Comparisons of Healthcare Systems Between Canada and the United States

Comparisons of the Healthcare Systems Between Canada and the United States

Healthcare is a global issue and healthcare reform has been a subject of great concern and discussion worldwide and for Americans and Canadians alike. Today the discussion about healthcare reform  in the Unites States (U.S.) the Affordable Care Act (ACA) nick named Obamacare is under political debate regarding how to change the healthcare system established in 2010 primarily based on pay for service. On the other hand Canada, a comparable neighbor to the U.S.A in terms of cultural similarities but with different societal views on how healthcare should be managed has universal healthcare system where the legal residents are covered by a healthcare system based on need. As both countries move to cut the rising cost healthcare, retaining and improving the quality of care provided is a key concern. A comparison of healthcare systems in the U.S. and Canada and benefits and opportunities of each system be will reviewed.

Countries for Comparison

The United States

The U.S. is the 3rd largest country in the world with a population of approximately 329,256,465 (CIA Fact Sheet, July 2018).  According to the CIA Fact Sheet (2018) the U.S. population is spread throughout the country with the largest concentration located in large urban areas. The U.S. has 50 states and one district and territories. There are various ethnicity in the U.S.; White 72.4%, Black 12.6%, Asian 4.8%, Amerindian and Alaska native 0.9%, native Hawaiian and other Pacific islander 0.2%, other 6.2%, two or more races 2.9%. Although there are many religions in the U.S., the main religions are Protestants at 46.5% of the population, Roman Catholics at 20.8%, Jewish at 1.9%, and Mormons at 1.6%. The other religions in smaller in numbers are listed as Christians, Muslims, Jehovah's Witnesses, Buddhists, Hindus, and other unaffiliated. The United States Census Bureau (2018), reports that the percentage of people under the poverty level in the U.S is at 12.3%. Within the American population the highest rates of poverty is seen in Hispanics and African Americans with the lowest number of those in poverty listed as White Americans.  The rate of those in poverty reflects the numbers of those who are not able to afford to pay for healthcare and thus unable to access healthcare (The Henry J. Kaiser Foundation, 2018).

Structure of the U.S. Healthcare System　

In the U.S. health insurance is provided for purchase, through employment or by the government with special programs like Medicare and Medicaid available for a select group of people who meet criteria for government funded health insurance.  For those who receive their health insurance through employment, employees pay a co-pay and the employer pays a portion of the cost through an insurance company. Insurance companies offer various packages for a negotiated fee that employers purchase and offer to their employees.

The U.S. healthcare system is regulated at both the state and federal levels. At the Federal level the Centers for Medicare and Medicaid Services (CMS) administers a healthcare program for adults 65 and older and for some people with disabilities.　 Medicare is the largest provider of health insurance for which 13% of the U.S. population is covered (A layman's guide to the U.S. health care system; Health care financing review, 1992).　　

At the state level of government, states have the option of participating in a federally subsidized expansion of Medicaid eligibility. Medicaid and the Children’s Health Insurance Program (CHIP) offer health insurance for low-income individuals that meet criteria. The Commonwealth Fund (2018) reports that the Affordable Care Act (ACA) of 2014 established a "shared responsibility between the government, employers, and individuals for ensuring access to affordable good-quality health insurance." Despite the introduction of the ACA that afforded the expansion of subsidized insurance coverage for low and middle-class residents, insurance coverage remains inconsistencies among the various income levels in the U.S. population (The Commonwealth Fund, 2018).

Canada

Canada is the second largest country on earth is bordered by the United States in the south and in the northwest and by 3 oceans; the Pacific Ocean in the west, the Atlantic Ocean in the east, the Arctic Ocean.　 Canada has 10 provinces and three territories with many Canadians living in the warmer climate in southern Ontario and Quebec, southwest British Columbia, and Alberta along the U.S. border. According to the Central Intelligence Agency Fact Sheet (2018) the population of Canada is 35,623,680 and is comprised of a mix of immigrants. Most Canadians were born in Canada and came from the original founding peoples; the Aboriginal peoples (First Nations, Inuit, Métis), French Canadians (descendants of Acadians, and Quebecers), and English Canadians (descendants of English, Welsh, Scottish, and Irish). Today, approximately 20% of Canadians were born outside of Canada and have come from countries from around the world (About Canada.ca, 2017). The main religions in Canada are; Catholic at 39%; Protestant at 20%; and other religions (Orthodox, other Christian, Muslim 3.2%, Hindu, Sikh, Buddhist, Jewish, other and none) making-up the other minor religions (CIA Fact Sheet, 2018)". The percentage of population below the poverty level is about 9.4% of the population and is the “Low-Income Cut-Off, a calculation that results in higher figures than found in many comparable economies since Canada does not have an official poverty line (CIA, 2018)."

