|
TRENDSCanadians Confront Health Care Reform
In 2002 Canadians were less anxious about the state of their health care system than they were a few years earlier, when perceptions peaked that the system needed major reform. They expressed strong support in 2002 for maintaining the status quo on health care financing (that is, no user fees and no two-tier care) within the traditional domains of physician and hospital care. But they appeared more receptive to two-tier care and for-profit delivery for the newer and rapidly expanding domains of home care and high-tech care.
Canadians have recently been through a series of soul-searching exercises to consider the problems facing their health care system and options for its reform. The provincial and national commissions that have led these exercises have reacted to growing perceptions that the system needs major reform.1 The most recent national inquiry, the Commission on the Future of Health Care in Canada (also known as the Romanow Commission), provided advice about the sustainability of the health care system and about how best to bring about change.2 The results of our survey of public opinion, which was conducted at the time of the commission’s final report, may be particularly instructive for the United States, given that both Americans and Canadians are grappling with what should constitute "core" services within their respective Medicare programs and the role for the for-profit sector in delivering these services.3 Beginning in the 1990s Canadians expressed growing concern that their health care system was failing to deliver timely access to high-quality care when needed; that Canadian Medicare—built around universal public insurance for hospitals and doctors—inadequately addresses increasing expenditures on prescription drugs and home care; and that an increased role for private financing and for-profit delivery may be necessary to sustain the health care system.4 Our survey updates measures of Canadians’ concerns about timely access to high-quality care and solicits views about perceived problems with the health care system, attitudes toward widely debated options for transforming the health care system, and the values underpinning these attitudes. The use of a series of tracking questions in our 2002 survey allowed us to reflect on the evolution of Canadians’ opinions about their health care system in comparison with other countries, namely the United States and the United Kingdom. Two private financing options were examined: user fees for medically necessary hospital and physician care, and "two-tier" physician and hospital care that would allow people to pay for faster or higher-quality care or both. These financing options were selected because they are now prohibited in the Canadian Medicare system yet are routinely presented as options for alleviating perceived access problems.5 For-profit delivery was also examined because it, too, is prohibited and has been much debated.6 We compared attitudes toward financing and delivery options for physician and hospital care versus attitudes toward the same options applied to high-tech care (for example, diagnostic equipment) and home care to determine whether Canadians viewed core Canadian Medicare services (financed publicly and delivered on a not-for-profit basis for more than thirty years) differently from rapidly expanding forms of care (financed and delivered through varied arrangements across the country).7
Our questionnaire included a combination of new questions and (for tracking purposes) questions used in previous surveys. An identical version of the questionnaire was translated into French for use in Québec. Telephone interviews with 1,874 people were conducted by random-digit dialing between 10 October and 22 December 2002.8 Interviews lasted twenty-one minutes (mean), which included the introduction and selection of a respondent within the household. At least fourteen attempts were made to reach a respondent, of which at least ten were made during the evening or weekend hours. Careful attention to the number and timing of callbacks and attempts to convert initial refusals yielded a 58 percent response rate (the number of completed interviews divided by the number of completed interviews plus the number of refusals).9
Perceived problems with the Canadian health care system. Previous international surveys published in Health Affairs documented a decline in public confidence in the Canadian health care system during the 1990s.10 Using a question from these surveys, we compared Canadians’ views in 2002 with the views in Canada, the United States, and the United Kingdom in 1988 and 1998 (Exhibit 1  ). Among the three countries, Canadians were uniquely satisfied with their system in 1988. But by 1998 Canadians had radically reevaluated the performance of their system. Their responses more closely matched U.S. views and were notably less positive than those in the United Kingdom. By 2002 views about the extent of system change required had changed considerably: More Canadians believed that major changes are needed, but fewer believed that complete rebuilding is needed.
Concerns about the quality of the health care system (Exhibit 2 ) and concerns about access to services (Exhibit 3) follow the same pattern of peaking over a similar time period. That said, in 2002 Canadians no longer believed that their system is excellent, as they did in the early 1990s, and they were clearly experiencing more difficulty obtaining needed health care than in the late 1980s, even if the worst of the perceived accessibility crisis appeared to be over in 2002.
