Canada and France have a long lasting friendly partnership that has seen both parties achieve strong economic and medical success throughout their history. Both Canada and France share many qualities, in their language, immigration, and academia of course, and both are present within the current G-7 as members of the world’s strongest countries economically.
Their respective healthcare systems, on the other hand, are different in structure, but thematically do have similarities. Through this article, we’ll analyze the internal elements of both the Canadian and French healthcare systems and understand what sets them apart and what links them together.
The Role of the Government
Canada is divided into 10 provinces and 3 territories. These respective provinces and territories hold the primary responsibility for organizing and delivering health services and supervising providers. Many have established regional health authorities that plan and deliver publicly funded services locally.
In general, these authorities are responsible for the funding and delivery of hospital, community, and long-term care, as well as mental and public health services. Nearly all health care providers are private. Overall, healthcare is quite divided in Canada and falls on the shoulders of the provinces and territories, rather than on a unified nation’s shoulders.
Public vs. Private
Public: In terms of publicly financed health care, the total and public health expenditures were forecast to account for an estimated 11 % and 8 % of GDP respectively. In this, 70 % of total health spending comes from public sources. The provinces and territories administer their own universal health insurance programs, covering all provincial and territorial residents. The federal government contributes to its provinces and territories through an inflow of cash funding to the provinces and territories on a per capita basis through the Canada Health Transfer. Conceptually, this transfer totalled $34 billion CAD in 2015–2016, accounting for an estimated 24 % of total provincial and territorial health expenditures.
Private: With regards to private insurance, it is held by about two-thirds of Canadians and covers services excluded from public reimbursement. This includes elements such as vision and dental care, prescription drugs, rehabilitation services, home care, and private rooms in hospitals. In 2013, approximately 90 % of premiums for private health plans were paid through group contracts with employers, unions, or other organizations. In 2015, private health insurance accounted for approximately 12 % of total health spending. The majority of insurers are for-profit. An example of private health care would be a family doctor and his office in a separate non-government affiliated building.
Services: To qualify for federal financial contributions under the Canada Health Transfer, provincial and territorial insurance plans must provide first-dollar coverage of medically necessary physician, diagnostic, and hospital services (including inpatient prescription drugs) for all eligible residents. Furthermore, provincial and territorial governments provide varying levels of additional benefits, such as outpatient prescription drugs, non-physician mental health care, vision care, dental care, home health care, and hospice care. Different provincial and territorial elements will impact the effectiveness and productivity of different healthcare systems. For example, there are differences between the healthcare system of Quebec vs. Ontario as there are more doctors per 100 000 people in Ontario than in Quebec. Thus, this could have an impact in terms of productivity.
Costs and spending: There is no cost-sharing for publicly insured physician, diagnostic, and hospital services. All prescription drugs provided in hospitals are covered publicly, with outpatient coverage varying by province or territory. Physicians are not allowed to charge patients prices above the negotiated fee schedule. Should this be the case, a massive fine will be implemented on the health servicer and a potential revoking of his/her medical license.
Safety net: Cost-sharing exemptions for non-insured services such as prescription drugs vary among provinces and territories, and there are no caps on out-of-pocket spending. For example, the prescription drug program in Ontario exempts low-income seniors and social assistance recipients from all cost-sharing except a CAD2.00 (USD1.60) co-payment, which is often waived by pharmacies.
Long-term care and social support: The federal Medical Expense Tax Credit supports tax credits for individuals whose medical expenses, for themselves or their dependents, are significant (above 3% of income). Moreover, a disability tax credit and an attendant care expense deduction also provide relief to individuals (or their dependents) who have prolonged mental or physical impairments, and to those who incur expenses for care that is needed to allow them to work. Ultimately, those who are in situations where their medical expenses take up a maximal level of their income are eligible to receive governmental funding compensation.
Digitization in Medical Documentation
Uptake of health information technologies has been increasing in recent years. Provinces and territories are responsible for developing their electronic information systems. At this moment, there is no national strategy for implementing electronic health records and no national patient identifier. However, the mergence overall of medical technology through an electronic platform is very prevalent in Canada. Statistically speaking, provinces have systems for collecting data electronically for the majority of their populations. The North American mindset has been open and welcomed electronic digitization quite quicker than European markets have. However, there is still work to do in order to continue documentation growth in Canada.
