A Women's Guide to Health Care Debates

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Pat Armstrong

We are being flooded with official reports and media coverage on health care, all offered as a way to the future of health care in Canada. A lot of numbers and terms are used in these discussions of health care reform. They can be confusing for those not heavily involved in health policy or economics. This guide is intended to help women sort through some of the numbers and terms, so they too can be part of an informed discussion on planning for care.

Why a woman’s guide?
Women make up over 80% of those who work for pay in the health care system.

Women also provide close to that much of the unpaid personal care provided at home and increasingly in institutions as well.

Women are the majority of those who receive care. According to the Ontario Women’s Health Council’s Submission to The Commission on the Future of Health Care in Canada (the ‘Romanow Commission’) "even factoring out childbirth, women are admitted to hospital more often, have longer lengths of stay when admitted, and are prescribed more drugs." This is because they are the ones who have the babies and because they tend to live longer than men.

Women are more likely than men to take others for care, and thus have more contact with the system than do men.

The kind of care women provide, where they provide the care and the kinds of health issues they face are often different from those of men. Moreover, there are significant differences among women in terms of the care they seek, require and receive.

Yet, despite this, and even with a woman as Federal Minister of Health, women are still under-represented as decision makers in this important debate.

Women, then, have a particular interest in health care.

How much do we spend on care?
There is a great deal of talk about how health care costs are out of control and it is often difficult to sort through the numbers, in part because there are various ways of calculating how much is spent on health care.

First, there are numbers on the percentage of Gross Domestic Product or GDP spent on health care. GDP simply means the total of all that is spent on goods and services in Canada. This way of presenting the numbers helps us see how the amount we spend on care is related to the amount we spend on other things. So if there is a lot of spending going on in other areas and we do not increase the amount we spend on care, then the percentage will go down. Of course, the reverse is also the case. In a recession, the proportion spent on health care will go up even if the actual amount we spend remains the same.

The number we hear most often is that we are spending just over 9% of GDP on health care. This is the same percentage we were spending in 1995 and just a tiny bit higher than in 1990.[1] By contrast, the United States spent almost 13% of their GDP on health care and that keeps going up.

However, these figures include both public and private spending; that is, they include everything we count as health care expenses. Public spending is what comes from government funds raised through taxes while private spending refers to both the money we pay directly out of our pockets and the money we pay indirectly though our insurance companies.

So that 9% of GDP is not what the government spends. What the government spends is considerably less. In 1998, our tax dollars accounted for 6.6% of GDP and this is less than they did at the beginning of the 1990s. This compares to the 6.1% of GDP the U.S. government spent. Yet for that money we covered everyone and the U.S. covered only the old, the very poor and disabled, and the military for some of their expenses.[2]

Second, there are the numbers based on per capita expenditures, or the amount spent per person. Of course, per capita expenditures are not the actual amount we spend on each individual but rather the total expenditure divided by the total number of people in the country. Per capita numbers allow us to look at expenses in a different way, one not linked to overall changes in the economy.

Here, too, the figures are usually given for all expenditures, including both what we pay privately and what comes from government funds. In 1999, Canadians spent just under $2,500 per person while Americans spent more like $4,400.[3]

But only 71% of that per person expenditure in Canada was government money. And during the 1990s, the amount the government spent per person actually went down.[4]

What then do these numbers tell us about health care spending? They tell us that during the last half of the 1990s, governments spent less on care—both on a per person basis and as a percentage of GDP. However, government spending has increased somewhat in the last couple of years. This is in line with other countries and in keeping with increases in overall spending. But this increase has not been enough to replace previous cuts.

What these numbers do not tell us is the cost to women of providing unpaid care. There is no calculation of earnings lost when women drop out of the labour force or take part-time work in order to provide care at home. There is no calculation of how much that unpaid labour is worth. There is no calculation of what this costs women in terms of promotion, and pensions in the future. These ‘lost opportunity costs’ are not calculated when the impact of transferring care back into the home is calculated. And they only tell us about money, not about the impact on the health and well being of women who have to make these choices.

What costs are rising?
The short answer to this question is drugs. In 1975, drugs accounted for just over 8% of health expenditures and 15% in 1999, and these increases do not include what hospitals spend on drugs.[5] We now spend more on drugs prescribed and paid for outside of hospitals than we spend on doctors. Hospitals’ share of spending has gone down significantly. Now hospitals account for less than 33% of all health spending, just over twice as much as drugs, and way down from 45% in 1975.

What does the Canada Health Act say?
We increasingly hear suggestions that the Canada Health Act needs to be changed. To assess these suggestions, it is necessary to know what the Canada Health Act says and does.

