CHSM307, Module 1 - Introduction
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Toronto Metropolitan University *
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Course
307
Subject
Medicine
Date
Feb 20, 2024
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13
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Introduction
Since before 1990, provincial governments have proposed numerous strategies to cure the wicked
problem that plagues the delivery of long-term care services. Over these years, numerous and wide-
ranging proposals and policy papers were produced on how to fix the system’s systemic delivery
problems. Despite provinces implementing new infrastructure, structural reorganizations, regulations,
surveillance, monitoring and accountability. As well as increasing staffing, giving better pay and
improving working conditions, the system continues to struggle to provide long-term care services to the
right people, at the right time, by the most appropriate care providers. To be able to comprehend why
these initiatives worked or failed, one needs to understand Canada’s concept of universal health care
and its social welfare system (also known in some literature as Canada’s social safety net).
This module presents the development of Canada’s universal health care system. Module two presents
the development of Canada’s social welfare system.
Once one understands Canada’s journey to insured universal health care (Medicare) and the
components of Canada’s social safety net, one gains sufficient knowledge to critically analyze and
critique government initiatives, past, present, and future to correct and improve the delivery of long-term
care to Canadians.
This unit provides the reader with a comprehensive understanding of Canada’s Medicare system. It
explores what the system provides and does not provide to support the delivery of long-term medical
care services in Canada.
The Beginning
“Let’s start in 1962.” (Koch, 1962) when Tommy Douglas, known as Canada’s father of Medicare, was
asked by the TV host Tom Koch that, as far as health care is concerned, why was it his [Douglas]
position that government is the best vehicle to offer Canadians access to health care as a insured
service. Douglas responded…
“The first would be that all of the health plans which are a very satisfactory second alternative
if you haven’t got a government sponsored plan, but the basic weaknesses are that they levy
a premium, which is the same, irrespective of whether the family has an income of $2,000 a
year or $20,000 a year. In other words, no private plan can take cognizance of the family’s
ability to pay. Only a government can levy taxes on that basis. Another issue is that for most
of these plans in order to stay solvent, they have to eliminate a great many groups of people,
because of age because of chronic conditions because of congenital illnesses, past medical
histories and so on. And these are precisely the people who need some kind of protection.”
(Koch, 1962)
The first step on Canada’s pathway to universal health care began with the British North American
Act (BNA) 1867
, later renamed the Constitution Act
in 1982. It was more than 94 years later that
Canada’s universal health care system emerged as 13 individual health care plans under the jurisdiction
of the provincial and territorial governments. (Thompson, 2020)
Valerie Thompson (2020) in chapter one of Health and Health Care Delivery in Canada (Third
Edition)
does a good job of tracing Canada’s journey to universal health care. From the cottage hospital
system in Newfoundland (Thompson, 2020) to the concept of public health to the drama on the floor of
the Saskatchewan provincial legislative building, follow how Saskatchewan politicians led the charge to
levy municipal taxes that raised money to entice physician to set up practice in rural areas. (Taylor,
1978).
Topics and Learning Objectives
Topics
Origins of Medical Care in Canada The Federal and Provincial Roles in Health Care Delivery Key Health Care Legislation
Learning Objectives
Identify four key pieces of legislation that shaped Canada’s health care delivery system
Describe the history of the Canadian health care delivery system
Identify elements of the Canada Health Act 1984
that pertain to long-term care delivery
Readings
Required
1. Koch, T. (Host). (1962, July 22). T
ommy Douglas, Canada’s father of Medicare. [Video
podcast]. CBC. https://www.cbc.ca/player/play/1809466521
2. Thompson, V. D. (2020). Health and health care delivery in Canada
(Third ed.).
Elsevier. Chapter One: The History of Health Care in Canada.
3. Government of Canada. (2019). Canada’s Health Care Delivery System
.
https://www.canada.ca/en/health-canada/services/health-care-system/reports-
publications/health-care-system/canada.html#a3
4. Government of Canada. (2021). Understanding how health care works in Canada
.
https://www.canada.ca/en/immigration-refugees-citizenship/services/new-immigrants/new-
life-canada/health-care.html [4.06 min]
5. National Collaborative Centre for Aboriginal Health. (2011). The Aboriginal Health
Legislation and Policy Framework in Canada
. https://www.nccih.ca/docs/context/FS-
HealthLegislationPolicy-Lavoie-Gervais-Toner-Bergeron-Thomas-EN.pdf
Please Note
Pay special attention to the material in Chapter One of Thompson. This information is key to
understanding the delivery of health care in Canada.
