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Canada Health Act

Canada Health Act

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Encyclopedia
The Canada Health Act http://laws.justice.gc.ca/en/C-6/ is a piece of Canadian federal
Government of Canada
The Government of Canada, formally Her Majesty's Government, is the system whereby the federation of Canada is administered by a common authority; in Canadian English, the term can mean either the collective set of institutions or specifically the Queen-in-Council...

 legislation
Legislation
Legislation is law which has been promulgated by a legislature or other governing body, or the process of making it...

, adopted in 1984, which specifies the conditions and criteria with which the provincial and territorial health insurance
Health insurance
Health insurance is insurance against the risk of incurring medical expenses among individuals. By estimating the overall risk of health care expenses among a targeted group, an insurer can develop a routine finance structure, such as a monthly premium or payroll tax, to ensure that money is...

 programs must conform in order to receive federal transfer payment
Transfer payment
In economics, a transfer payment is a redistribution of income in the market system. These payments are considered to be exhaustive because they do not directly absorb resources or create output...

s under the Canada Health Transfer
Canada Health Transfer
The Canada Health Transfer is the Canadian government's transfer payment program in support of the health systems of the provinces and territories of Canada...

 http://www.fin.gc.ca/fedprov/cht-eng.asp. These criteria require universal coverage (for all "insured persons") for all "medically necessary" hospital and physician services, without co-payments.

The CHA deals only with how the system is financed. Because of the constitutional division of powers among levels of government, adherence to CHA conditions is voluntary. However, the fiscal levers have helped to ensure a relatively consistent level of coverage across the country. Although there are disputes as to the details, the CHA remains highly popular.

In popular discussion, the CHA
CHA
CHA may stand for:Sports* Canadian Hockey Association * College Hockey America, the NCAA Division I conference* College Hockey Association, the ACHA Division II conference* Continental Hockey Association...

 is often conflated with the health care system
Health care in Canada
Health care in Canada is delivered through a publicly-funded health care system, which is mostly free at the point of use and has most services provided by private entities. It is guided by the provisions of the Canada Health Act. The government assures the quality of care through federal standards...

 in general. However, the CHA is silent about how care should be organized and delivered, as long as its criteria are met.

Another cause for debate is the scope of what should be included as "insured services". For historical reasons, the CHA's definition of insured services is largely restricted to care delivered in hospitals or by physicians. As care has moved from hospitals to home and community, it increasingly has been moving beyond the terms of the CHA. International data shows that approximately 70% of Canadian health expenditures are paid from public sources, placing Canada below the OECD
Organisation for Economic Co-operation and Development
The Organisation for Economic Co-operation and Development is an international economic organisation of 34 countries founded in 1961 to stimulate economic progress and world trade...

 average.

History: Federalism



Canada
Canada
Canada is a North American country consisting of ten provinces and three territories. Located in the northern part of the continent, it extends from the Atlantic Ocean in the east to the Pacific Ocean in the west, and northward into the Arctic Ocean...

 is a federal
Federalism
Federalism is a political concept in which a group of members are bound together by covenant with a governing representative head. The term "federalism" is also used to describe a system of the government in which sovereignty is constitutionally divided between a central governing authority and...

 country in which power is distributed between the national government, and the 10 provinces and 3 northern territories. The division of power was spelled out in the British North America Act 1867
Constitution Act, 1867
The Constitution Act, 1867 , is a major part of Canada's Constitution. The Act created a federal dominion and defines much of the operation of the Government of Canada, including its federal structure, the House of Commons, the Senate, the justice system, and the taxation system...

 http://laws.justice.gc.ca/eng/Const/index.html (renamed the Constitution Act in 1982). Section 92(7) lists as one of the "exclusive powers of provincial legislatures" "The Establishment, Maintenance, and Management of Hospitals, Asylums, Charities, and Eleemosynary Institutions in and for the Province, other than Marine Hospitals." Although this language does not specifically give authority over 'health care,' subsequent court cases and interpretations have generally established the provinces have paramount authority in this area.