The Role of the Government
As a whole, the provision of health care in France is a national responsibility. Furthermore, the French system has evolved from a labour-based system to the modern-day mixed public–private system. Over the past two decades, however, the state has been increasingly involved in controlling health expenditures funded by statutory health insurance (SHI); thus, leading towards a more public-funded structure.
Planning and regulation within health care involve negotiations among provider representatives, the state, and SHI. Outcomes of these negotiations are translated into laws passed by parliament. In addition to setting national strategy, the responsibilities of the central government include allocating budgeted expenditures among different sectors (hospitals, ambulatory care, mental health, and services for disabled residents) and, with respect to hospitals, among regions.
The Administration of Health and Social Affairs is represented by Regional Health Agencies, which are responsible for population health and health care, including prevention and care delivery, public health, and social care.
Public vs. Private
Public: SHI is financed by employer and employee payroll taxes. Coverage is universal and compulsory, provided to all residents by non-competitive SHI. Thus, SHI eligibility is either gained through employment or granted, as a benefit, to students, to retired persons, and to unemployed adults who were formerly employed (and their families). Citizens can opt out of SHI only in rare cases (e.g., individuals working for foreign companies). However, as a whole, as a French resident, one has the right to healthcare as its spread and distribution is universal.
The state covers the insurance costs of residents who are not eligible for SHI, such as the long-term unemployed, and finances health services for undocumented immigrants who have applied for residence. Visitors from elsewhere in the European Union (EU) are covered by an EU insurance card. In contrast, non-EU visitors are covered for emergency care only. Collectively, as a minimal, everyone is covered for emergency care.
Private: Most voluntary health insurance (VHI) is complementary, covering mainly the co-payments for usual care, balance billing, and vision and dental care (minimally covered by SHI). Furthermore, complementary insurance is provided mainly by not-for-profit, employment-based mutual associations or provident institutions, which are allowed to cover only co-payments for care provided under SHI.
Services: Lists of covered procedures, drugs, and medical devices are defined at the national level as they are structurally applied to all regions of the country. The Ministry of Health, a pricing committee within the ministry, and SHI funds all play roles in setting these lists, rates of coverage, and prices.
Costs and spending: Cost-sharing takes three forms: coinsurance; co-payments, and balance billing in primary and specialist care. Total out-of- pocket spending made up less than 10% of total health expenditures. Therefore, as a whole, most of the healthcare spending in France is taken into the hands of the public entity.
Safety net: There is an entitlement program in France that is focused towards those less fortunate. People with low incomes are entitled to free or state-sponsored VHI, free vision care, and free dental care, with the total number of such beneficiaries estimated at around 10 percent of the population.
Long-term care and social support: Home care for the elderly is provided mainly by self-employed physicians and nurses and, to a lesser extent, by community nursing services. Long-term care in institutions is provided in retirement homes and long-term care units. Of these, 54 % are public, 28 % private non-profit, and 18 % for-profit, although the percentage of for-profit institutions is increasing. In addition, temporary care for dependent patients and respite services for their caregivers are available without restrictions from the states or regions.
Digitization in Medical Documentation
Approximately 551,000 patients, or 0.8 % of the population, have an EHR, and an estimated 600 hospitals and 6,000 health professionals use them. Thus, this demonstrates how France still has a long way to go when it comes down to digital implementation. Hospital-based and office-based professionals and patients have a unique electronic identifier, and any health professional can access the record and enter information subject to patient authorization. Security is insured by internal and external access cards. By law, patients have full access to the information in their own records, either directly or through their GP.
Altogether, France has a long way to go in order to keep up with the digital instalment of some of its European counterparts. However, as expressed by the French government, there is a sharp desire and want to take big steps towards digitalization for its capabilities in clarity, storage, and data sharing among professionals.
All in all, in France, the majority of the distribution of healthcare is public; whereas in Canada, it is mostly private. In terms of servicing, the English and Canadian systems both provide outstanding resources and cover costs for those who have too much on their plate.
With regards to digitization, Canada has taken bigger leaps towards better electronic documentation. In France, the process towards digitization has been much slower. However, the French government is in serious advancement towards moving away from paper documentation.
Gabriel Pugliese, 2018