BNA 1867
With the passage of the British North American Act
of 1867 (BNA) the Dominion of Canada was born
and the division of responsibility between the provinces and the federal government for the delivery of
health care was set (Thompson, 2020).
By virtue of the BNA 1867, the roles and responsibilities for the delivery of health care are clearly
delineated between the federal and provincial/territorial governments.
The provincial and territorial governments have most of the responsibility for delivering health and
other social services.
With respect to health care, the federal government is responsible for Indigenous communities,
members of the armed forces, people detained by Correctional Services, veterans and selected
refugee claimants. As of April 2013, regular members of the RCMP were covered for basic health
benefits by the province and territory in which they live.
The federal, provincial and municipal governments share the responsibility for public health, which
includes sanitation, infectious diseases, health promotion and disease prevention.
Think About It
What organizations attended to the health care needs of Canadians in the eighteenth and
nineteenth century?
“The federal government’s role in the provision of health services is primarily through the limited
public health and prevention services offered by the First Nations and Inuit Health Branch (FNIHB).
Click-n-reveal: What role does the federal government play in the delivery of health care to
Canada’s Aboriginal population?
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Services are offered to status (registered) Indians living on-reserve and to Inuit living in their
traditional territories (Health Canada, 2003a; 2008).
The Branch provides non-insured health benefits (NIHB) such as prescription drugs, dental and
vision coverage to all status/registered Indians and Inuit, regardless of where they live; however,
non-insured health benefits are not offered to Métis. Physician and hospital care is provided by
provincial and territorial governments (Health Canada, 2008).
Thus, for First Nations peoples living on-reserve, health care is predominately the federal
government’s responsibility; other Aboriginal groups, with very few exceptions, fall under the
purview of the provincial or territorial governments.” (National Collaborative Centre for Aboriginal
Health, 2011, p. 2)
The Hospital Insurance and Diagnostic Act 1957
Canada’s universal health care system primarily consists of two components: medical practitioners
services, and institutional care (acute, rehabilitative, mental health institutions).
The Hospital Insurance and Diagnostic Act (1957)
(federal) offered to reimburse, or cost share,
one-half of provincial and territorial costs for specified hospital and diagnostic services. The Act covered
the cost of care in an acute care setting as long as the physical determined it necessary. Care provided
in outpatient clinics was insured, but care provided in tuberculosis sanitariums, mental institutions or
home for the aged was not insured. By 1961 all the provinces and territories had agreed to provide
publicly funded inpatient hospital and diagnostic services.
Activity
The Hospital Insurance and Diagnostic Act
did not come into effect until 1957. Seek out and
speak to someone that was born in Canada before 1957. Ask them to describe what health care
was like before the Canada had universal health care.
Medical Care Insurance Act 1966
With the passing of the Medical Care Act
in 1966, publicly funded medical care insurance plans (for
insured services there was no bill at the end of the physician appointment) were provided to Canadians.
The Medical Care Act (1966)
offered to reimburse, or cost share, one-half of provincial and territorial
costs for medical services provided by a doctor outside hospitals. Within six years, all the provinces and
territories had universal physician services insurance plans for medically necessary care.
Think About It – What is medically necessary?
“Medically necessary services are not defined in the Canada Health Act
. It is up to
the provincial and territorial health insurance plans, in consultation with their
respective physician colleges or groups, to determine which services are medically
necessary for health insurance purposes. If it is determined that a service is medically
necessary, the full cost of the service must be covered by the public health insurance
plan to be in compliance with the Act. If a service is not considered to be medically
required, the province or territory need not cover it through its health insurance plan.”
(Government of Canada, 2019)
Since the Diagnostic and Services Act
of (1957) to 1977 became law, the federal government financial
contribution to the provinces and territories to support universal free health care was 50% (also knows
as the 50 cent dollar) of the insured hospital and physician services. With costs escalating the federal
government changes the funding formula with the aim of containment.
Federal-Provincial Fiscal Arrangements and
Established Programs Financing Act (EPF Act 1977)
While the Hospital Insurance and Diagnostic
and the Medical Care Act
allowed Canadians to
received hospital care and medical care (insured services) free at the time of delivery, the services and
the practitioners still required payment. Canadians pay for the medical services they receive through an
intricate system of shared costs between the federal and provincial/territorial governments, and
provincial/territorial taxes.
