Medicare (French: assurance-maladie) is the unofficial name for Canada's publicly funded universal health insurance system.^[1] The formal terminology for the insurance system is provided by the Canada Health Act and the health insurance legislation of the individual provinces and territories.

Under the terms of the Canada Health Act, all "insured persons" (basically, legal residents of Canada, including permanent residents) are entitled to receive "insured services" without copayment. Such services are defined as medically necessary services if provided in hospital, or by 'practitioners' (usually physicians).^[2] Approximately 70% of Canadian health expenditures come from public sources, with the rest paid privately (both through private insurance, and through out-of-pocket payments). The extent of public financing varies considerably across services. For example, approximately 99% of physician services, and 90% of hospital care, are paid by publicly funded sources, whereas almost all dental care is paid for privately.^[3] Most doctors are self-employed private entities.

History[link]

The first implementation of public hospital care in Canada came at the provincial level in Saskatchewan in 1946 and in Alberta in 1950, under provincial governments led by the CCF and the Social credit party respectively ^[4]. The first implementation of nationalized public health care -at the federal level- came about with the Hospital Insurance and Diagnostic Services act (HIDS), which was passed by the Liberal majority government of Louis St. Laurent in 1957 ^[5], and was adopted by all provinces by 1961. Lester B. Pearson's government subsequently expanded this policy to universal health care with the Medical Care Act in 1966.^[6] Some have argued^{[citation needed]} that these developments towards public national health care came as a result of the Saskatchewan government's health plan in 1961-1962 by Douglas and Woodrow Stanley Lloyd, who became premier of the province when Douglas resigned to become the leader of the new federal New Democratic Party, though the medicare legislation itself was actually drafted (and first proposed to parliament) by Allan MacEachen, a Liberal MP from Cape Breton ^[7].

Eligibility[link]

Although in theory all Canadians should qualify for coverage, each province or territory operates its own health insurance program, and provinces and territories have enacted qualification rules which effectively exclude many Canadians from coverage. For example, to qualify for enrollment in Ontario, one must, among other requirements, "be physically present in Ontario for 153 days in any 12-month period; and be physically present in Ontario for at least 153 days of the first 183 days immediately after establishing residency in the province."^[8] While there are exceptions for students studying out of province, and for mobile workers, many Canadians who regularly travel from one province to another for other reasons, as well as those who often travel outside Canada, cannot qualify for enrollment in any province. Proof-of-residency provisions requiring presentation of documents such as utility bills and bank statements also operate to exclude migrants and the homeless from enrollment.

Funding[link]

Funding for the insurance plans comes from the general revenues of the Canadian provinces/territories, assisted by transfer payments from the federal government through the Canada Health Transfer. Some provinces charge health care premiums, but these are in effect taxes (since they are not tied to service use, nor to provincial health expenditures). The system is accordingly classified by the OECD as a tax-supported system, as opposed to the social insurance approaches used in many European countries. Currently, patients do not pay out of pocket costs to visit their doctor. Boards in each province regulate the cost, which is then reimbursed by the federal government.^{[citation needed]}

Delivery[link]

Canada uses a mix of public and private organizations to deliver health care; in turn, these organizations bill the provincial health authorities, with few exceptions.^[9] Hospitals are largely non-profit organizations, historically often linked to religious or charitable organizations. In some provinces, individual hospital boards have been eliminated and combined into quasi-private regional health authorities, subject to varying degrees of provincial control. Laboratory services are often delivered by for-profit investor-owned corporations.

With rare exceptions, medical doctors are small for-profit independent businesses. Historically, they have practiced in small solo or group practices and billed the medicare system on a fee for service basis. Unlike the practice in some other countries, hospital-based physicians were rarely hospital employees, and also billed the provincial insurance plans on a fee-for-service basis. Since 2000, physicians have been allowed to incorporate for tax reasons (dates of authorization vary province to province). However, efforts to achieve primary health care reform have increasingly encouraged physicians to work in multidisciplinary teams, and be paid through blended funding models, including elements of capitation and other 'alternative funding formulas'. Similarly, some hospitals (particularly teaching hospitals and rural/remote hospitals) have also experimented with alternatives to fee-for-service.