Canada is a constitutional monarchy meaning that the Queen or King of England is the head of state, and the Prime Minister is the head of government. The government of Canada is comprised of three levels of government; federal, provincial, and municipal. The federal government supports "health research, health promotion and protection, disease monitoring and prevention and also provides tax support for health-related cost and tax credits for: disability, medical expenses, caregivers and disabled dependents, tax rebates to public institutions for health services, deductions for private health, and insurance premiums for the self-employed (About Canada.ca, 2017)."

Health Insurance in Canada is managed through provinces and territories who receive funding from federal cash contributions under the Canada Health Transfer Canada Act (CHT) and they also receive additional federal funding and support through other fiscal transfers. Provincial and territorial health care insurance plans meet standards described in the Canada Health Act (CHA) that establishes criteria and conditions related to insured health and extended health care services. "The CHA ensures that all eligible residents of Canada have reasonable access to insured health services on a prepaid basis, without direct charges at the point of service (Canada.ca, 2016)." According to the standards set by the CHT healthcare insurance must be publicly administered, be comprehensive, universal, have portability, and accessibility (Canada.ca, 2016). "

Under the administrative criteria the provincial and territorial plans must be administered and operated on a non-profit basis by a public authority and that all medically necessary services (medically necessary services are not defined in the Canada Health Act) provided are covered. The provincial and territorial health care insurance service organization consults with their respective physician colleges or groups and together, they decide which services are medically necessary for health care insurance purposes. A service considered medically necessary is fully covered by the public health care insurance plan. Plans also cover all residents for travel within Canada with limited coverage provided for travel outside the country. Once a resident of any province moves to another province their coverage continues for 3 months until coverage is assumed under the plan of the new province or territory (Canada.ca, 2016).

Vulnerable Groups

Some population groups such as First Nations people living on reserves, Inuit, serving members of the Canadian Forces, eligible veterans, inmates in federal penitentiaries, and some groups of refugee claimants qualify for care automatically. Supplemental coverage is provided to certain groups of people, such as seniors, children, and social assistance recipients that helps pay for health care services that are not generally covered under the publicly funded health care system. These services include vision care, dental care, prescription drugs, and ambulance services, independent living (home care). “Those who do not qualify for supplementary benefits under government plans pay for these services through out-of-pocket payments and private health insurance plans (Canada.ca, 2016). “

Comparison of Systems and their Challenges

U.S. Healthcare Challenges

Despite the introduction of the Patient Protection and Affordable Care Act (ACA) of 2010 that was designed to extend health  insurance coverage to Americans through private health insurance for the general population, and Medicaid for the impoverished (CIA Fact Sheet, 2018)" there remains wide spread disparities in the lack of the uninsured and under insured of minority and vulnerable populations in their inability to access good quality healthcare. Federal programs such as Federally Qualified Health Centers (FQHCs), Medicaid, and the Children’s Health Insurance Program (CHIP) provide public health insurance coverage for vulnerable populations. The Affordable Care Act (ACA) was introduced to close the gap and reduce those gaps in disparities by providing subsidies to allow those with low incomes to purchase health insurance (The Commonwealth Fund, 2018).

Access to Care

According to the Commonwealth Fund (2018) health disparities in the U.S. is widespread among the vulnerable populations such as the chronically ill or disabled; those with low income or the homeless, those in rural areas; the LGBTQ community; or the very old or the very young who may lack preventative care. The negative impact of the inability to access care may be due to the fear of being discriminated against; being disabled and not able to access care due to challenges faced in obtaining care; the lack of access to coordinated care; and poor patient engagement. According to the CDC (2018), 90% of the nation's $3.3 trillion in annual healthcare expenditures are for people with chronic and mental health conditions. Evolving the health system to address the needs American residents, especially those who are considered vulnerable through preventative care and consistent accessible and affordable care is essential to keeping patient’s healthy, healthcare reform, and cost saving for the industry.

Canadian Healthcare Challenges

Challenges to the Canadian healthcare system are the uninsured, under insured, the increasing elderly population, and the impact of chronic illness on the system further some negative impacts to the system are the under use of prevention and screening, wait time, and access to specialists. In a move to improve the quality of care and services and to provide cost effective timely care the healthcare system is in need of reform. Although Canada provides health insurance for all their residents services such as prescription drugs, rehabilitative services, home care, and dental care are not covered by public insurance.  In addition, the increasing elderly population and the chronic illnesses associated with aging have added challenges in meeting the needs of vulnerable residents of the population.  Those that are chronically ill will contribute to rising costs as a result for the increase in services they will use, which the system was not designed for.  Per the Canadian Foundation for Health Improvement (2015) "Canadians are increasingly in need of community-based, outpatient and ambulatory care, however the healthcare system is geared to hospital and physician care indicating there will be a need to reform the system to home care and outpatient ambulatory care to contain the expense associated with hospital care and to also increase the involvement of patients in order to provide patient centered care. The physician- and hospital-centric model of healthcare in Canada was not designed to prevent disease or help patients manage chronic conditions.”