Over time, the mismatch between fiscal resources and fiscal capacity became increasingly problematic. If Canadians were to have similar levels of service, it would be necessary for the national government to somehow equalize the ability to pay for it. Yet attempts by the national government to implement programs directly encountered resistance from the provinces. This resulted in several legal battles. In a few cases, where there was agreement that the federal government should take the lead, adverse court decisions were handled by amending the constitution (e.g., in 1940, in response to a court decision that federal unemployment insurance was unconstitutional, the Constitution Act, 1867 was amended to give the national Parliament jurisdiction over unemployment insurance). More commonly, however, other approaches have been used. Canadian health policy has accordingly been strongly related to Fiscal federalism
Fiscal federalism
As a subfield of public economics, fiscal federalism is concerned with "understanding which functions and instruments are best centralized and which are best placed in the sphere of decentralized levels of government"...

 and questions as to how best to address Fiscal imbalance
Fiscal imbalance
- Meaning and Types :Fiscal imbalance is the term used to denote a mismatch in the revenue powers and expenditure responsibilities of a government. In the literature on fiscal federalism, two types of fiscal imbalances are measured: Vertical Fiscal Imbalance and Horizontal Fiscal Imbalance...

. In consequence, Canada does not have - and arguably cannot have - a national health care system.

The Constitution Act does give potential powers over elements of health care to the federal government through various clauses (e.g., quarantine), but the role of the federal government has been highly debated. As summarized by a Senate Committee led by Michael Kirby, the federal government has a number of roles to play, including assisting the provinces in paying for health services. Although this has not been tested in court, the federal government has assumed that it is entitled to use its spending powers to set national standards. However, the extent to which 'strings' can be (and are) attached to federal transfers has remained contentious, and most federal governments have been unwilling to antagonize the provinces.

Health insurance before the CHA


The development of Canadian health insurance http://www.civilization.ca/cmc/exhibitions/hist/medicare/medic00e.shtml has been well described by Malcolm Taylor, who participated in many of the negotiations in addition to studying it as an academic. Unlike the UK, Canada never implemented a National Health Service; health care was and largely remains privately delivered. For many decades, it was also privately financed through a variety of programs. In consequence, as Taylor wrote, most Canadians "daily faced the potentially catastrophic physical and financial consequence of unpredictable illness, accident, and disability," and providers, unwilling to deny needed care, had growing bad debts. A number of efforts to establish social insurance systems in Canada had been unable to overcome provincial opposition to federal 'incursion' into their jurisdiction. These included the 1937 Rowell-Sirois Commission
Rowell-Sirois Commission
The Rowell-Sirois Commission officially known as the Royal Commission on Dominion-Provincial Relations was a Canadian Royal Commission looking into the Canadian economy and federal-provincial relations. It was called in 1937 and reported in 1940....

 on Dominion-Provincial Relations, and the 1945 Green Book proposals of Prime Minister Mackenzie King as part of the post-World War II reconstruction. At the same time, Canada resembled other developed economies in its receptivity to a more expansive government role in improving social welfare
Welfare state
A welfare state is a "concept of government in which the state plays a key role in the protection and promotion of the economic and social well-being of its citizens. It is based on the principles of equality of opportunity, equitable distribution of wealth, and public responsibility for those...

, particularly given the widespread sacrifices during World War II and the still active memories of the Great Depression
Great Depression
The Great Depression was a severe worldwide economic depression in the decade preceding World War II. The timing of the Great Depression varied across nations, but in most countries it started in about 1929 and lasted until the late 1930s or early 1940s...

.

Accordingly, following the collapse of the conference proposals in 1946, in 1947, the social democratic premier of Saskatchewan
Saskatchewan
Saskatchewan is a prairie province in Canada, which has an area of . Saskatchewan is bordered on the west by Alberta, on the north by the Northwest Territories, on the east by Manitoba, and on the south by the U.S. states of Montana and North Dakota....

, Tommy Douglas
Tommy Douglas
Thomas Clement "Tommy" Douglas, was a Scottish-born Baptist minister who became a prominent Canadian social democratic politician...

 of the Co-operative Commonwealth Federation
Co-operative Commonwealth Federation
The Co-operative Commonwealth Federation was a Canadian political party founded in 1932 in Calgary, Alberta, by a number of socialist, farm, co-operative and labour groups, and the League for Social Reconstruction...

