There have been five commission in the last five years investigating the future sustainability of Medicare in Canada: the Fyke Report in Saskatchewan, the Clair Report in Quebec, the Mazankowski Report from Alberta, the Kirby Report (produced for the Senate), and last, but by no means least, the Romanow Commission, have now all finally reported.
Notwithstanding the different ideologies of the governments that appointed these men, all of their reports have confirmed the fundamental principles of Canada's publicly funded Medicare. It is a system where access to important medical care is distributed on the basis of need, rather than ability to pay and services covered under Medicare are financed almost exclusively through general taxation revenues. But profound questions linger and will continue to linger long after the many volumes of commission reports have gathered dust. Specifically, these questions are:
This issue is made more pressing by the acceptance of the First Ministers in the Health Accord of 2003 that the core of publicly funded Medicare should expand beyond the traditional sectors of hospital and physician services and into home care and eventually into prescription drugs. As the categories of services that may receive full public funding broaden, who decided what particular services within those categories should be publicly funded or should not be publicly funded?
With respect to the question of "what" services to fund, it is impossible to generalize given the different resource constraints and values. A human rights approach, as epitomized in the Convention on Economic Social & Cultural Rights, is vital for determining a basic minimum of access to health care. However, as a country develops it expands its medical care system beyond the "core" demanded by international human rights conventions to a much larger and more ambiguous "core".
This ambiguity can be caused by an increased choice in health care delivery options due to technological or pharmaceutical advancements. How does one decide on which delivery option to choose? Is it a simple cost decision? For example, if a surgical operation costs $150,000 with a 5% change of success, should this be publicly funded? Or, if a new drug achieves the same health outcome at a price that is 20% above the existing drug on the market but has no side-effects; should this be publicly funded?
We would argue that, in theory, the choices or decisions made should be a function of:
It seems clear, however, that decision making about what is publicly funded in Canada's Medicare is not made like this. Instead, the choices are function of:
The Canada Health Act requires full public funding of "medically necessary" hospital services and "medically required" physician services. Neither the Act nor provincial legislation provides a definition of "medically necessary" and "medically required." How, then, do provinces determine which particular physician services to fund?
We are part of a team of 10 interdisciplinary scholars exploring these questions over the course of a three-year program of research. We are beginning our analysis in Ontario and working our way through the other provinces.