The Federal-Provincial Fiscal Arrangements and Established Programs Financing Act (1977)
replaced the federal government’s 50% cost sharing agreement with the provinces to one of block
funding. Block funding consisted of a combination of cash payments and tax points. “A block fund is a sum of money provided from one level of government to another for a specific
purpose. With a transfer of tax points, the federal government reduces its tax rates and provincial
and territorial governments simultaneously raise their tax rates by an equivalent amount. This new
funding arrangement meant that the provincial and territorial governments had the flexibility to
invest health care funding according to their needs and priorities. Federal transfers for post-
secondary education were also added to the health transfer.” (Government of Canada, 2019)
Click-n-reveal: What is block funding?
What do you think? Do Canadians receive free medical care under Canada’s universal
health care system?
Yes
No
Not sure
Submit
Canada Health Act (1984)
The Canada Health Act (1984)
was passed by parliament, updating the earlier hospital and medical
care insurance acts, and outlining the five principles of a public health system – universality, portability,
comprehensiveness, accessibility and public administration – that provinces and territories must meet to
receive the full federal cash transfers for health and social programs.
Canada Health Act (1984)
replaced the federal hospital, and medical insurance acts replaced and
consolidated the Hospital and Diagnostic Services Act and the Medical Care Insurance Act)
.
It reaffirmed the five principles underpinning Canada’s universal health care system, prohibited extra
billing, eliminated user fees for insured services and set provincial penalties for violating the Canada
Health Act
with a dollar-for-dollar provincial reduction of provincial bock funding (penalty) for any
provincial extra billing of which the federal government was aware.
Canada Health Care Act Criteria and Conditions for the Delivery of Universal Health Care for all
Eligible Canadians
Criteria
Conditions
Public administered managed by a public
authority
Provinces/territories will provide the federal
government with
Comprehensive
Access to prepaid medically necessary
services
Information – insured health care services,
extended health care services
Portable
Public Recognition – federal financial contribution
to both insured and extended health care
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Criteria
Conditions
Can be accessed across provincial and
territorial borders and internationally with
restrictions
services
Universality
No matter young or old, rich or poor, or health
status, Canadians are eligible for insured
health benefits
Accessible
Reasonable access to services where and
when they are available
(Thompson, 2020)
Roles of the Provincial and Territorial Governments in Health
Care
Administration of their health insurance plans,
planning and funding of care in hospitals and other health facilities,
services provided by doctors and other health professionals,
planning and implementation of health promotion and public health initiatives; and
negotiation of fee schedules with health professionals.
(Government of Canada, 2019)
Read the case examples 1.2 to 1.6 inclusive. If you have questions, ask your instructor to explain further.
Think About It
When does long term care fit into Canada Health Care Act (1984)
?
Stepping Stone Six – Commissioned Reports and
Accords
As the changes imposed by the Established Programs and Financing (EPA) Act (1977)
and the
Canada Health Act (1984)
trickled down through the provincial health care delivery systems, hospitals
had problems running balanced budgets. Health care professionals (nurses, physicians) left Canada for
countries that operated their health care delivery systems on a private sector model.
Provinces shifted spending priorities from institutional to in-home community delivery of health care and
shifted their focus from treatment to prevention, health promotion and disease prevention.
By 2002, three major reports were commissioned and released:
1. The Mazankowski Report: A Framework for Reform
(2001)
2. The Kerby Report: The Health of Canadians – The Federal Role
(2002)
3. The Romanow Report: Building on Values: The Future of Health Care in Canada
(2002)
(Thompson, 2020, p. 25–26).
In response to the distrust and animosity that was building between the federal minister of health and
his/her/their provincial/territorial counterparts (first ministers) met and negotiated key reforms in primary
health care, pharmaceuticals management, health information and communications technology, and
health equipment and infrastructure they were willing to initiate in their provinces.
Reading
From the Readings page, review the Thompson (2020) chapter one material on each of the
accords.
First Ministers’ Meeting 2000
First Ministers’ Accord on Health Care Renewal 2003
First Ministers’ Meeting on the Future of Health Care 2004
Annual Conference of Ministers of Health 2005
The Kelowna Accord 2006
2014 Health Accord 2017 Health Accord
(Thompson, 2020, p. 27–30)
Test Your Knowledge
Using all of the materials you have reviewed in this module as your guide, match each year with the
correct legislation.