 (CCF), decided to go it alone, and established Canada's first publicly-funded hospital insurance plan. Other provinces - including British Columbia
British Columbia
British Columbia is the westernmost of Canada's provinces and is known for its natural beauty, as reflected in its Latin motto, Splendor sine occasu . Its name was chosen by Queen Victoria in 1858...

, Alberta
Alberta
Alberta is a province of Canada. It had an estimated population of 3.7 million in 2010 making it the most populous of Canada's three prairie provinces...

, and Ontario
Ontario
Ontario is a province of Canada, located in east-central Canada. It is Canada's most populous province and second largest in total area. It is home to the nation's most populous city, Toronto, and the nation's capital, Ottawa....

, introduced their own insurance plans, with varying degrees of coverage, and varying degrees of success. When Newfoundland
Newfoundland and Labrador
Newfoundland and Labrador is the easternmost province of Canada. Situated in the country's Atlantic region, it incorporates the island of Newfoundland and mainland Labrador with a combined area of . As of April 2011, the province's estimated population is 508,400...

 joined Canada, it brought along its system of cottage hospital
Cottage Hospital
The original concept of a cottage hospital was a small rural hospital having up to 25 beds. One advantage of such a hospital in villages was the familiarity the local physician might have with their patient that may affect their treatment...

s. These policy initiatives increased pressure on the federal government to get involved, both to assist those provinces which had introduced programs, and to deal with the perceived inequity in those provinces whose citizens did not yet have coverage for hospital care.

The federal government had also acted by using its spending power; in 1948, it introduced a series of National Health Grants to directly provide funds to the provinces/territories for such purposes as hospital construction, professional training, and public health. This increased the number of hospital beds, but did not address the issue of how their operating costs would be covered. The result was that the Progressive Conservative government of John Diefenbaker
John Diefenbaker
John George Diefenbaker, PC, CH, QC was the 13th Prime Minister of Canada, serving from June 21, 1957, to April 22, 1963...

, who also happened to represent Saskatchewan, introduced and passed (with all-party approval) the Hospital Insurance and Diagnostic Services Act of 1957. This shared the costs of covering hospital services. By the start date (July 1, 1958) five provinces—Newfoundland, Manitoba
Manitoba
Manitoba is a Canadian prairie province with an area of . The province has over 110,000 lakes and has a largely continental climate because of its flat topography. Agriculture, mostly concentrated in the fertile southern and western parts of the province, is vital to the province's economy; other...

, Saskatchewan, Alberta, and British Columbia - had programs in place which could receive the federal funds. By January 1, 1961, when Quebec
Quebec
Quebec or is a province in east-central Canada. It is the only Canadian province with a predominantly French-speaking population and the only one whose sole official language is French at the provincial level....

 finally joined, all provinces had universal coverage for hospital care.

Saskatchewan decided to take the money released by the federal contributions to pioneer again, and following lengthy consultations with the provincial medical association, introduced a plan to insure physician costs (The Saskatchewan Medical Care Insurance Plan). By this time, Douglas had moved to national politics, as leader of the federal New Democratic Party (NDP), The provincial plan precipitated a strike
Saskatchewan Doctors' Strike
The 1962 Saskatchewan Doctors' Strike was a 23-day labour action exercised by medical doctors in the Canadian province of Saskatchewan in an attempt to force the Co-operative Commonwealth Federation government of Saskatchewan to rescind its program of universal medical insurance...

 by the province's physicians (1962). It was eventually settled, but the CCF lost the 1964 election to Liberal Ross Thatcher. The plan, however, remained popular, and encouraged other provinces to examine similar programs. A policy debate ensued, with some arguing for universal coverage, and others (particularly the Canadian Medical Association
Canadian Medical Association
The Canadian Medical Association , with more than 70,000 members, is the largest association of doctors in Canada and works to represent their interests nationally. It formed in 1867, three months after Confederation...

) arguing for an emphasis on voluntary coverage, with the government assisting only those who could not afford the premiums. Three provinces - BC, Alberta, and Ontario - introduced such programs.