The Canada Health Act is a very short piece of federal government legislation that sets out the five principles provinces must follow in health care. Although provinces have responsibility for health care, the federal government has considerable power to raise money through taxes. The federal government used this power to introduce and enforce the Act. Initially, the federal government said to the provinces that it would pay half of what the provinces spend on doctors and hospitals if the provinces follow the principles of the Canada Health Act.

These five principles are:

1. Universality. Everyone must be covered, under uniform terms and conditions. This means that you cannot have what is often called a two-tier system that provides different kinds of services for those who pay more or provide faster service for those who pay. Women are less likely than men to have the means, either through insurance or through direct payment, to access extras or even necessary care that costs money, so universality is particularly important for them.
2. Accessibility. Not only must everyone be covered under uniform terms and conditions but services must also be provided in a way that "does not impede or preclude, either directly or indirectly, whether by charges made to insured persons or otherwise, reasonable access to those services." The Act also provides for "reasonable compensation" for medical practitioners and dentists. Extra charges, or what are often called user fees, are thus banned. Like universality, this principle is critical for women because more women than men are poor, more women are sick and fewer women have the financial means to pay for care. Moreover, universality and accessibility help reduce differences among women by reducing the reliance on personal financial resources.
3. Comprehensiveness. The provinces must pay for all medically necessary services provided in hospitals and by doctors. The Act also refers to “other health care practitioners” and specifies that all tests, drugs and accommodation needs in the hospital must be covered. The Act does not define ‘medically necessary’. Who defines medically necessary and how it is defined is therefore very important. Women are less likely than men to be in a position to make these decisions, although the increasing number of women doctors is shifting some of the balance.
4. Portability. This mainly refers to the capacity to take your coverage with you from province to province. However, because the public system pays for services rather than for individuals, Canadians have the right to move from service to service and from job to job without restrictions or penalties. This means women have some choices about care, and can seek services that respond to their particular needs. This contrasts sharply with some other countries, where coverage is linked not only to employment but also to a particular job. Other systems reduce choice of practitioner or have strict controls about whom patients can see.
5. Public Administration. Provinces must have a non-profit agency to administer the public health care plan. In practice, and by law in some provinces, hospitals are also non-profit.

Provinces have some choices about how care is delivered as long as they follow these five principles. Because the Act most clearly applies to hospitals and doctors, there is even greater variety among provinces once care is provided by someone other than a doctor or in someplace other than a hospital. This means provinces and territories have considerable flexibility in how they organize care and room for innovation. It also means, however, as we are seeing in current debates, that there are different interpretations of the Act. It should be noted that there is nothing about affordability in the Act, even though some of the public discussion suggests this is the case.

Which government pays for what?
The federal and provincial governments have been blaming each other for problems in care. Much of the debate is about money.

The federal government rather quickly moved away from paying for half of all doctor and hospital costs. Instead, a formula based on past per capita costs and on the need to provide extra support to some provinces was developed. Some of the money was paid in the form of tax points. This basically means the federal government allowed provinces to collect some of the taxes to pay for care. As a result, the federal contribution was harder to calculate and the federal government had less money to use as a means of enforcing the five principles. The transfers were gradually reduced. Then several years ago, the federal government put all the money for health, education and welfare into one package called the Canadian Health and Social Transfer and significantly reduced the money available. It became even harder to see how much the federal government gave to care and harder to withhold funds as a means of enforcing the principles. Under the 1999 Social Union Agreement with the provinces, the federal government gave a large amount of additional money on the condition that the provinces promise to use it for care.

With all these changes, it should not be surprising that provinces/territories and the federal government calculate the amount of the federal contribution differently. What cannot be questioned is that the amount has changed, is paid differently and does not guarantee regular funding from the federal government.

What does privatization mean?
Privatization is used to refer to a number of different things in health care in Canada. To understand what is being discussed, it is first necessary to understand what we mean by public care in Canada.

When the federal government introduced the public funding of care, the strategy was to pay for services out of government funds. Care was to be delivered on the basis of need, not ability to pay. The hospitals were almost all nonprofit organizations run either by local governments or independent, non-profit religious organizations or charities. Today neither the provincial nor the federal government owns many hospitals. Few doctors are directly employed by government. Rather they function as private businesses—billing the government on a fee for services basis. Medicare, then, was really about paying others to deliver services, although virtually all those who are paid are either non-profit and charitable organizations or self-employed independent professionals. In other words, we already have many private organizations and individuals delivering care. We already have what some call a purchaser-provider split because the government pays but does not directly provide.