Matching Exercise
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Reset Exercise
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Module Summary
It was not until the BNA 1867, the first stepping stone, that the lines of health care responsibility were
clearly delineated with the responsibility for the delivery of health care to the provinces with the federal
Year
1995
1964
1977
2004
1947
1984
1948
1957
1867
2003
Legislation
The Hospital Insurance and Diagnostic
Services Act
Federal CHST split into two transfers:
the Canada Health Transfer (CHT) and
the Canada Social Transfer (CST), April
1.
The Federal-Provincial Fiscal
Arrangements and Established
Programs Financing Act
The Medical Care Act
Canada Health and Social Transfer
(CHST)
First ministers' Accord on Health Care
Renewal, announced February 5.
The British North America Act
Federal Government Health Grants
Program
The Canada Health Act
Saskatchewan initiates provincial
universal public hospital insurance plan,
January 1.
government providing financial support.
The BNA’s act of delineating the responsibility for medical care between the federal and
provincial/territorial governments set the stage for Canada to have thirteen independent provincial and
territorial operated health care systems. Each province provides medically necessary health care as
prescribed by physicians to meet the unique health care needs of each province and territory’s citizens.
Services that are not medically necessary (some dental, physiotherapy, chiropractor) were deemed
extended health care benefits and were not funded or only partially funded under certain circumstances.
Medical services not deemed medically necessary or that do not qualify for public funding may be
purchased and paid for directly by the individual, employment-based group insurance plan, or privately
purchased private insurance.
Most provincial and territorial laws restrict the services offered by private providers to those not covered
by publicly funded plans, resulting in supplementary coverage. Private insurers are restricted from
offering coverage that duplicates that of the publicly funded plans, but they can compete in the
supplementary coverage market.
Module Discussion
Week 1 Discussion
Required
Post your responses to each of the following topics to the “
Week 1 Discussion Topics
” in
D2L.
Please clearly indicate each of the topics you are responding to in your posting.
Topics
1. Describe and summarize the main purpose and recommendations of the Mazankowski,
Kirby, and Romanow reports in 50 words or less per report. Select one of the reports
and
provide a critical appraisal of the extent to which its recommendations were implemented.
Include as part of your analysis whether these same issues persist in today’s health care
environment.
Be precise in your critical analysis.
Please write in complete sentences. 2. List and describe three pieces of legislation that played a significant role in establishing
Canada’s universal Medicare delivery system.
Be precise is your critical analysis.
Please write in complete sentences.
3. Define “medically necessary”, “extra billing” and “user charges”, and how they relate to
each other in the context of the Canada Health Act of 1984
.
Be precise is your critical analysis.
Please write in complete sentences.
Pleae Note
You can access the Discussion Forums from the Communications menu in your D2L course.
Please make sure that your participation in all discussion forums adheres to the Toronto
Metropolitan University online Etiquette Guidelines listed in your course outline.
Students are encouraged to respond to all discussion questions. The discussion board material is
testable and may be included on course tests and examinations.
Tests and Assignments
Reminder
Please check the course outline for test or assignment dates.
References
Koch, T. (Host). (1962, July 22). Tommy Douglas, Canada’s Father of Medicare
. [Video podcast].
CBC. https://www.cbc.ca/archives/entry/tommy-douglas-canadas-father-of-medicare
Taylor, M. G. (1978). Health Insurance and Canadian Public Policy: The seven decisions
that created the Canadian health insurance system
. McGill-Queen's University Press.
Thompson, V. D. (2020). Health and health care delivery in Canada
(Third ed.). Elsevier.
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Government of Canada. (2019). Canada’s Health Care Delivery System
.
https://www.canada.ca/en/health-canada/services/health-care-system/reports-publications/health-
care-system/canada.html#a3
Government of Canada. (2021). Understanding how health care works in Canada
.
https://www.canada.ca/en/immigration-refugees-citizenship/services/new-immigrants/new-life-
canada/health-care-card.html
National Collaborative Centre for Aboriginal Health. (2011). The Aboriginal Health Legislation and
Policy Framework in Canada
. https://www.nccih.ca/docs/context/FS-HealthLegislationPolicy-
Lavoie-Gervais-Toner-Bergeron-Thomas-EN.pdf
Ontario Centre for Learning, Research, and Innovation in Long-Term Care. (2018). A Home for All:
Younger Residents Living in Long-Term Care
. https://clri-ltc.ca/files/2019/01/Younger-Residents-in-
LTC-Handout.pdf