The federal reaction was to appoint a Royal Commission on Health Services. First announced by Prime Minister Diefenbaker in December 1960, it was activated in the following June. Its chair was Justice Emmett Hall
Emmett Matthew Hall
Emmett Matthew Hall, CC, QC was a Canadian jurist and civil libertarian and is considered one of the fathers of the Canadian system of Medicare....

, the chief justice of Saskatchewan, and a life-long friend of Mr. Diefenbaker. Three years later, following extensive hearings and deliberations, it released an influential report, which recommended that Canada establish agreements with all provinces to assist them in setting up comprehensive, universal programs for insuring medical services, on the Saskatchewan model, but also recommended adding coverage for prescription drugs, prosthetic services, home care services, as well as optical and dental services for children and those on public assistance. (None of these have yet been added to the formal national conditions, although most provinces do have some sort of coverage for these services.)

By this time, the Liberals, under Lester B. Pearson
Lester B. Pearson
Lester Bowles "Mike" Pearson, PC, OM, CC, OBE was a Canadian professor, historian, civil servant, statesman, diplomat, and politician, who won the Nobel Peace Prize in 1957 for organizing the United Nations Emergency Force to resolve the Suez Canal Crisis...

 were in power. Following intense debate, the Pearson government introduced the Medical Care Act which was passed in 1966 by a vote of 177 to two. These two Acts established a formula whereby the federal government paid approximately 50% of approved expenditures for hospital and physician services. (The actual formula was a complex one, based on a combination of average national expenditures and spending by each province. In practice, this meant that higher-spending provinces received more federal money, but that it represented a lower proportion of their expenditures, and vice versa for lower-spending provinces.) By 1972, all provinces and territories had complying plans. However, the fiscal arrangements were seen as both cumbersome and inflexible. By 1977, a new fiscal regimen was in place.

Change in fiscal arrangements: the 1977 act


In 1977, HIDS, the Medical Care Act, and federal funds for post-secondary education (also under provincial jurisdiction) were combined into a new Federal-Provincial Fiscal Arrangements and Established Programs Financing Act of 1977 (known as EPF). This legislation de-coupled the legislation governing the amount of the federal transfer from the legislation establishing the terms and conditions to be met to receive it.

Under this new arrangement, cost sharing was no more. Provinces/territories now had more flexibility, as long as the federal terms and conditions continued to be met. The federal government had more predictability. Rather than an open-ended commitment, EPF established a per capita entitlement (not adjusted for age-sex or other demographic factors) which would be indexed to inflation. This money would go into provincial general revenues. To simplify a complex formula, the EPF entitlement could be seen as consisting of two components. Part of the funds were in the form of "tax transfers" whereby "the federal government agreed with provincial and territorial governments to reduce its personal and corporate income tax rates, thus allowing them to raise their tax rates by the same amount. As a result, revenue that would have flowed to the federal government began to flow directly to provincial and territorial governments." This transfer could not be reversed by subsequent governments, meaning that the federal government had no fiscal leverage over this component of the transfer. (Indeed, there has been an ongoing controversy as to whether this component should even be considered part of the federal contribution.) The remainder of the entitlement was in the form of cash grants. Although the per capita amount was intended to be escalated to inflation, subsequently, the federal government tried to deal with its fiscal position by unilaterally first reducing and then freezing the inflation escalator. As the cash portion threatened to disappear, in 1996, the federal government combined the EPF transfers with another cost-shared program, the Canada Assistance Plan (CAP), to form the Canada Health and Social Transfer
Canada Health and Social Transfer
The Canada Health and Social Transfer was a system of block transfer payments from the Canadian government to provincial governments to pay for health care, post-secondary education and welfare, in place from the 1996-97 fiscal year until the 2004-05 fiscal year...

 (CHST). This enabled the federal government to both cut the total transfers (by approximately the amount in the CAP) while retaining a 'cash floor' on the total amount. In 2004, these transfers were split into the Canada Health Transfer (CHT) and the Canada Social Transfer. The federal Department of Finance publishes brief guides to these programs. Nonetheless, many argue that there has been no explicit federal transfer for health care since 1977, since these programs are no longer tied to specific spending.