In summary, the system is known as a "public system" due to its public financing, but is not a nationalized system such as the UK's NHS; most medicare services are provided privately.^[10]

An additional complexity is that, because health care is deemed to be under provincial jurisdiction, there is not a "Canadian health care system". Most providers are private, and may or may not coordinate their care. Publicly funded insurance is organized at the level of the province/territory; each manages its own insurance system, including issuing its own healthcare identification cards (a list of the provincial medical care insurance programs is given at the end of this entry). Once care moves beyond the services required by the Canada Health Act — for which universal comprehensive coverage applies — there is inconsistency from province to province in the extent of publicly funded coverage, particularly for such items as outpatient drug coverage and rehabilitation, as well as vision care, mental health, and long-term care, with a substantial portion of such services being paid for privately, either through private insurance, or out-of-pocket.^[11][12] Eligibility for these additional programs may be based on various combinations of such factors as age (e.g., children, seniors), income, enrollment in a home care program, or diagnosis (e.g., HIV/AIDS, cancer, cystic fibrosis).

The Canada Health Act requires coverage for all medically necessary care provided in hospitals or by physicians; this explicitly includes diagnostic, treatment and preventive services. Coverage is universal for qualifying Canadian residents, regardless of income level. Services of non-physicians working within hospitals are covered; but provinces can, but are not forced to, cover services by non-physicians if provided outside hospitals. Changing the site of treatment may thus change coverage. For example, pharmaceuticals, nursing care, and physical therapy must be covered for inpatients, but there is considerable variation from province to province in the extent to which they are covered for patients discharged to the community (e.g., after day surgery). The need to modernize coverage was pointed out in 2002 by both the Romanow Commission and by the Kirby committee of the Canadian Senate (see External links below). Similarly, the extent to which non-physician providers of primary care are funded varies; Quebec offers primary health care teams through its CLSC system).

Drug coverage[link]

Each province may also provide its own prescription drug benefit plan, although the Canada Health Act requires only coverage for pharmaceuticals delivered to hospital inpatients.^[13] Provincial prescription drug benefit plans differ across provinces. Some provinces cover only those in particular age groups (usually, seniors) and/or those on social assistance. Others are more universal. Quebec achieves universal coverage through a combination of private and public plans. Co-payments also vary.^[14] Provinces maintain their own provincial formularies, although efforts are underway to institute a Common Drug Review.^[15] Note that there is ongoing controversy in Canada, as in other countries, about inclusion of expensive drugs and discrepancies in their availability, as well as in what if any provisions are made for allowing medications not yet approved to be administered under "exceptional drug" provisions.^[16] Drug costs are contentious. Their prices are controlled by the Patented Medicine Prices Review Board (PMPRB).^[17] The PMPRB's pricing formula ensures that Canada pays prices based on the average of those charged to selected countries; they are neither the highest, nor the lowest.

Dental care, eye care and other services[link]

Dental care is not required to be covered by the government insurance plans. In Quebec, children under the age of 10 receive almost full coverage, and many oral surgeries are covered for everyone.^[18] Canadians rely on their employers, individual private insurance, pay cash themselves for dental treatments, or receive no care. In some jurisdictions, public health units have been involved in providing targeted programs to address the need of the young, the elderly or those who are on welfare. The Canadian Association of Public Health Dentistry tracks programs, and has been advocating for extending coverage to those currently unable to receive dental care.^[19]

The range of services for vision care coverage also varies widely among the provinces. Generally, "medically required" vision care is covered if provided by physicians (cataract surgery, diabetic vision care, some laser eye surgeries required as a result of disease, but not if the purpose is to replace the need for eyeglasses). Similarly, the standard vision test may or may not be covered. Some provinces allow a limited number of tests (e.g., no more than once within a two-year period). Others, including Ontario, Alberta, Saskatchewan, and British Columbia, do not, although different provisions may apply to particular sub-groups (e.g., diabetics, children).