Another challenge to the Canadian healthcare system is increased wait times for specialty appointments and access to care. The Canadian government has worked to reduce wait times in five areas: cancer care, cardiac care, diagnostic imaging (DI), joint (hip and knee) replacement, and sight restoration (cataract surgery) (CIHI, 2017). The healthcare system  bases appointments on the urgency of need for service and has set benchmarks for certain procedures.  The Canadian government has reported bench marked  results that have reduced the wait times  and in addition, the gap in coverage for dental care, prescriptions, home care, and rehabilitative services. Access to care and the large number of those that are uninsured and under insured are reflected in the inability to access care due to inability to pay despite coverage (CIHI, 2017).

Services

Both the U.S. and Canada face challenges on the uninsured and access to care and for Canadians issues in access to care is reflected in the increased wait times for cancer care, cardiac care, diagnostic imaging, joint replacements and sight restoration. Preventative care is instrumental in preventing and delaying the onset of disease and keeps diseases from becoming worse or debilitating with a positive impact of reducing skyrocketing healthcare costs through preventive services such as cancer screenings, preventive visits, and vaccinations. In reality, "Nationally, Americans use preventive services at about half the recommended rate. Cost-sharing such as deductibles, co-insurance, or co-payments also reduce the likelihood that preventive services will be used. The introduction of ACA required that certain private health plans cover preventive services without charging a deductible. The services included well-woman visits, support for breastfeeding equipment, domestic violence screening and counseling (CDC, 2018)."

Access to healthcare is a challenge to the U.S. healthcare system even with the introduction of the ACA.  Per the National Health Statistics Reports (2016) high uses of emergency room visits with those on Medicaid may be related to more serious medical needs since this population is in poorer health than people with private Insurance even when accounting for age and income, factors that are directly related to poor preventative care.

The Healthy People Midcourse Review (2016) writes that there are significant disparities in access to care by sex, age, race, ethnicity, education, and family income. These disparities exist with all levels of access to care, including health and dental insurance; having an ongoing source of care; and access to primary care. The National  Health Statistic Report (2016) reports “that disparities include: race, ethnicity, socioeconomic status, age, sex, disability status, sexual orientation, gender identity, and residential location which determine accessibility and that this will require the healthcare system to provide patient centered care at the home instead of the hospital; more culturally sensitive staff; more healthcare workers to treat patients that are in rural areas and the use of technologies such as tele-medicine as a vehicle to deliver healthcare. Addressing the lack of access of the vulnerable also must include addressing the timeliness of access to behavioral health and mental health as well as rehabilitative care to successfully provide good quality care."

Expenses

Healthcare expenditures continue to rise worldwide related to an aging population and increasing costs of medications and medical equipment.  Healthcare spending in the U.S. was $3.3 trillion or $10,348 per capita and healthcare was 17.9%  of the U.S. Gross Domestic Product (CMS.gov, 2018). In comparison, the Canadian Institute for Health Information (2016) estimates healthcare spending was $228.1 billion in 2016 and $6,299 per ca pita Canadian 11.1 % of Canada's economy, was spent on healthcare in 2016.

Outcomes

The 2016 Commonwealth Fund International Survey of 11 nations finds that adults in the United States are far more likely than those in other countries to go without needed care because of costs and to struggle to afford basic necessities such as housing and healthy food. U.S. adults are also more likely to report having poor health and emotional distress (IHCS profiles, #). The following are survey results from IHCS Profiles comparing what users of both healthcare systems reported: 　

• Regular primary care physician (PCP) does not spend time to explain things so you can understand: CA 26% U.S. 23%
• Cost-related access barrier in the past year among low income adults: U.S. 43% CA 30%
• Problem with Care coordination: CA 33% U.S. 36%
• Regular physician has not discussed diet and exercise: CA 58 U.S. 49% Outcomes for: Life expectancy, infant mortality, chronic disease rates, obesity rates, childhood vaccination rates, daily smokers According to ****the prevalence of Obesity (BMI>30), 2014 is 38% in the U.S. and 26% in Canada in 2014.

