Health Affairs, 23, no. 3 (2004): 186-193 doi: 10.1377/hlthaff.23.3.186 © 2004 by Project HOPE	New Online   New Issue: China & India   Obesity In China   Pay Cuts For Medicare Docs   Access To Care Woes

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Health Tracking

TRENDS

Canadians Confront Health Care Reform

Abstract

 
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.

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

Survey Methods

Top Editor's Notes Survey Methods Survey Findings Discussion NOTES

 
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

Survey Findings

Top Editor's Notes Survey Methods Survey Findings Discussion NOTES

 
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.

View larger version (36K): [in this window] [in a new window]   EXHIBIT 1 Assessments Of Health Care Systems In Canada, The United States, And The United Kingdom, Selected Years 1988–2002

View larger version (23K): [in this window] [in a new window]   EXHIBIT 2 Canadians’ Assessments Of The Quality Of Their Health Care System, Selected Years 1991–2002

View larger version (28K): [in this window] [in a new window]   EXHIBIT 3 Canadians’ Assessments Of Access To Health Care, Selected Years 1989–2002

View larger version (22K): [in this window] [in a new window]   EXHIBIT 4 Canadians’ Attitudes Toward The Sources Of Problems Confronting The Canadian Health Care System, Selected Years 1995–2002

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). Governments’ roles in maintaining free and equitably delivered doctor and hospital care are highly visible in Canada and have been since the introduction of Medicare more than thirty years ago. Notwithstanding Canadians’ views about patients’ abusing the health care system, the majority of them remained opposed to user fees in 2002. The same solidaristic principles, however, have not informed how governments treat home care and high-tech care, and views did not appear to be held as strongly for these forms of care. More-over, Canadians were more receptive to two-tier options for expanding some forms of care (such as high-tech care and home care) than for hospital care. They also appeared to be more supportive of for-profit over two-tier options when they considered these within the context of high-tech care and home care.

View larger version (19K): [in this window] [in a new window]   EXHIBIT 5 Canadians’ Attitudes Toward Health System Transformation, 2002

Discussion

Top Editor's Notes Survey Methods Survey Findings Discussion NOTES

 
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.

Editor's Notes

Top Editor's Notes Survey Methods Survey Findings Discussion NOTES

 
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.

NOTES

Top Editor's Notes Survey Methods Survey Findings Discussion NOTES

 