Naturopathic services are covered in some cases, but homeopathic services are generally not covered. Chiropractic is partially covered in some provinces. Cosmetic procedures are not typically covered. Psychiatric services (provided by physicians) are covered, fee-for-service psychology services outside of hospitals or community based mental health clinics are usually not. Physical therapy, occupational therapy, speech therapy, nursing, and chiropractic services are often not covered unless within hospitals. Some provinces, including Ontario include some rehabilitation services for those in the home care program, those recently discharged from hospitals (e.g., after a hip replacement), or those in particular age categories. Again, considerable variation exists, and provinces can (and do) alter their coverage decisions.

Inter-provincial Imbalances[link]

The fact that health insurance plans are administered by the provinces and territories in a country where large numbers of residents of certain provinces work in other provinces may lead to inequitable inter-provincial outcomes with respect to revenues and expenditures. For example, many residents of the Atlantic provinces work in the oil and gas industry in the western province of Alberta. For most of the year these workers may be contributing significant tax revenue to Alberta (e.g. through fuel, tobacco and alcohol taxes) while their health insurance costs are borne by their home province in Atlantic Canada.

Opinions on Medicare[link]

This section needs additional citations for verification. Please help improve this article by adding citations to reliable sources. Unsourced material may be challenged and removed. (July 2007)

Polling data in the last few years have consistently cited medicare as among the most important political issues in the minds of Canadian voters. Along with peacekeeping, medicare was found, based on a CBC poll, to be among the foremost defining characteristics of Canada.

It has increasingly become a source of controversy in Canadian politics. As a recent report from the Health Council of Canada has noted "Herein lies one of the puzzles of Canadian health care: Canadians increasingly view the health care system as unsustainable and under threat, even as their own experiences with the system are mostly positive."^[20]

As analysts have noted, the root of the concern may be traced to successful cost control efforts in the mid 1990s, where public health expenditure per capita, in inflation-adjusted dollars, actually fell.^[21] These efforts arose from efforts by the federal government to deal with its deficit, which led to cuts in their transfers to the provinces, and in turn to squeezing hospital budgets and physician reimbursements. The number of physicians being trained was reduced. The result was seen in increased wait times, particularly for elective procedures. More recently, government has been reinvesting in health care, but public confidence has been slow to recover.

A number of studies have compared Canada with other countries, and concluded that each system has its own strengths and weaknesses.^[22][23] The World Health Organization, ranked Canada in 2000 as 30th worldwide in performance. However, the basis for these rankings has been highly contentious. As Deber noted, "The measure of "overall healthsystem performance" derives from adjusting "goal attainment" for educational attainment. Although goal attainment is in theory based on five measures (level and distribution of health, level and distribution of "responsiveness" and "fairness of financial contribution"), the actual values assigned to most countries, including Canada, were never directly measured. The scores do not incorporate any information about the actual workings of the system, other than as reflected in life expectancy. The primary reason for Canada's relatively low standing rests on the relatively high educational level of its population, particularly as compared to France, rather than on any features of its health system."^[24] Other countries had similar complaints, and the WHO has not repeated this ranking.

2003 Accord[link]

In 2003, the prime minister and the provincial premiers agreed upon priority areas for reinvestment. The 2003 First Ministers’ Accord on Health Care Renewal^[25] reaffirmed their commitment to the principles of the Canada Health Act. They indicated the following principles:

"Drawing from this foundation, First Ministers view this Accord as a covenant which will help to ensure that:

• all Canadians have timely access to health services on the basis of need, not ability to pay, regardless of where they live or move in Canada;
• the health care services available to Canadians are of high quality, effective, patient-centred and safe; and
• our health care system is sustainable and affordable and will be here for Canadians and their children in the future."

The accord set the following priority areas: primary health care, home care, catastrophic drug coverage, access to diagnostic/medical equipment and information technology and an electronic health record. The extent of progress in meeting reform goals has varied across these areas.

