The Political and Economic Sustainability of Health Care in Canad ...

ability to enforce the national requirements of the Canada Health Act (Banting 1995; Maslove 1998). Indeed, several provinces began to challenge Ottawa’s role in mandating health care services.

These mandates are expressed in the Canada Health Act of 1984 (CHA), which consolidated and expanded the previous federal legislation in support of health care programs. Specifically, under the CHA, in order for the provinces to receive full federal financial contributions, provincial health plans are required to provide for the delivery of all necessary (required) hospital and physician services. Programs must also meet criteria of public (non-profit) administration, comprehensiveness, universality, and portability (from one province to another and out-of-country for temporary absences). The act includes a list of the comprehensive hospital services that the federal government expects the provinces to cover in their respective plans, a list intended to prevent hospitals’ unbundling and charging for any services required as part of an episode of care. In addition, “extra-billing” of patients by physicians and user charges are not permitted for fully insured health care services covered under the legislation. Such services comprise, notably, all necessary inpatient and outpatient hospital services, including in-hospital pharmaceuticals, most physician services, and dental surgery when performed in a hospital. Under the act, the federal government also agrees to provide financial contributions for a range of extended health care services undertaken by provincial governments, such as pharmaceuticals outside of hospitals (not specifically named in the CHA), nursing-home care, and in-home care (Maslove 1998; Palley and Forest 2004; Palley, Pomey, and Forest 2011). These services may carry user charges or coinsurance and deductible fees as the provinces see fit.

The case of pharmaceuticals provides a good example of what provinces can or cannot achieve when they act independently of a federal or national framework. No provincial plans have brought pharmaceuticals under a single-payer plan; all utilize private drug plans in combination with a public plan that varies in scope (who is covered) and in depth (what is