APA has had a special relationship with our Canadian colleagues for decades. Psychiatrists trained and practicing in Canada are regular members of APA. APA has three district branches in Canada: Ontario, Quebec and Eastern Canada, and Western Canada. To date, 9 percent of APA’s annual meetings have been held in Canada (Montreal, Niagara Falls, Quebec, and Toronto). Seven APA presidents lived/worked in Canada at the time they held office: Drs. Daniel Clark (1891-92), Richard Bucke (1897-98), Thomas Burgess (1904-05), James Anglin (1917-18), Walter English (1930-31), George Stevenson (1940-41), and Ewen Cameron (1952-53). Three APA presidents were born in Canada but lived or worked in the United States: Drs. Alexander MacDonald (1903-04), William Russell (1931-32), and Harold Eist (1996-97).
One of the most striking differences between our two countries is in our health care systems. Canada has universal health insurance, while the system in the United States has been largely based on employer-covered health insurance, except for government-funded Medicare and Medicaid. The U.S. system is undergoing major transformation at this time. The Affordable Care Act, supported by President Obama, has brought significant changes that are particularly helpful for people with mental illness. For example, it eliminates lifetime dollar limits on insurance coverage, allows single individuals younger than 26 to remain on their parents’ insurance, and provides access to insurance for uninsured individuals with preexisting conditions (in 2014, the law will prohibit coverage denial due to preexisting conditions). These measures will help provide access to health care for many people who do not currently have it. Nonetheless, the U.S. system will continue to be markedly different from its Canadian counterpart.
I invited Suzane Renaud, M.D., president of the Canadian Psychiatric Association (CPA), and Fiona McGregor, M.D., immediate past president of the CPA, to describe the Canadian health care system from a psychiatric perspective. Below are their comments.
Suzane Renaud, M.D., and Fiona McGregor, M.D.
One of us (Dr. Renaud), a Quebec psychiatrist who trained in the United States, has been involved at the APA district branch level and served as a representative to the APA Assembly for a decade. The other (Dr. McGregor) is a Scottish-trained psychiatrist who came to Canada 22 years ago. Thus, coming from disparate backgrounds, we are excellent models of integrative practice.
In Canada, everyone enjoys the benefits of universal health insurance that Canadians regard as their birthright. Over 90 percent of Canadians in repeated polls believe this is an essential part of the government’s responsibilities. How did our two countries develop such different health care systems? Canada separated from the United Kingdom 90 years after the U.S. Declaration of Independence. Canada’s Constitution Act of 1867 carried provisions for legislating health care and divided the jurisdiction of health between the provinces and federal government. In 1957 the Canadian government entered into an agreement with the provinces to establish a comprehensive universal plan.
Because of alarm over provincial spending on health care, which the federal government met dollar for dollar, the Canada Health Act was passed in 1984. This defines the principles—but not the practice—of how health care is delivered. The principles are
Public administration of health insurance by an accountable nonprofit agency: This has kept costs far below those of the United States.
Comprehensiveness: All insured services must be covered.
Universality: All citizens living within a province are covered.
Portability: Insurance is portable across Canada.
Accessibility: Access time to necessary services should be reasonable.
Currently our federal government covers only 26 percent of all health care costs, leaving itself in a weak position to advocate for national standards. Our current government is not interested in standards, to the dismay of 90 percent of Canadians, according to a recent poll by the Canadian Medical Association.
Health care spending has not increased dramatically, apart from the cost of pharmaceuticals, and so far our government has been deaf to the lobby calling for a national “pharmacare” strategy that would enormously reduce costs.
How does the Canada Health Act affect us as psychiatrists? One of the joys of this system as physicians is the lower cost and reduced time spent on administrative tasks such as billing, not having to choose which patients can be seen, not having to justify treatment strategies, and having access to medications that patients can afford. The downside is that since the system is public, the workload is heavy and accompanied by the pressure to respond to all needs.
Generally the first port of call for those with mental illness is the primary care system, as self-referral to a psychiatrist is becoming a rarity. Secondary care is delivered in different ways, depending on the province.
The culture of private-practice psychiatry is declining as psychiatrists see the benefits of working as part of multidisciplinary teams. There is usually good collaboration with other professionals in the mental health field as all belong to a unique public-system network.
The issue of wait lists in Canada is often misrepresented, but most patients say that once they are in the system, the quality of care is good. The hallmark of this single-payor system is that the security of payment allows Canadian psychiatrists to give attention to the treatment of patients without discrimination over which patients they can see. Continuity of care is guaranteed as psychiatrists are responsible and control treatment plans, including the frequency of follow-up or transfer back to first-line services (usually family doctors). The physician is responsible for finding appropriate care, but limited numbers of inpatient beds can present a challenge. The CPA is constantly advocating for greater parity of health care funding for mental health (a current goal is to increase funding from 7 percent to 9 percent of total budget).
The CPA has 4,354 members, comprising 52 percent of Canadian psychiatrists. The smaller size of our organization necessitates, as well as allows for, more flexibility in decision making. There is no counterpart to the APA Assembly. Rather, volunteers work on committees onto which they are delegated by their provincial associations. Both associations publish a journal, develop position papers, and have working committees and an annual conference.
The CPA collaborates with the provincial organizations and lobbies on federal health responsibilities. The CPA continues to state the need for appropriate psychiatric care and fight against stigma, similar to APA.
It is fascinating to observe how our two countries, with similar mental health care concerns, deal so differently with issues as a result of differences in the two cultures. Our two countries now have similar family incomes; however, the Canadian health care system protects individuals at a low cost for the same health issues. Since the risk of encountering a mental illness in a lifetime is high, universal health insurance continues to be a good idea according to the Canadian point of view. ■