The second component of the federal plan, specification of the terms and conditions which provincial/territorial insurance plans must meet, continued to be those established in HIDS and the Medical Care Act. (Note that there were almost no conditions attached to the CAP or post-secondary education components of the transfers.) The genesis of the CHA was recognition of the extent to which the federal ability to control provincial behaviour had been reduced. One particular problem was the absence of any provision for graduated withholding of the federal contribution. Because there was little desire to withhold the full contribution for minor violations of terms and conditions, provinces increasingly were permitting extra billing for insured services. In response to the resulting political uproar, the federal government again turned to Justice Emmett Hall
Emmett Matthew Hall
Emmett Matthew Hall, CC, QC was a Canadian jurist and civil libertarian and is considered one of the fathers of the Canadian system of Medicare....

 and asked him to report on the future of medicare. His 1979 report, 'Canada's National-Provincial Health Program for the 1980s' noted some of the areas recommended in his earlier report which had not yet been acted on, and warned that accessibility to health care was being threatened through rising user fees. The federal response was to pass the 1984 Canada Health Act which replaced both HIDS and the Medical Care Act and clarified the federal conditions.

The 1984 act


On December 12, 1983 the Canada Health Act was introduced by the Liberal Trudeau
Pierre Trudeau
Joseph Philippe Pierre Yves Elliott Trudeau, , usually known as Pierre Trudeau or Pierre Elliott Trudeau, was the 15th Prime Minister of Canada from April 20, 1968 to June 4, 1979, and again from March 3, 1980 to June 30, 1984.Trudeau began his political career campaigning for socialist ideals,...

 government, spearheaded by then Minister of Health Monique Bégin
Monique Bégin
Monique Bégin, PC, OC, FRSC is an academic and former Canadian politician.Begin was born in Rome and raised in France and Portugal before immigrating to Canada at the end of World War II...

. As she noted, the government decided not to expand coverage (e.g., to mental health and public health), but instead to incorporate much of the language from the HIDS and Medical Care Acts. The Canada Health Act was passed unanimously by Parliament in 1984, and received Royal Assent on 1 April. Following election of a Conservative government under Brian Mulroney
Brian Mulroney
Martin Brian Mulroney, was the 18th Prime Minister of Canada from September 17, 1984, to June 25, 1993 and was leader of the Progressive Conservative Party of Canada from 1983 to 1993. His tenure as Prime Minister was marked by the introduction of major economic reforms, such as the Canada-U.S...

 in September 1984, in June 1985, after consultation with the provinces, new federal Health Minister Jake Epp
Jake Epp
Arthur Jacob "Jake" Epp, PC, OC is an executive and former Canadian politician.Born into a Mennonite family in Manitoba, Jake Epp was a high school history teacher in Steinbach, Manitoba before entering politics...

 wrote a letter to his provincial counterparts that clarified and interpreted the criteria points and other parts of the new act.

Key features of the CHA


The preamble
Preamble
A preamble is an introductory and expressionary statement in a document that explains the document's purpose and underlying philosophy. When applied to the opening paragraphs of a statute, it may recite historical facts pertinent to the subject of the statute...

 of the act states that the objective of Canadian Health Care policy
Health care in Canada
Health care in Canada is delivered through a publicly-funded health care system, which is mostly free at the point of use and has most services provided by private entities. It is guided by the provisions of the Canada Health Act. The government assures the quality of care through federal standards...

 is "that continued access to quality health care without financial or other barriers will be critical to maintaining and improving the health and well-being of Canadians.The primary objective of the Act is "to protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers." (Section 3).

To do so, the act lists a set of criteria and conditions that the provinces must follow in order to receive their federal transfer payments: Public administration, Comprehensiveness, Universality, Portability, and Accessibility. There is also a requirement that the provinces ensure recognition of the federal payments and provide information to the federal government. An overview published by the federal government clarifies the conditions as follows:

Public administration


The health insurance plans must be "administered and operated on a non-profit basis by a public authority, responsible to the provincial/territorial governments and subject to audits of their accounts and financial transactions." (Section 8). This condition is the most frequently misunderstood; it does not deal with delivery, but with insurance. However, it does reduce the scope for private insurers to cover insured services (although they are still able to cover non-insured services, and/or non-insured persons).