Evaluating claims about the system[link]

Evaluating the accuracy of claims about the system is hampered by several factors. The highly decentralized nature of health care delivery means that good data is not always available. It is often difficult to distinguish compelling but atypical anecdotes from systemic problems. Considerable effort is being made to develop and implement comparable indicators to allow better assessment of progress. However, the Health Council of Canada — with a mandate to monitor and report on health reform — complained in 2007 that progress has stalled.^[26]

The debate about health care has also become heavily ideological. The Fraser Institute, a think tank supporting "competitive market solutions for public policy problems" is a frequent critic of medicare. It publishes yearly reports about wait times which are then used to argue that the system is both failing and unsustainable.^[27] Others criticize their methodology, which is based on physician perceptions rather than actual waits.^[28] Other complaints come from the political left, who object to 'privatization' (by which they usually mean a heavier involvement of for-profit providers). (See, for example, the Canadian Health Coalition web page.^[29] There are frequent debates in the media and on line between advocates and opponents of Canadian healthcare.

Wait times and access[link]

Common complaints relate to access, usually to elective surgery (especially hip and knee replacement and cataract surgery) and diagnostic imaging. These have been the primary targets of health care reinvestment, and it appears that considerable progress has been made for certain services, although the implications for procedures not on the target list are unclear.^[30][31][32] Canadian physicians have been heavily involved, particularly in developing appropriateness criteria to ensure timely access for necessary care.^[33] It is estimated to have cost Canada's economy $14.8 billion in 2007 to have patients waiting longer than needed for medical procedures.^[34]

Health human resources[link]

A related issue is the volume, and distribution, of health human resources.^[35] There are ongoing issues about the distribution of physicians, with the pendulum swinging from arguing that there were too many, to arguing that there were too few. As Ben Chan found, the major factor driving the drop in physician numbers was changes in training programs.^[36] Combined with such factors as changes in the hours worked by each physician, and a decrease in the proportion of doctors choosing to go into family practice, there were shortages in some areas, particularly for general practitioners (GP) / family doctors. One response has been to encourage 'primary care reform', including greater use of multidisciplinary health care teams.^[37] There are also ongoing issues regarding nurses. (See Nursing Health Services Research Unit, which links to some reports.^[38] CIHI also gives data about nursing.)

Delisting[link]

Delisting is the term used in Canada when a province decides that a medical procedure will no longer be covered by Medicare in that province.

While Medicare is country wide, and is required to be portable and to have equal access, there are differences between what provinces will cover. In some cases, this has resulted in lost grants to the provinces; in other cases it has not.^{[citation needed]}

An example of a delisted service is circumcision in Ontario. It is still possible to have a boy circumcised in Ontario by a doctor but the parents must pay the cost.^{[citation needed]}

The issue of delisting services is becoming increasingly a battleground in Canadian Medicare. In an effort to save health care money the provinces are increasingly delisting services; however, some delisted services are ones that could be considered "medically necessary". For example, except for seniors and children, eye exams to check vision are no longer covered in Ontario.^{[citation needed]}

Parallel private debate[link]

Some politicians and think tanks have proposed removing barriers to the existence of a parallel private healthcare system. Others note that such systems act to erode cost control and impede equity.^[39] Though polling suggests support for such reforms has been increasing, it has yet to be adopted as official policy by any of the main federal political parties.

Under federal law, private clinics are not legally allowed to provide services covered by the Canada Health Act. Regardless of this legal issue, many do offer such services. There are disputes as to whether surgical procedures can be performed. Two related issues have obstructed the growth of such clinics. One is regulatory — hospital-based quality assurance often failed to encompass them. This gap has been filled in most provinces, but sometimes only after celebrated incidents in which patients died in unregulated clinics, including one physician who performed cosmetic surgery in an Ontario hotel room. The second is economic — there may be no way for physicians to recoup the additional costs of running a surgical facility from their fees. Here, provinces can choose to offer 'facility fees' to these clinics, but doing so has often been contentious, particularly if hospitals felt that these costs would be better devoted to allowing them to increase their operating room time.

Note that uninsured persons can pay for care (including medical tourism), and that insured persons can still pay for uninsured services. These are both niche markets.

