesting increases in spending along these lines may be unsustainable and carry some risk of crowding out other programs or requiring fiscal adjustments.

In the second scenario (short-term trend model), the assumptions regarding health-specific inflation and other factors are altered to reflect trends only between the shorter and more recent period between 2011 and 2016. Under this scenario, health care spending is projected to grow at about 2.9 percent per annum on average between 2016 and 2021. As a result, it is expected that health care spending will continue to represent about the same portion of total program spending—growing from 40.1 percent in 2016 to 40.5 percent in 2021. Relative to the size of the economy, health spending is again expected to remain roughly constant—decreasing marginally from 7.3 percent of the economy in 2016 to 7.0 percent of the economy in 2021. Under this scenario, there is less risk of crowding out other programs and requiring fiscal adjustments.

After years of increasing health care spending at an unsustainable pace, it seems as through provincial governments have started to reach their limits over the past 5 years—understanding that a continuation of such increases would result in either reductions in other spending, or higher taxation, higher deficits and debt, or some combination of these three.

Indeed, given expected inflationary and demographic pressures, if governments increase health care spending in the future in line with trends observed over the last 5 (rather than 15) years, the present ratio of health care spending to program spending and GDP may be preserved (at least in the near future). However, the continual presence of long wait times and low ratios of human and technological medical resources despite historically high levels of spending raise new questions about whether the public health care system will be able to deliver adequate services to patients without fundamentally altering its structure.