Medicare (French: assurance-maladie ) is the unofficial name for Canada's publicly funded universal health insurance system. The formal terminology for the insurance system is provided by the Canada Health Act and the health insurance legislation of the individual provinces and territories.
Under the terms of the Canada Health Act, all "insured persons" (basically, legal residents of Canada, including permanent residents) are entitled to receive "insured services" without copayment. Such services are defined as medically necessary services if provided in hospital, or by 'practitioners' (usually physicians). Approximately 70% of Canadian health expenditures come from public sources, with the rest paid privately (both through private insurance, and through out-of-pocket payments). The extent of public financing varies considerably across services. For example, approximately 99% of physician services, and 90% of hospital care, are paid by publicly funded sources, whereas almost all dental care is paid for privately. Most doctors are self-employed private entities.
Tommy Douglas is commonly known as the father of medicare, and was instrumental in its first implementation in the province of Saskatchewan. His groundwork, along with the future aid of Prime Minister Lester B. Pearson helped to make medicare a national entity from 1966.
Funding
Funding for the insurance plans comes from the general revenues of the Canadian provinces/territories, assisted by transfer payments from the federal government through the Canada Health Transfer. Some provinces charge health care premiums, but these are in effect taxes (since they are not tied to service use, nor to provincial health expenditures). The system is accordingly classified by the OECD as a tax-supported system, as opposed to the social insurance approaches used in many European countries.
Delivery
Canada uses a mix of public and private organizations to deliver health care; in turn, these organizations bill the provincial health authorities, with few exceptions. Hospitals are largely non-profit organizations, historically often linked to religious or charitable organizations. In some provinces, individual hospital boards have been eliminated and combined into quasi-private regional health authorities, subject to varying degrees of provincial control. Laboratory services are often delivered by for-profit investor-owned corporations.
With rare exceptions, medical doctors are small for-profit independent businesses. Historically, they have practiced in small solo or group practices and billed the medicare system on a fee for service basis. Unlike the practice in some other countries, hospital-based physicians were rarely hospital employees, and also billed the provincial insurance plans on a fee-for-service basis. Since 2000, physicians have been allowed to incorporate for tax reasons (dates of authorization vary province to province). However, efforts to achieve primary health care reform have increasingly encouraged physicians to work in multidisciplinary teams, and be paid through blended funding models, including elements of capitation and other 'alternative funding formulas'. Similarly, some hospitals (particularly teaching hospitals and rural/remote hospitals) have also experimented with alternatives to fee-for-service.
In summary, the system is known as a "public system" due to its public financing, but is not a nationalized system such as the UK's NHS; most medicare services are provided privately.
An additional complexity is that, because health care is deemed to be under provincial jurisdiction, there is not a "Canadian health care system". As noted, most providers are private, and may or may not coordinate their care. Publicly-funded insurance is organized at the level of the province/territory; each manages its own insurance system, including issuing its own healthcare identification cards (a list of the provincial medical care insurance programs is given at the end of this entry). Once care moves beyond the services required by the Canada Health Act - for which universal comprehensive coverage applies - there is inconsistency from province to province in the extent of publicly-funded coverage, particularly for such items as outpatient drug coverage and rehabilitation, as well as vision care, mental health, and long-term care, with a substantial portion of such services being paid for privately, either through private insurance, or out-of-pocket. Eligibility for these additional programs may be based on various combinations of such factors as age (e.g., children, seniors), income, enrollment in a home care program, or diagnosis (e.g., HIV/AIDS, cancer, cystic fibrosis).
The Canada Health Act requires coverage for all medically necessary care provided in hospitals or by physicians; this explicitly includes diagnostic, treatment and preventive services. Coverage is universal for qualifying Canadian residents, regardless of income level. Services of non-physicians working within hospitals are covered; but provinces can, but are not forced to, cover services by non-physicians if provided outside hospitals. Changing the site of treatment may thus change coverage. For example, pharmaceuticals, nursing care, and physical therapy must be covered for inpatients, but there is considerable variation from province to province in the extent to which they are covered for patients discharged to the community (e.g., after day surgery). The need to modernize coverage was pointed out in 2002 by both the Romanow Commission and by the Kirby committee of the Canadian Senate (see External links below). Similarly, the extent to which non-physician providers of primary care are funded varies; Quebec offers primary health care teams through its CLSC system).
Drug coverage
Each province may also provide its own prescription drug benefit plan, although the Canada Health Act requires only coverage for pharmaceuticals delivered to hospital inpatients. Provincial prescription drug benefit plans differ across provinces. Some provinces cover only those in particular age groups (usually, seniors) and/or those on social assistance. Others are more universal. Quebec achieves universal coverage through a combination of private and public plans. Co-payments also vary. Provinces maintain their own provincial formularies, although efforts are underway to institute a Common Drug Review. Note that there is ongoing controversy in Canada, as in other countries, about inclusion of expensive drugs and discrepancies in their availability, as well as in what if any provisions are made for allowing medications not yet approved to be administered under "exceptional drug" provisions. Drug costs are contentious. Their prices are controlled by the Patented Medicine Prices Review Board, otherwise called the PMPRB. The PMPRB's pricing formula ensures that Canada pays prices based on the average of those charged to selected countries; they are neither the highest, nor the lowest.
Dental care, eye care and other services
Dental care is not required to be covered by the government insurance plans. In Quebec, children under the age of 10 receive almost full coverage, and many oral surgeries are covered for everyone. Canadians rely on their employers, individual private insurance, pay cash themselves for dental treatments, or receive no care. In some jurisdictions, public health units have been involved in providing targeted programs to address the need of the young, the elderly or those who are on welfare. The Canadian Association of Public Health Dentistry tracks programs, and has been advocating for extending coverage to those currently unable to receive dental care.
The range of services for vision care coverage also varies widely among the provinces. Generally, "medically required" vision care is covered if provided by physicians (cataract surgery, diabetic vision care, some laser eye surgeries required as a result of disease, but not if the purpose is to replace the need for eyeglasses). Similarly, the standard vision test may or may not be covered. Some provinces allow a limited number of tests (e.g., no more than once within a two-year period). Others, including Ontario, Alberta and Saskatchewan, do not, although different provisions may apply to particular sub-groups (e.g., diabetics, children).
Naturopathic services are covered in some cases, but homeopathic services are generally not covered. Chiropractic is partially covered in some provinces. Cosmetic procedures are not typically covered. Psychiatric services (provided by physicians) are covered, fee-for-service psychology services outside of hospitals or community based mental health clinics are usually not. Physical therapy, occupational therapy, speech therapy, nursing, and chiropractic services are often not covered unless within hospitals. Some provinces, including Ontario include some rehabilitation services for those in the home care program, those recently discharged from hospitals (e.g., after a hip replacement), or those in particular age categories. Again, considerable variation exists, and provinces can (and do) alter their coverage decisions.
Opinions on Medicare
Polling data in the last few years have consistently cited medicare as among the most important political issues in the minds of Canadian voters. Along with peacekeeping, medicare was found, based on a CBC poll, to be among the foremost defining characteristics of Canada.
It has increasingly become a source of controversy in Canadian politics. As a recent report from the Health Council of Canada has noted "Herein lies
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