Opponents of Medicare often raise issues such as long wait times, a 'brain-drain' drawing qualified professionals away from Canada to other jurisdictions where working in the health care field is more profitable, and impairment of the Canadian health care system due to budget cuts. Fox News ran a story in 2007 reporting that during a period of above average numbers of births, at least 40 Canadian mothers of premature babies had to travel to the U.S. for treatment due to insufficient capacity for premature babies in British Columbia neonatal units. Nonetheless, Canada's Medicare system covered the health care costs of those mothers affected.^[40]

In 2003, the Government in Canada spent $2,998 USD per capita on healthcare as compared to $5,711 USD per capita in the United States, while almost every Canadian citizen is fully covered.^[41] In the United States a high percentage of the population is uncovered or only marginally covered, despite higher proportional spending along with large private investment.

The lack of competition has given healthcare unions a monopoly on essential services, thus ensuring a very strong bargaining position. Nova Scotia is currently debating healthcare legislation aimed at removing the threat of striking healthcare workers and replacing it with binding arbitration.^[42]

Proposed reforms[link]

One proposed solution for improving the Canadian healthcare system is to increase funding. Proponents of this approach point to^{[citation needed]} the rise of neo-conservative economic policies in Canada and the associated reduction in welfare state expenditure (particularly in the provinces) from the 1980s onwards as the cause of degradation in the system. In fact, there is evidence^{[citation needed]} that the percentage of total government expenditures spent on healthcare has been increasing, in part due to a higher percentage of older Canadians.

Other critics of healthcare state^{[citation needed]} that increased funding will not solve systemic problems in the healthcare system including a rising cost of medical technology, infrastructure, and wages. These critics say^{[citation needed]} that Canada's proximity to the United States causes a "brain drain" or migration of Canadian-trained doctors and nurses (as well as other professionals) to the United States, where private hospitals can pay much higher wages and income tax rates are lower (partially because health care is not covered through taxation). Some of these critics^{[citation needed]} argue that increased privatization of healthcare would improve Canada's health infrastructure. Others^[43] argue vehemently against it. For example, large resources are required to train and educate doctors. Since the number of available doctors is therefore limited, doctors working for a private system would not be working under the public system creating little to no net increase in available services.

Critics of greater privatization state^{[citation needed]} that healthcare should be kept public, (public in funding only, as most services are provided by the private sector including doctors who in most cases are private corporations) in part because it separates Canadians from Americans by mandating equality and fairness in health care. This is in contrast to other states^{[citation needed]} where doctors are on a per capita based salary. In this sense the Canadian Healthcare system is merely a publicly funded one where services are provided by a mixture of public and private entities, which most Canadians appreciate and desire.^{[citation needed]} Changing the system to eliminate the balance between public and private service providers to a completely public system is one such alternative.

Ontario's reform experiments[link]

Since the early 1990s, Ontario has implemented several systematic reforms to reduce health care costs. Similar reforms have been implemented in other provinces.

User premiums[link]

Currently in Ontario, people who earn salaries above $20,000 must pay an annual health care premium ranging from $60–$900.^[44] Funding for medicare in Ontario also comes in part from a dedicated Employer Health Tax (EHT) that ranges from 0.98%-1.95% of employer payroll.^[45] Eligible employers are exempted from EHT on the first $400,000 of payroll.^{[citation needed]} British Columbia and Quebec charge similar premiums. Alberta charged $44 a month or $88 per family until it abolished premiums in 2009.^{[citation needed]}

Medical clinics[link]

Ontario has increased the number of 24-hour drop-in medical clinic networks^{[citation needed]} to reduce costs associated with treating off-hours emergencies in hospital emergency rooms.

Many family doctor practices have created their own clinics, offering 24-hour service for their patients if needed. Each doctor in the practice takes a turn at being "on call" on a rotating basis. Patients who have family doctors belonging to these practices are able to have a doctor come to their home in extreme situations. There is no additional charge for these services as they are billed to the Province, the same as an office visit.