1. Although their mandates, timelines, and structures differ from one another, they loosely parallel presidential, legislative, and foundation commissions in the United States in their ad hoc and time limited mandates. For a review and key recommendations of these commissions (excluding the final report of the Commission on the Future of Health Care in Canada), see C. Fooks and S. Lewis, "Romanow and Beyond: A Primer on Health Reform Issues in Canada," Discussion Paper no. H05 (Ottawa: Canadian Policy Research Networks, November 2002). Regarding perceptions of the need for reform, see K. Donelan et al., "The Cost of Health System Change: Public Discontent in Five Nations," Health Affairs 18, no. 3 (1999): 206–216.[Abstract]
2. Commission on the Future of Health Care in Canada, Building on Values: The Future of Health Care in Canada (Ottawa: Commission on the Future of Health Care in Canada, November 2002).
3. Although we support the practice of cross-national health policy learning, we recognize the challenges of undertaking this type of research and the limitations—in particular, of exporting lessons from Canada to the United States. See J.A. Morone, "American Political Culture and the Search for Lessons from Abroad," Journal of Health Politics, Policy and Law 15, no. 1 (1990): 129–143.
4. M. Mendelsohn, Canadians’ Thoughts on Their Health Care System: Preserving the Canadian Model through Innovation (Ottawa: Commission on the Future of Health Care in Canada, June 2002); and Canadian Institute for Health Information, Health Care in Canada (Ottawa: CIHI, 28 May 2003).
5. C. Tuohy, C. Flood, and M. Stabile, "How Does Private Financing Affect Public Health Care Systems? Marshalling the Evidence from OECD Nations," Journal of Health Politics, Policy and Law (forthcoming); and R. Deber, "Getting What We Pay For: Myths and Realities about Financing Canada’s Health Care System" (Background Paper prepared for the Dialogue on Health Reform: Sustaining Confidence in Canada’s Health Care System, 4 March 2000).
6. D. Gratzer, ed., Better Medicine: Reforming Canadian Health Care (Toronto: ECW Press, 2002); and P.J. Devereaux et al., "A Systematic Review and Meta-Analysis of Studies Comparing Mortality Rates of Private For-Profit and Private Not-for-Profit Hospitals," Canadian Medical Association Journal 166, no. 11 (2002): 1399–1406.[Abstract/Free Full Text]
7. Three policy legacies have shaped Canada’s health care system and given rise to the "core" and "non-core" services distinction: federal/provincial division of powers; the "private practice, public payment" arrangement for the delivery of medical care services institutionalized through provincial and federal legislation in the 1960s; and the privileging of physician and hospital services within federal health care legislation stipulations for universal, first-dollar coverage. See B. Hutchison, J. Abelson, and J.N. Lavis, "Primary Care in Canada: So Much Innovation, So Little Change," Health Affairs 20, no. 3 (2001): 116–131.[Abstract/Free Full Text]
8. Interviews were conducted by the Institute for Social Research at York University.
9. There were also 613 initial numbers generated through random-digit dialing that were not households, as well as 137 numbers that were never answered and for which we could not determine household status. There were an additional 294 numbers reached where language problems were insurmountable, a mental or physical handicap prevented interview completion, or the number was a second phone for minor-age children or a second phone for a cottage or alternative residence. Data are weighted so that they are nationally representative of the Canadian population. Additional technical documentation, including the long-form questionnaire used for the interview, is available at the Canadian Opinion Research Archive, post.queensu.ca/cora.
10. Donelan et al., "The Cost of Health System Change."
11. M.E. Rasell, "Cost Sharing in Health Insurance—A Reexamination," New England Journal of Medicine 332, no. 17 (1995): 1164–1168;[Free Full Text] and K. Grumbach and T. Bodenheimer, "Reins or Fences: A Physician’s View of Cost Containment," Health Affairs 9, no. 4 (1990): 120–126.[CrossRef][Medline]
12. Canadians were asked the same question in our 2002 survey—"Do you agree or disagree with the following statement: If I had a serious illness or injury, I would prefer to be treated in the U.S."—that they were asked in a 1995 Angus Reid poll.
13. There is a great deal of for-profit provision of non-core services (such as drugs, tests, and technology) in the Canadian health care system. Furthermore, within the arena of core services, physicians are almost exclusively in "not-only-for-profit" entrepreneurial, independent, or group practices that bill the public insurer. Historically, the hard-line restrictions on for-profit provision in the Canadian health care system have been for the administration of the public insurance system and hospitals; however, these policies are now changing in some Canadian provinces. See R.G. Evans, Strained Mercy: The Economics of Canadian Health Care (Toronto: Butterworths, 1984).
14. The dependent variables used in the regression analysis were the user fee, two-tier, and for-profit reform scenarios put to respondents, as well as an index variable that combined two questions asking about attitudes toward profit and private companies in the health care system. Detailed results are available from the authors; contact Julia Abelson at abelsonj{at}mcmaster.ca.
15. Government of Canada, "First Ministers’ Meeting—Communiqué on Health" (Ottawa: Government of Canada, 11 September 2000).
16. CIHI, Drug Expenditures in Canada, 1985–2002 (Ottawa: CIHI, 2002); and G. Ballinger, J. Zhang, and V. Hicks, Home Care Estimates in National Health Expenditures: Feasibility Study (Ottawa: CIHI, July 2001).
17. P. Pierson, "When Effect Becomes Cause: Policy Feedback and Political Change," World Politics 45, no. 4 (1993): 595–628;[CrossRef] and P. Pierson, "Increasing Returns, Path Dependence, and the Study of Politics," American Political Science Review 94, no. 2 (2000): 251–267.[CrossRef][ISI]
18. M. Barer, R.G. Evans, and G. Stoddart, "Controlling Health Care Costs by Direct Charges to Patients: Snare or Delusion?" Occasional Paper no. 10 (Toronto: Ontario Economic Council, 1979); and R.G. Evans, M. Barer, and G. Stoddart, "User Fees: Why a Bad Idea Keeps Coming Back," Canadian Journal on Aging 14, no. 2 (1995): 360–390.Two studies by P.J. Devereaux and colleagues comparing for-profit and not-for-profit care were published in 2002, as the Romanow Commission was preparing its final report. There was a great deal of media coverage of both studies, and these, in conjunction with the anticipation of the release of the final commission report, became a major focus of policy debate. P.J. Devereaux et al., "A Systematic Review and Meta-Analysis of Studies Comparing Mortality Rates of Private For-Profit and Private Not-for-Profit Hospitals," Canadian Medical Association Journal 166, no. 11 (2002): 1399–1406; and P.J. Devereaux et al., "Comparison of Mortality between Private For-Profit and Private Not-for-Profit Hemodialysis Centers: A Systematic Review and Meta-Analysis," Journal of the American Medical Association 288, no. 19 (2002): 2449–2457.[Abstract/Free Full Text]
19. The relationship between values and health reform attitudes have been explored in previous Health Affairs papers.See, for example, R.J. Blendon et al., "The Beliefs and Values Shaping Today’s Health Reform Debate," Health Affairs 13, no. 1 (1994): 274–300.
20. On 5 February 2003 the prime minister of Canada and the provincial premiers signed the First Ministers’ Accord on Health Care Renewal, which set out "an action plan for reform," including substantial new financial investments in health care.

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