Canadians Confront Health Care Reform

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Tr e n d s Canadians Confront Health Care Reform A 2002 survey shows that Canadians’ attitudes toward health system changes are in a state of flux. by Julia Abelson, Matthew Mendelsohn, John N. Lavis, Steven G. Morgan, Pierre-Gerlier Forest, and Marilyn Swinton 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.

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a n a d i a n s h av e r e c e n t ly 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

Julia Abelson ([email protected]) 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. PierreGerlier 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.

186 DOI 10.1377/hlthaff.23.3.186 ©2004 Project HOPE–The People-to-People Health Foundation, Inc.

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increased role for private financing and forprofit 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 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 twentyone minutes (mean), which included the intro-

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duction 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 n 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. n 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

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EXHIBIT 1 Assessments Of Health Care Systems In Canada, The United States, And The United Kingdom, Selected Years 1988–2002

that underpins Medicare is fundamentally unaffordable: 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-

EXHIBIT 2 Canadians’ Assessments Of The Quality Of Their Health Care System, Selected Years 1991–2002

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EXHIBIT 3 Canadians’ Assessments Of Access To Health Care, Selected Years 1989–2002

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 n 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

EXHIBIT 4 Canadians’ Attitudes Toward The Sources Of Problems Confronting The Canadian Health Care System, Selected Years 1995–2002


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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 twotier 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. 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 sociodemographic 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

EXHIBIT 5 Canadians’ Attitudes Toward Health System Transformation, 2002

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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 mediDiscussion cally necessary physician and “There may be a n Papering over probhospital care) on current and backlash if the new lems with money (for now). future policy-making procmoney does not Our survey data reveal that in esses and the policies that 2002 Canadians were less translate into shorter they produce.17 A vast majoranxious about their health ity of the Canadian public apwaiting times and care system than they were a peared to have internalized other improvements few years earlier, when perthe policy legacy of “private in system ceptions peaked that the syspractice, public payment” for performance.” tem needed major reform and physician and hospital care was failing to deliver timely that has created and reinaccess to high-quality care forced institutional barriers to change. when needed. Canadians’ anxiety seems to As Canadians move further away from the have peaked when reductions in federal gov- familiarity of these “core” services and the ernment health care contributions were most longstanding policy debates associated with severe. Since then, the federal government in- reform in these areas (that is, user charges for creased its contributions as part of its 2000 doctor and hospital care), their views about pre-election “health care budget.”15 Although transformative options that have been the sublong-term concerns still remain, our survey re- ject of more recent debate are less assured.18 In sults demonstrate that the Canadian public the absence of tracking data for these options, has acknowledged that governments have in large part because of the conflating of pribeen responding to their concerns about the vate and for-profit delivery in previous public health system. But there may be a limit to how opinion surveys, we cannot say whether Canamuch can be accomplished simply by putting dians have reached a settled judgment about more money into the system. There may also be these options. When the defining features of a backlash if the new money does not trans- two-tier care and for-profit delivery were exlate, or is not shown to translate, into shorter plained to them, Canadians appeared to be waiting times and other improvements in sys- slightly more open to for-profit delivery than tem performance. two-tier care for “non-core” high-tech and n Holding on strongly to free, single-tier home care services. Of the two options, twodoctor and hospital care. Despite dramatic tier care may be perceived to pose a greater shifts in the delivery of health care over the challenge to universality, a defining feature of past two decades, with more and more ser- their health care system. vices being provided outside the hospital and n Predictors of support for change. The by health care professionals other than doc- generally weak and inconsistent results for extors, in 2002 Canadians still viewed doctors periential and sociodemographic variables and hospitals as the pillars of their health care suggest the need to consider other predictors 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.


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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 n 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. 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.

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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 Dis-

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content in Five Nations,” Health Affairs 18, no. 3 (1999): 206–216. 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). Although we support the practice of crossnational 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. 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). 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). 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-forProfit Hospitals,” Canadian Medical Association Journal 166, no. 11 (2002): 1399–1406. 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. Interviews were conducted by the Institute for Social Research at York University. 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 addi-

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12.

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tional 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. Donelan et al., “The Cost of Health System Change.” M.E. Rasell, “Cost Sharing in Health Insurance—A Reexamination,” New England Journal of Medicine 332, no. 17 (1995): 1164–1168; and K. Grumbach and T. Bodenheimer, “Reins or Fences: A Physician’s View of Cost Containment,” Health Affairs 9, no. 4 (1990): 120–126. 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. 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-forprofit” 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). 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 [email protected]. Government of Canada, “First Ministers’ Meeting—Communiqué on Health” (Ottawa: Government of Canada, 11 September 2000). 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). P. Pierson, “When Effect Becomes Cause: Policy Feedback and Political Change,” World Politics 45,


no. 4 (1993): 595–628; and P. Pierson, “Increasing Returns, Path Dependence, and the Study of Politics,” American Political Science Review 94, no. 2 (2000): 251–267. 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-forProfit 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-forProfit Hemodialysis Centers: A Systematic Review and Meta-Analysis,” Journal of the American Medical Association 288, no. 19 (2002): 2449–2457. 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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