The Role of Provincial and Territorial

Governments
in Health Care
Chapter 7

Copyright 2016 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

Learning Outcomes
7.1 Discuss the common structural elements among
the provincial and territorial governments.
7.2 Describe the purpose and general structure of
regionalization initiatives.
7.3 Explain how provincial and territorial health care
is financed.
7.4 Discuss provincial and territorial health insurance
coverage for those who meet eligibility criteria.
7.5 Explain how drug plans help cover the cost of
medications.
Copyright 2016 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

Division of Powers

Canada does not have a national health

insurance plan
Canada has 13 separate insurance programs
run by 10 provinces and 3 territories, loosely
bound by federal agreements and the Canada
Health Act
Provincial and territorial governments oversee
the health of their populations
To receive federal funding, provinces and
territories must abide by the Canada Health Act
Copyright 2016 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

Structure of the Health Plans:

An Overview

Each ministry is headed by an elected member

of Parliament appointed to the position of
minister of health (MOH)
The ministries

Provide leadership and support to service delivery

partners
Implement and regulate health insurance
Negotiate salaries and other policies with physicians
professional associations

All provinces and territories provide three

general categories of health care
Copyright 2016 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

Levels of Care

Copyright 2016 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

Regionalization Initiatives Across

Canada

In the early 1990s, governments conducted

public forums, reviews, and other studies to
determine a way to improve health care delivery
The conclusion: to decentralize decisions about
health care issues through regionalization
The regional approach was based on the belief
that involving the community in decisions would

Increase public participation in health care initiatives

Enable the ministry to address the unique needs of
each community
Copyright 2016 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

Health Care: Who Pays for It?

Each province and territory has a method (e.g.

premiums, payroll tax) of financing health care
services not covered by federal funding
Private and volunteer organizations provide
significant revenue for specific services or
hospitals

For example, when a community hospital builds a new

wing, a government grant covers part of the expense,
and volunteer groups and the municipal government
make up the balance.
Copyright 2016 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

Other Sources of Funds

Provincial, territorial, and municipal governments

Provide some funds for services such as

Preventive health measures
Medical- and hospital-based services (both inpatient and
outpatient)
Treatment of chronic diseases
Community-based rehabilitation care
Care for nursing home residents

Fund and regulate hospitals

Contribute financially to
Community health organizations
Services delivered by certain health care professionals (other
than physicians)
Teaching and research institutions

Copyright 2016 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

Health Insurance

Third-party health insurance offsets the costs of

noncovered services
Approximately 60% of Canadians carry private
health insurance
Employee plans provide benefits such as

Vision and dental care

Private nursing services
Assistive devices
Enhanced medical services
Copyright 2016 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

Provincial Insurance Plans

All of the following criteria must be met for a

person to be eligible for provincial or territorial
health insurance:
Canadian citizenship or permanent resident status
Resident of the province or territory in which he or she
is seeking health coverage
Physically in that jurisdiction for at least six months of
the year

Copyright 2016 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

10

Health Cards

Once an application is approved, the ministry issues the

applicant a health card
Health care fraud has been a costly problem. As a result:

Health care facilities require individuals to present their health

cards at the point of service for validation.
Most jurisdictions now have photo identification health cards and
increased security measures to protect the information on the
cards.
It is a serious offence to knowingly facilitate the illegal use of a
health card.
Health care professionals are encouraged to watch for and to
report anything suspicious.
Lost cards must be reported immediately, as must changes of
address or name.
Copyright 2016 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

11

Insured and Uninsured Services

Provincial and territorial governments must decide on

All provinces and territories provide specific services (e.g.,

eye care, dental care, drug benefits) to certain population
groups, such as

The need for different types of hospital beds

The mix of professional health care staff
The structure of the system
Hospital budgets
Physicians fees

Those receiving income assistance or guaranteed income supplements

Older adults (i.e., those over 65)
Disabled persons
Children of low-income families (in many jurisdictions)

The federal government provides health insurance to First

Nations, Inuit, and Innu populations living on reserves
Copyright 2016 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

12

Hospital Services

In the hospital setting, insured services for inpatients

include

Standard hospital accommodation

Meals
Certain medications
Operating room and delivery room services and anesthetic facilities
Diagnostic and laboratory services
Routine medical and surgical supplies
Routine nursing care
Certain rehabilitative services (e.g., physiotherapy)

Private nursing care is not covered unless a doctor orders

it (then it is considered medically necessary).
The cost of a private room may be covered under some
circumstances.
Copyright 2016 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

13

Ambulance Services

Ambulance services are not addressed in the Canada

Health Act; therefore, the provinces and territories can
establish their own guidelines and fee schedules.
People using an ambulance, even for medically
necessary reasons, may be responsible for a
copayment.
Fees are not usually charged for medically necessary
transportation between hospitals.
Interfacility transfers (e.g., from one nursing home to
another) usually require a copayment.
Most jurisdictions either reduce or eliminate the
copayment for low-income individuals and families.

Copyright 2016 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

14

Insured Health Care Providers Other

Than Physicians

Some provinces and territories provide residents

with limited insurance coverage for the services
of health care providers other than doctors.
A monetary limit may be imposed per calendar
year, or coverage may be provided only for
lower-income households.

Copyright 2016 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

15

Extended Health Care Services

Long-term care homes offer 24-hour nursing care

and support to individuals no longer able to live on
their own.
In most provinces and territories, these facilities
are overseen by legislation that sets standards of
care and performs regular inspections.
Long-term care facilities are encouraged to seek
accreditation through Accreditation Canada.
Provincial and territorial governments design their
own funding formulas for long-term care facilities.
Copyright 2016 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

16

Extended Health Care Services

Most provinces and territories offer a variety of

other services, such as

Home care
Adult day care programs
Respite care
Assisted living accommodation
Group homes
Hospice care
Palliative care

Copyright 2016 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

17

Drug Plans

Most Canadians have private or employersponsored insurance plans with drug benefits.
Private insurance plans require beneficiaries to
pay dispensing fees.
Some plans will cover only drugs prescribed
from a formulary list
Many private insurance plans offer an open
access plan, insuring all prescription
medications approved by Health Canada
prescribed on an outpatient basis.
Copyright 2016 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

18