Hospitals in some major Canadian cities, such as London, Ontario, have restructured their emergency services to share emergency treatment among several hospitals.^{[citation needed]} One hospital may provide full emergency room care, while another sees patients who have broken limbs, minor injuries and yet another sees patients suffering cold, flu, etc.

Recently, the first nurse practitioner-led office to relieve waiting times caused by a shortage of primary practitioners was opened in Sudbury, Ontario.^[46][47]

Alternatives to fee-for-visit or service[link]

Ontario has also attempted to move the system away from bill for service or visit and toward preventive and community-based approaches to healthcare. The Ontario government in the early 1990s helped develop many community health care centres, often in low-income areas, which provide both medical and social support which combines health care with programs such as collective kitchens, Internet access, anti-poverty groups and groups to help people quit smoking.

While funding has decreased for these centres, and they have had to cut back,^{[citation needed]} they have had a lower cost than the traditional fee-for-service approach.^{[citation needed]} Many of these centres are filled to capacity in terms of general doctors, and there are often fairly long waiting lists and the centres also utilize nurse practitioners, who reduce the workload on the doctors and increase efficiency.

Midwives and hospital birthing reforms[link]

Ontario and Quebec have recently licensed midwives, providing another option for childbirth which can reduce costs for uncomplicated births. Midwives remain close to hospital facilities in case the need for emergency care emerges. These births often cost much less than the traditional hospital delivery.^{[citation needed]} Hospitals have also reformed their approach to birthing by adding private birthing areas, often with a hot tub (which is good for relieving pain without medication).

Privatization[link]

Currently, privately owned and operated hospitals that allow patients to pay out-of-pocket for services cannot obtain public funding in Canada, as they contravene the "equal accessibility" tenets of the Canada Health Act. Some politicians and medical professionals have proposed^{[citation needed]} allowing public funding for these hospitals. Workers' Compensation Boards, the Canadian Military, the RCMP, federally incarcerated prisoners, and medical care for which an insurance company has liability (e.g., motor vehicle accidents) all pay for health care outside of the public systems in all provinces.^[2][48]

In Quebec, a recent legal change has allowed this reform to occur. In June 2005, the Supreme Court of Canada overturned a Quebec law preventing people from buying private health insurance to pay for medical services available through the publicly funded system and this ruling does not apply outside the province. See: Chaoulli v. Quebec (Attorney General).^[49]

In November 2005, the Quebec government announced that it would allow residents to purchase private medical insurance to comply with this ruling.

Private insurance from companies such as Blue Cross, Green Shield and Manulife have been available for many years to cover services not covered by Medicare, such as dental care and eye care. Private insurance is provided by many employers as a benefit.

The Canadian Medical Association (CMA) released a report^[50] in July 2007 endorsing private healthcare as a means to improve an ailing healthcare system. Dr. Brian Day, who acted as President of the CMA in 2007/2008, is the owner of the largest private healthcare hospital in Canada and a proponent of mixed public and private healthcare in Canada.

Canadian Health Practitioner standards[link]

It is generally accepted that physicians arriving in Canada from other countries must meet Canadian Health Practitioner standards. So there is concern that doctors from other countries are not trained or educated to meet Canadian standards. Consequently, doctors who want to practice in Canada must meet the same educational and medical qualifications as Canadian-trained practitioners. Others suggest that the Canadian Medical Association, the Ontario Medical Association, and the regulatory bodies (the provincial Colleges of Physicians and Surgeons) have created too much red tape to allow qualified doctors to practise in Canada.^[51] Canada's health system is ranked 30th in the world, suggesting the logic of the doctor shortage defies the statistics.^[52] In fact according to a report by Keith Leslie of the Canadian Press in the Chronicle Journal, Nov 21, 2005, over 10,000 trained doctors are working in the United States, a country ranked 37th in the world. It would suggest money or the perception of better working conditions, or both, are resulting in an exodus of Canadian doctors (and nurses) to the USA.^[53]