Comprehensiveness


The health care insurance plans must cover "all insured health services provided by hospitals, medical practitioners or dentists" (Section 9). The Act lists, in the Definitions (Section 2), what is meant by insured services - in general, this retains the restriction to hospital and physician services arising from the earlier legislation. The provinces are allowed, but not required, to insure additional services. Note that the CHA refers to "surgical dental services" but only if these must be provided within a hospital. In practice, this almost never occurs, and the annual health expenditure data published by the Canadian Institute for Health Information (CIHI) confirm that Canadian dental services are almost entirely financed privately. Lobbying by other providers, including nurses, led the act to speak of 'practitioners' rather than physicians; physician services had to be covered, but provinces were allowed, but not required, to define other health professions as qualifying under the Act. To date, this provision has been used only occasionally; for example, some provinces have added Midwifery
Midwifery
Midwifery is a health care profession in which providers offer care to childbearing women during pregnancy, labour and birth, and during the postpartum period. They also help care for the newborn and assist the mother with breastfeeding....

, which means that their services are also fully publicly paid for.

Universality


All insured persons must be covered for insured health services "provided for by the plan on uniform terms and conditions" (Section 10). This definition of insured persons excludes those who may be covered by other federal or provincial legislation, such as serving members of the Canadian Forces or Royal Canadian Mounted Police, inmates of federal penitentiaries, and persons covered by provincial workers' compensation. Some categories of resident, such as landed immigrants and Canadians returning to live in Canada from other countries, may be subject to a waiting period by a province or territory, not to exceed three months, before they are classified as insured persons; this waiting period arises from the portability provisions.

Portability


Because plans are organized on a provincial basis, provisions are required for covering individuals who are in another province. The conditions attempt to separate temporary from more permanent absences by using three months as the maximum cut-off. As the above-mentioned summary clarifies, "Residents moving from one province or territory to another must continue to be covered for insured health care services by the "home" province during any minimum waiting period, not to exceed three months, imposed by the new province of residence. After the waiting period, the new province or territory of residence assumes health care coverage." The portability provisions are subject to inter-provincial agreements; there is variation in what is considered emergency (since the portability requirement does not extend to elective services), in how out-of-country care is covered (since there is no 'receiving' province), in how longer absences are dealt with (e.g., students studying in another province), whether the care will be paid for at home province or host province rates, and so on.

Accessibility


Finally, the insurance plan must provide for "reasonable access" to insured services by insured persons, "on uniform terms and conditions, unprecluded, unimpeded, either directly or indirectly, by charges (user charges or extra-billing) or other means (age, health status or financial circumstances);" (Section 12.a). This section also provides for "reasonable compensation for...services rendered by medical practitioners or dentists" and payments to hospitals that cover the cost of the health services provided. Note that neither reasonable access nor reasonable compensation are defined by the CHA, although there is a presupposition that certain processes (e.g., negotiations between the provincial governments and organizations representing the providers) satisfy the condition. The CHA allows for dollar-for-dollar withholding of contributions from any provinces allowing user charges or extra-billing to insured persons for insured services. As noted below, this provision was effective in 'solving' the extra-billing issue.

Additional conditions


Section 13 lists two additional conditions which must be met by the province in order to receive its full share of the federal transfers. The first condition is that the federal Minister of Health is entitled to specific information relating to a province's insured & extended health care services. This information is used in drafting annual reports, presented to parliament, on how the province administered its health care services over the previous year. Again, there was - and continues to be - controversy as to how detailed this information should be.

The second condition is that the province must "give recognition" to the federal government "in any public documents, or in any advertising or promotional material, relating to insured health services and extended health care services in the province" (Section 13.b). Again, this is controversial.

Violations and penalties


In order to document compliance with the act the federal Minister of Health
Minister of Health (Canada)
The Minister of Health is the Minister of the Crown in the Canadian Cabinet who is responsible for overseeing the federal government's health department and the enforcing the Public Health Agency of Canada, Canada Health Act, the law governing Medicare...

 annually reports to the Canadian Parliament on how the act has been administered by each province over the course of the previous fiscal year.