One form of privatization being suggested these days is the privatization of care delivery. Given that we already have private delivery by non-profit organizations or independent professionals, what is meant by privatization of delivery is delivery by for-profit organizations. This would be a fundamental change in the way care is delivered not because private organizations would do it but rather because they would need to make a profit when they do deliver care.

It is often argued that for-profit companies are more efficient and provide better care because they have to compete effectively in order to keep their business. However, there are only a limited number of ways to make a profit and thus stay in business. One is to charge more; another is to cut the labour costs by paying people less, by hiring fewer people or by making them work harder; and a third is by reducing quality. There is very little evidence to support the claim that for-profit companies can provide the same quality of care at the same price as not-for-profit companies, and some evidence that for-profit companies either provide poorer care or have greater costs. When the focus is on cutting labour costs, it is women who feel the impact first because they are four out of five of the people employed to provide care. When the focus is on cutting quality—a process that usually means changing the way providers work—women also suffer because they make up the majority of those receiving care.

Another form of privatization that is increasingly offered as a solution to cost increases relates to payment. User fees that would make individuals pay for services is one kind of payment privatization. The idea is that fees would both discourage people from misusing the system and raise money for care. However, all the evidence suggests it does not add much money and only discourages the poor and the sick from seeking care. Another way of privatizing costs is ‘delisting’, which basically means particular kinds of care are no longer covered. Some forms of care have never been covered under the public system and some have always involved fees, although the shift in costs to individuals or their insurance companies is increasingly obvious. In 1990, the public system paid for three-quarters of the costs of care; by 1999, the public share was down to 71%.[6] Over half of this money comes directly out of individuals’ pockets.

The two biggest personal expenditure items are dental care and prescription drugs, although insurance companies still pay more than half these costs. Leaving a hospital usually means leaving the public provision of drugs, although some provinces have pharmacare plans that cover some drugs or provide a ceiling at which costs will be covered. Such plans can not only help individuals get the drugs they need; they may also help control costs overall by using the regulation and purchasing power of the government to reduce prices. Most of this insurance coverage comes from workplace plans. A significant number of Canadians have no coverage for these costs, however. Women are less likely than men to have such plans.[7] Where individuals carry the biggest load is in the cost of care in institutions such as nursing homes. Women are the majority in these homes and thus the majority of those carrying this cost of care.

Yet another form of privatization is seldom described as such but is a form that is particularly important for women. This involves the shift of care work and responsibility for care to the household. When care is sent home, women are expected and increasingly required to provide the care.

What are the issues in home care?
Homecare has become a central issue for several reasons.

One reason is the changes in health policy that are sending care home. Hospital care has been redefined to include only those who require the most immediate and acute care. Patients are sent home quicker and sicker, while they still require a great deal of care. More surgery is done on an outpatient basis, with patients released the same day and sent home for care. More services are provided on an out-patient basis, with services once provided in the hospital now provided at home. And finally, institutions that once were homes to people with a variety of disabilities have been closed. This is particularly the case for those with mental disabilities. All these policy changes mean more care is required at home—if the patient has a home. Furthermore, once people are released from hospital, the principles of the Canada Health Act apply only to insured services, not to the work and costs of care borne by the household. And by household we usually mean women.

Second, technologies have changed in ways that make it possible to provide complicated care at home. Although the transfer of care work to the household is often described as a return of care to the household, it is clear that our grandmothers never inserted catheters, hooked up IVs or attached oxygen tents. Indeed, some women provide care in the home that can only be done in the hospital by those with years of formal training. Technologies, along with social support programmes, have also made it possible for women and men to live longer with chronic illness or disability. This means that home based acute care, such as dialysis, may be done over many years.

Homecare has not become an issue because women have abandoned their traditional care work in order to pursue careers. While most women need and want paid work, they still provide a great deal of care in the home and are doing more every day. Indeed, a smaller proportion of the population is cared for in institutions today than was the case a hundred years ago. At the same time the demands for care are rising. Estimates indicate that around 90% of health care is provided at home by unpaid providers, indicating that women in particular are carrying heavy caring workloads along with their paid jobs.

What about the aging population?
Although a decade ago the main issue was costs that were out of control, today the main issue seems to be an aging population. The argument is that we will not be able to afford care for the baby boomers who are growing old, especially with lower birth rates that mean the younger generation will not be large enough to support the elderly. Most of the elderly are women. Moreover, women are a large majority of those who need public care because they usually outlive their spouses.

However, there are reasons to challenge the notion of an impending crisis caused by all those aging women.

First, even if we keep spending the same amount we do now on the elderly, the increase will be gradual and about 1% per year during the period when the baby boomers become seniors.