It is important to recognize that many consider the doctor shortage in Canada to be a very severe problem affecting all sectors of health care. It may relate in part to the details of how doctors are paid; a detail often misunderstood. In Canada, almost all doctors receive a fee per-visit, not per-service. It has been suggested that this type of "fee-for-visit" payment system can encourage complexity, volume visits, repeat visits, referrals, and testing.^[54][55]

One consequence of the shortage in Canada is that a great many patients are left without family doctors, and trained specialists, making early intervention very difficult. As the article in the Toronto Star specially isolates, it is not so much a problem of a doctor shortage but of a shortage of 'licensed doctors'. Michael Urbanski states that Canada already has a hidden reserve of foreign-trained MDs eager to begin medical practice. "However, what's crucial to understanding the issue of doctor shortage in Ontario is that while the Liberal government is planning to go "poaching" for other countries' doctors, there are an estimated 4,000 internationally trained doctors right here in Ontario working at low-wage jobs."^[56]

A CBC report [6](August 21, 2006) on the health care system reports the following:

Dr. Albert Schumacher,^[57] former president of the Canadian Medical Association estimates that 75 per cent of health-care services are delivered privately, but funded publicly. "Frontline practitioners whether they're GPs or specialists by and large are not salaried. They're small hardware stores. Same thing with labs and radiology clinics …The situation we are seeing now are more services around not being funded publicly but people having to pay for them, or their insurance companies. We have sort of a passive privatization.

In a report by Keith Leslie of the Canadian Press in the Chronicle Journal, Nov 21, 2005, commenting on an Ontario Medical Association Report, prepared by the human resources committee states "The year 2005 finds the province in the midst of a deepening physician resources crisis". The report continues to report, "the government should make it easier for doctors from other provinces to work in Ontario and .... ". Here we have signs of inter-provincial competition affecting the doctor shortage in one province over another.^[53] Essentially, privatized healthcare is not a choice of interest for lower income Canadians, it is most likely to be unaffordable and unfair to those who suffer on a social standard.

Provincial insurance plans[link]

Though the Canada Health Act provides national guidelines for healthcare, the provinces have exclusive jurisdiction over health under the constitution and are free to ignore these guidelines, although if they ignore the guidelines, the federal government may deny federal funding for healthcare. All provinces currently abide by the Canada Health Act in order to receive this funding; however the Alberta legislature has considered proposals^{[citation needed]} to ignore the Act to allow them to implement reforms not allowed under the Act.

The federal government has no direct role in the delivery of medicine in the provinces and territories so each province and territory has its own independent public health insurance program. Under the Canada Health Act, each province and territory must provide services to members of plans in other provinces and territories.

List of provincial programs[link]

See also[link]

• Father of medicare
• Ontario Health Insurance Plan
• Medicare (Australia)
• Medicare (United States)
• National Health Service (UK)
• Canada Health Act
• Canada Health Transfer
• Canada Health and Social Transfer
• Indian Health Transfer Policy (Canada)
• Health care in Canada
• Canada's Health Care providers, 2007
• Canadian Institute for Health Information
• Canadian and American health care systems compared
• Royal Commission on the Future of Health Care in Canada
• Saskatchewan Doctors' Strike of 1962
• Health Evidence Network of Canada

References[link]

External links[link]

• Canada Health Act
• Canadian Health Coalition (Canadian lobby group supporting public medicare)
• Medicare: A People's Issue
• Maple Leaf Web: The Charter & Public Health Care in Canada
• CBC Digital Archives - The Birth of Medicare
• Building on Values: The Future of Health Care in Canada (The Romanow Report, PDF) archived at Collections Canada
• Health Canada page linking to key Federal reports and commissions and their background material, including Romanow Report and Kirby Commission
• Pharmaceutical Pricing and Reimbursement Policies in Canada. OECD Health Working Papers 24, 2006
• Marchildon's backgrounder on Canadian healthcare for WHO 2005
• Benjamin Isitt and Melissa Moroz, "The Hospital Employees' Union Strike and the Privatization of Medicare in British Columbia, Canada," International Labor and Working-Class History, 71 (Spring 2007): 91-111
• Canada Health Insurance