Perceived sources of problems. In 2002 a substantial majority of Canadians held the view that patients and, to a lesser and decreasing extent, doctors abuse the health care system (Exhibit 4 ). However, Canadians did not believe that the public financing model that underpins Medicare is fundamentally un-affordable: only about one-third of respondents agreed with this statement (Exhibit 4), and these views have not changed since the late 1990s. Despite the widespread use of cost sharing for patients and utilization controls for physicians in the United States, which would at first glance appear to be possible solutions to health system abuse, Canadians have not embraced the U.S. model of health care delivery.11 The Canadian health system remains an important component of Canadians’ sense of differentiation from the United States; however, the intensity of this feeling has sub-sided. In our 2002 survey, 12 percent of respondents stated a preference for being treated in the United States, compared with 7 percent stating this preference in 1995.12
Attitudes toward reform options. In 2002 Canadians were firm in their beliefs that health care is a right of citizenship (93 percent agreed, and only 6 percent disagreed), but they were divided on the issue of the role that the market versus the state should play in the financing and delivery of health care. More than half (51 percent) of respondents believed that profit making in the health care system can be justified (42 percent disagreed), and 62 percent believed that there is nothing wrong with having private, for-profit companies and competition play a role in the health care system (34 percent disagreed).13 But at the same time, 57 percent also believed that more money should be put into the system even if it means paying more in taxes (40 percent disagreed). To obtain more specific views about these complex issues, we presented respondents with several scenarios, each of which tapped views about a different aspect of the public/private financing and not-for-profit/for-profit delivery debates. Through these scenarios we sought to discern public attitudes toward three options for transforming the health care system: (1) user fees, defined as "a patient paying part of the cost for the health care they receive"; (2) two-tier delivery, defined as "people being allowed to pay for faster and/or higher quality care"; and (3) for-profit care, defined as "private firms setting up alongside the not for profit health care system and competing with it."
Canadians make a distinction between doctors and hospitals on the one hand and home care and high-tech care on the other, and they more strongly oppose changes to the traditional domains of doctors and hospitals (Exhibit 5
We conducted exploratory regression analysis to identify drivers of support for transformative changes to the health care system, as defined by our user fee, two-tier, and for-profit scenarios.14 We provide a brief summary of reactions to these options here. First, contact with the health care system, such as whether one had been hospitalized in the previous year or is now providing home care, is not an important predictor of attitudes toward these options. Second, those who know more about the health care system, as measured by their knowledge of the Commission on the Future of Health Care in Canada, are somewhat more opposed to these changes. Third, most socio-demographic factors were not very important in explaining opinions about these options. However, a consistent pattern of age effects was found. Younger Canadians were consistently more supportive of the scenarios presented to them, while older Canadians were particularly opposed to two-tier options. Fourth, what appears to emerge most strongly as an explanation for support or opposition to these options is competing values. Support for private and for-profit scenarios comes from those who are generally more supportive of science, technology, and individualism; more socially conservative; and more opposed to equity and solidarity as overarching principles. Although these relationships warrant further examination, a combination of these deeper core values—an embrace of technology, individualism, social conservatism, and a rejection of equity—characterize attitudinal support for user fee, two-tier, and for-profit scenarios.