Second, these figures assume current health care practices. It is quite possible to assess how care is delivered to seniors within the system as a means of improving care while controlling costs. Drug prescribing provides just one example. We could involve pharmacists more in advising both doctors and seniors on drugs, and in the process save millions of dollars on adverse drug reactions.

Third, the boomers are in general healthier than the generation that is now old, in part because they have grown up with a public health care system and with other social supports absent before the Second World War. They are also more likely to have had relatively secure employment and pensions plans at work, although this is more likely for the men than the women.

What is primary health care reform?
Primary health care is most often defined as your first point of contact with the health care system. While many people access health care through the emergency room, primary health care usually refers to doctors, clinics and health centres. Indeed, recent reform discussions have focused on primary care reform, at least in part as a means of keeping people out of emergency rooms.

Sometimes primary care reform is mainly concerned with encouraging doctors to work together with other doctors in group practices. Such group practices, it is assumed, could better handle the need for care all day every day or what is often called 24/7 care.

Sometimes primary care reform is concerned with creating clinics or centres that would include a broader range of care providers. Nurse practitioners in particular have been suggested as a means of sharing the workload, of decreasing costs because they are paid less than doctors and of encouraging health promotion strategies because they spend more time with each patient. Midwives may also be part of the team, but there is less talk about the role of other care providers.

Most primary health care reform is concerned with moving away from the fee-for-service means of paying physicians. The assumption here is that payment by the number and kind of services provided encourages more prescriptions, more tests, more complicated treatment and less time spent with each patient. Various alternative forms of payment are suggested, each of which has different implications for doctors, others who provide care and for patients.

What is ‘rostering’ and ‘capitation’?
‘Rostering’ refers to a system that requires individuals to make a commitment to only see a particular doctor/practice group or clinic for a period of time. This time can vary between a few months and a year. This is supposed to reduce extra doctor visits or ‘doctor shopping’. Physicians are given financial incentives to keep their patients on this roster, the implication being that if individuals are satisfied with the care they won’t go elsewhere. This is a big assumption.

Rostering is often combined with ‘capitation’ payments. This means that the doctor or clinic is paid on the basis of the number of people signed up rather than on the number of services provided or fee-for-service payments. The capitation fee is based on the average cost of providing health care services to a person of a set age and sex. The physician or clinic receives—and gets to keep—the fee regardless of the amount of service provided to an individual. It is often justified as a means of encouraging doctors to provide more health information, health promotion, discouraging over treatment or misuse and ensuring a higher quality care. It is one method that allows for the hiring of staff other than doctors to provide care.

However, there is very little evidence demonstrating that women currently misuse the system or that rostering guarantees the gender sensitive care that women have been seeking.

Rostering does appear to reward physicians for seeing generally well people since they get paid a flat fee no matter how frequently they provide services and therefore penalizes them when they carry a case load of those with chronic mental or physical health problems— often those who are poor or elderly.

Rostering does mean a fundamental shift away from our current system which signs individuals up with the provincial health service and allows them to use any services covered by the plan.

For more on health care reform
See the Canadian Women’s Health Network’s Submission to the Commission on the Future of Health Care in Canada regarding health reform at http://www.cwhn.ca/resources/romanow/index.html or the Women’s Health Clinic Brief to the Standing Senate Committee on Social Affairs, Science and Technology at http://www.cwhn.ca/resources/whc-brief/index.html

Exposing Privatization: Women and Health Care Reform in Canada by Pat Armstrong et al. (Toronto: Garamond, 2001) provides extensive research from the Centres of Excellence for Women’s Health across Canada.

A plain language pamphlet, Women and Health Care Reform, can be ordered from the CWHN.

Follow the activities of the Commission on the Future of Health Care in Canada (Romanow Commission) at http://www.healthcarecommission.ca/. You can also subscribe to a newsletter that can be mailed or faxed.

Pat Armstrong, Ph.D., is Chair of the Centres of Excellence for Women’s Health National Coordinating Group on Health Care Reform and Women and an internationally recognized scholar on women and health reform in Canada.

Notes:
[1] Canadian Institute for Health Information (CIHI). 2001. National Health Expenditure Trends 1975-2001. Ottawa: Canadian Institute for Health Information, Table A1.
[2] Conference Board of Canada, The Future Cost of Health Care in Canada, 2000-2020: Balancing Accountability and Affordability, Ottawa: Conference Board of Canada, 2001 [3] CIHI. 2001. Table 7b.
[4] CIHI. 2001. Figure 7.
[5] CIHI. 2001. Pg.18.
[6] CIHI. 2001. Table B.3.3.
[7] CIHI. 2001. Table 4.