For non-compliance with the any of the five criteria listed above, the federal government may withhold all or a part of the transfer payment with “regard to the gravity of the default” (Section 15). Thus far all non-compliance issues have been settled through discussion or negotiation. Some argue that the federal government has not actively attempted to enforce these conditions, with particular issues around handling of portability (e.g., the reduction of coverage for residents while traveling abroad) and comprehensiveness (e.g., de-insuring of some medical procedures).

In accordance with section 20, if a province were to violate the prohibition on extra-billing or user charges, the corresponding amount of that collected would be deducted from the transfer payment. Details about these amounts are available from the Canadian government websites.

One aspect of the CHA was provision for reimbursement of funds withheld for extra-billing and user charges if these were eliminated within three years. Although often contentious (e.g., Ontario's physicians went on strike), all provinces complied with the provisions of the Act. Although the amounts withheld were relatively modest - financial penalties totaling $246,732,000 were withheld from the provinces in the first two years—provinces found it difficult to resist the pressure. (They found that many interest groups seeking additional funds would argue that it could be afforded if the province/territory eliminated their extra billing/user fees. Faced with multiple claims on the same pot, most provinces decided that the easiest path was to eliminate these charges.)

In 1993, British Columbia allowed approximately 40 medical practitioners to use extra-billing in their practices. In response, the federal government reduced B.C.’s EPF payments by a total of $2,025,000 over the course of four years.

In 1996, Alberta had their EPF payment reduced by a total of $3,585,000 over the course of a few years due to the use of private clinics that charged user fees. Newfoundland suffered the loss of $323,000 until 1998 and Manitoba lost a total of $2,056,000 until 1999 from user fees being charged at private clinics. Nova Scotia has also forgone EPF payment for their use of user fees in private clinics.

As required by section 23 of the Canada Health Act, the federal government publishes a yearly report describing the extent to which each province and territory has complied with the Act. The most recent is for 2008-2009. http://www.hc-sc.gc.ca/hcs-sss/pubs/cha-lcs/index-eng.php

See also

  • Canada Health Transfer
    Canada Health Transfer
    The Canada Health Transfer is the Canadian government's transfer payment program in support of the health systems of the provinces and territories of Canada...

  • Canada Health and Social Transfer
    Canada Health and Social Transfer
    The Canada Health and Social Transfer was a system of block transfer payments from the Canadian government to provincial governments to pay for health care, post-secondary education and welfare, in place from the 1996-97 fiscal year until the 2004-05 fiscal year...

  • Indian Health Transfer Policy (Canada)
    Indian Health Transfer Policy (Canada)
    The Indian Health Transfer Policy of Canada, provided a framework for the assumption of control of health services by Aboriginal Canadians and set forth a developmental approach to transfer centred on the concept of self-determination in health. Through this process, the decision to enter into...

  • Health care in Canada
    Health care in Canada
    Health care in Canada is delivered through a publicly-funded health care system, which is mostly free at the point of use and has most services provided by private entities. It is guided by the provisions of the Canada Health Act. The government assures the quality of care through federal standards...

  • Canada's Health Care providers, 2007
    Canada's Health Care providers, 2007
    Canada’s Health Care Providers, 2007 is a reference on the country’s health care workforce. It looks at how the health provider landscape has evolved, examines the complexities of health human resources planning and management in the current environment and provides the latest information on supply...

  • Canadian Institute for Health Information
  • Canadian and American health care systems compared
    Canadian and American health care systems compared
    Comparison of the health care systems in Canada and the United States are often made by government, public health and public policy analysts. The two countries had similar health care systems before Canada reformed its system in the 1960s and 1970s. The United States spends much more money on...

  • Royal Commission on the Future of Health Care in Canada
  • Medicare (Canada)
    Medicare (Canada)
    Medicare 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...

  • Medical Services Plan
    Medical Services Plan
    The Medical Services Plan of British Columbia is the government-administered single-payer health insurance scheme in the Canadian province of British Columbia, operating under the auspices of the country's national Medicare program...

     of British Columbia
  • Ontario Health Insurance Plan
    Ontario Health Insurance Plan
    The Ontario Health Insurance Plan is the government-run health insurance plan for the Canadian province of Ontario...