Papering over problems with money (for now). Our survey data reveal that in 2002 Canadians were less anxious about their health care system than they were a few years earlier, when perceptions peaked that the system needed major reform and was failing to deliver timely access to high-quality care when needed. Canadians’ anxiety seems to have peaked when reductions in federal government health care contributions were most severe. Since then, the federal government increased its contributions as part of its 2000 pre-election "health care budget."15 Although long-term concerns still remain, our survey results demonstrate that the Canadian public has acknowledged that governments have been responding to their concerns about the health system. But there may be a limit to how much can be accomplished simply by putting more money into the system. There may also be a backlash if the new money does not translate, or is not shown to translate, into shorter waiting times and other improvements in system performance. Holding on strongly to free, single-tier doctor and hospital care. Despite dramatic shifts in the delivery of health care over the past two decades, with more and more services being provided outside the hospital and by health care professionals other than doctors, in 2002 Canadians still viewed doctors and hospitals as the pillars of their health care system and were staunchly opposed to changes in their financing arrangements. The principle of universal access to health care based on need and not ability to pay was less vigorously supported when it came to home care and high-tech care, which were still perceived to be "outside" the public system, despite the increasing proportion of each provincial government’s health care budget taken up by these services.16 These findings suggest the powerful influence of past policies (that is, first-dollar coverage for medically necessary physician and hospital care) on current and future policy-making processes and the policies that they produce.17 A vast majority of the Canadian public appeared to have internalized the policy legacy of "private practice, public payment" for physician and hospital care that has created and reinforced institutional barriers to change. As Canadians move further away from the familiarity of these "core" services and the longstanding policy debates associated with reform in these areas (that is, user charges for doctor and hospital care), their views about transformative options that have been the subject of more recent debate are less assured.18 In the absence of tracking data for these options, in large part because of the conflating of private and for-profit delivery in previous public opinion surveys, we cannot say whether Canadians have reached a settled judgment about these options. When the defining features of two-tier care and for-profit delivery were explained to them, Canadians appeared to be slightly more open to for-profit delivery than two-tier care for "non-core" high-tech and home care services. Of the two options, two-tier care may be perceived to pose a greater challenge to universality, a defining feature of their health care system. Predictors of support for change. The generally weak and inconsistent results for experiential and sociodemographic variables suggest the need to consider other predictors of support for change. Our exploratory analysis revealed core values to be the strongest, most consistent set of predictors, which suggests the relevance of exploring more fully the relationships between values and attitudes toward health care reform, particularly in domains with differing policy legacies, such as "core" and "non-core" services.19 Prospects for the future. As new and reoriented health care investments are realized within Canadian Medicare, through the processes set into action by the Commission on the Future of Health Care in Canada and the federal and provincial first ministers’ health care accord, Canadians’ attitudes toward these changes will continue to evolve and, in turn, be shaped by future policies.20 The same may hold true for parts of U.S. Medicare. Elderly Americans have grown accustomed to seeing hospitals and physicians as "core" services, and they may soon grow accustomed to seeing prescription drugs in the same light.
Julia Abelson (abelsonj{at}mcmaster.ca) is an assistant professor in the Department of Clinical Epidemiology and Biostatistics, a member of the Centre for Health Economics and Policy Analysis, and an associate member of the Department of Political Science, McMaster University, in Hamilton, Ontario. Matthew Mendelsohn is an associate professor in the Department of Political Studies, Queen’s University, in Kingston, Ontario. John Lavis is an associate professor in the Department of Clinical Epidemiology and Biostatistics, a member of the Centre for Health Economics and Policy Analysis, and an associate member of the Department of Political Science, McMaster University. Steven Morgan is a member of the Centre for Health Services and Policy Research and an assistant professor in the Department of Health Care and Epidemiology, University of British Columbia, in Vancouver. Pierre-Gerlier Forest is the G.D.W. Cameron Chair, Health Canada, and a professor in the Department of Political Science, Université Laval, Québec. Marilyn Swinton is research coordinator in the Centre for Health Economics and Policy Analysis, McMaster University. This project was supported by a Canadian Institutes of Health Research (CIHR) grant. Julia Abelson holds a CIHR New Investigator Award. John Lavis holds a Canada Research Chair in Knowledge Transfer and Uptake. Pierre-Gerlier Forest receives salary support from the G.D.W. Cameron Chair in Health Canada. The authors thank David Northrup and Liza Mercier from the Institute for Social Research at York University for their contributions to the survey design and execution, Fiona Miller and Jerry Hurley for comments on survey drafts, and Mollyann Brodie for helpful comments on an earlier version of the paper.
This article has been cited by other articles:
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Top
Survey Methods
Survey Findings