Indicators	Canada	United States
Maternity death rates per 100,000 live births	7 (CIA Fact Sheet, 2018)	14 (CIA Fact Sheet, 2018)
Childhood vaccination rates	Diphtheria, Pertussis, Tetanus 89%(OCED, 2018)	DPT 91% (OCED, 2018)
Daily smokers	12.5 % of the population age 15+ (OCED, 2018)	11.8% of population age 15+ (OCED, 2018)
Prevalence of Obesity	64.1% of population age 15+ (OCED, 2017)	71% of population age 15+ (OCED, 2017)
Infant Mortality Rates	5 per 1000 deaths (The World Bank, 2017)	6 per 1000 deaths (2017) (The World Bank, 2017
Life Expectancy	82.30 (World Bank, 2018)	6 per 1000 deaths (2017) (The World Bank, 2017)

Impact on Patients

There are opportunities for improvement for both Canada and the U.S.A to provide quality care and to reduce the cost of health services, but the impact on the quality and timeliness of services may be a factor in making improvements and may incur a negative impact for the receivers of care. For instance, Canadians may experience long waiting times as long as 13.3 weeks for needed surgeries such as hip replacements, cataract surgery, or cardiovascular surgery according to Ridic, Gleason, and Ridic, (2012). 

Impact on patients and how it reflects the ANA Nursing Code of Ethics

The American Nursing Association (ANA) Nursing Code of ethics speaks to nursing involvement in biomedical ethics on ethical issues "including health-related problems that impact policy or society as a whole; dilemmas that arise within organizations; and those that affect patient populations or individual patients. On a policy or societal level, broad questions are asked that includes discussion about whether access to healthcare is a right or a privilege; Nurse Practitioners may participate in preparation of position statements and guidance documents from federal and national organizations (Epstein & Turner, 2015)."

The Canadian public health system provides basic healthcare of all their residents, but they also have populations such as the indigent population who experience difficulty accessing healthcare and as a result experience worsening chronic illnesses associated with poor quality of life and poor environments. Focusing on social determinants of health is a vehicle for addressing the lack of services such as dental care and the financial burdens associated with prescription coverage that they have started to explore.   One of the missions that the American Nurses Association speaks to is whether access to healthcare is a right.  In Canada Canadians see access to healthcare as a right and as such all Canadian residents have healthcare.  

The U.S. healthcare system negatively impacts patients who lack access to care particularly in rural areas and for minority and vulnerable populations; the lack of medical staff to address the needs of those in rural or hard to serve areas; the inability to see a provider in the community. Chronic illness resulting from lack of access and failure to address the social determinants of health that leads to illnesses such as addiction behavioral health and maternal health. The ANA speaks to address these issues by encouraging nurse to become involved and active of social and political issues that address health related issues of society (Epstein & Turner, 2015). Fortunately, the ANA seeks to support policies that provide access to healthcare for millions who were not able to afford health service in the past.

Opportunities

What could the other country learn/adopt from the U.S.?

From an economic standpoint, the U.S. system has some distinct advantages over the Canadian system: more resources are available, waiting lists are shorter, and there is a larger private market that provides consumers with healthcare.  In addition healthcare dollars are not based on monies from taxes that are passed unto the healthcare consumer. An American patient willing to pay up-front can receive the diagnostic imaging necessary at any given time whereas his or her Canadian counterpart may have to wait for appointment.

Lee and Noble (2002) write that "The Canadian system has been demonstrated to be more efficient, cost-effective and accessible than market-driven systems.  However, health care costs continue to rise, waiting lists are lengthy, health care workers are appealing for better remuneration, and public expectations have risen. Clearly, changes are needed if Canada is to keep its commitment to quality and equity. The world sees Canada’s health care as one that supports the principles of accountability, cost-effectiveness and one in which equity of access, universality and the ethical principles of distributive justice are maintained.  With increased pressures on the system, will it be feasible to maintain health care standards that are extolled across the world?”  Some recommendations are for the Canadian health system to set-up a system like the U.S. where fees are paid for service much to the outrage of a majority of Canadians.   Another suggestion is to establish medical savings accounts or a health benefits tax and see privatization as the only way to improve the system.

What could the U.S. learn/adopt from Canada?

Providing universal healthcare in the U.S. can prevent needless chronic illnesses and prevent patients who may not seek care because of a financial burden from becoming chronically ill or even die. The U.S. has a lot to learn from Canada on how to provide healthcare to its residents so that they receive consistent healthcare and avoid gaps in care that cause people to be under insured or uninsured. In Canada health care is provided regardless of the ability to pay and as such is based on need and not income.   Both the U.S.A and Canada share similarities such as language and culture, the impact on the recipients of healthcare insurances is most seen in the numbers of those insured and uninsured and in the impact of cost on access to services provided.  "Achieving Better Care requires coordinating services across a complex health care system that requires improving care requires facilities and providers to work together to expand access, enhance quality, and reduce disparities (Agency for Healthcare Research and Quality, 2018)."

References

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