Canada
Coat of arms of Canada Flag Coat of arms
Motto: A Mari Usque Ad Mare  (Latin) "From Sea to Sea"
Anthem: "O Canada" Royal anthem: "God Save the Queen"[1][2]
Capital		Ottawa 45°24′N 75°40′W / 45.4°N 75.667°W / 45.4; -75.667
Largest city		Toronto
Official language(s)		English and French
Recognised regional languages		Chipewyan, Cree, Gwich’in, Inuinnaqtun, Inuktitut, Inuvialuktun, Slavey (North and South) and Tłįchǫ[3]
Demonym		Canadian
Government		Federal parliamentary democracy and constitutional monarchy[4]
-	Monarch	Elizabeth II
-	Governor General	David Johnston
-	Prime Minister	Stephen Harper
-	Chief Justice	Beverley McLachlin
Legislature		Parliament
-	Upper house	Senate
-	Lower house	House of Commons
Establishment		from the United Kingdom
-	Constitution Act, 1867	July 1, 1867
-	Statute of Westminster	December 11, 1931
-	Canada Act	April 17, 1982
Area
-	Total	9,984,670 km2 (2nd) 3,854,085 sq mi
-	Water (%)	8.92 (891,163 km2/344,080 mi2)
Population
-	2012 estimate	34,839,000[5] (35th)
-	2011 census	33,476,688[6]
-	Density	3.41/km2 (228th) 8.3/sq mi
GDP (PPP)		2011 estimate
-	Total	$1.396 trillion[7] (14th)
-	Per capita	$40,541[7] (12th)
GDP (nominal)		2011 estimate
-	Total	$1.736 trillion (10th)
-	Per capita	$50,436[7] (9th)
Gini (2005)		32.1[8] (medium)
HDI (2011)		0.908[9] (very high) (6th)
Currency		Canadian dollar ($) (CAD)
Time zone		(UTC−3.5 to −8)
-	Summer (DST)	(UTC−2.5 to −7)
Date formats		dd-mm-yyyy, mm-dd-yyyy, and yyyy-mm-dd (CE)
Drives on the		Right
ISO 3166 code		CA
Internet TLD		.ca
Calling code		+1

Canada ( /ˈkænədə/) is a North American country consisting of ten provinces and three territories. Located in the northern part of the continent, it extends from the Atlantic Ocean in the east to the Pacific Ocean in the west, and northward into the Arctic Ocean. Spanning over 9,900,000 km² (3,800,000 sq mi), Canada is the world's second-largest country by total area, and its common border with the United States is the longest land border in the world.

The land that is now Canada has been inhabited for millennia by various Aboriginal peoples. Beginning in the late 15th century, British and French colonial expeditions explored, and later settled, along the region's Atlantic coast. France ceded nearly all of its colonies in North America in 1763 after the Seven Years' War. In 1867, with the union of three British North American colonies through Confederation, Canada was formed as a federal dominion of four provinces. This began an accretion of provinces and territories and a process of increasing autonomy; the Canada Act 1982 severed the vestiges of legal dependence on Britain.

Canada is a federal state that is governed as a parliamentary democracy and a constitutional monarchy, with Queen Elizabeth II as its head of state. The country is officially bilingual at the federal level. Canada's diversified economy is one of the world's largest, and is reliant upon its abundant natural resources and upon trade – particularly with the United States, with which Canada has had a long and complex relationship. It is a member of the G7, G8, G20, NATO, OECD, WTO, Commonwealth of Nations, Francophonie, OAS, APEC, and United Nations.

Etymology[link]

The name Canada comes from the St. Lawrence Iroquoian word kanata, meaning "village" or "settlement".^[10] In 1535, indigenous inhabitants of the present-day Quebec City region used the word to direct French explorer Jacques Cartier to the village of Stadacona.^[11] Cartier later used the word Canada to refer not only to that particular village, but also the entire area subject to Donnacona (the chief at Stadacona); by 1545, European books and maps had begun referring to this region as Canada.^[11]

In the 17th and early 18th centuries, "Canada" referred to the part of New France that lay along the St. Lawrence River and the northern shores of the Great Lakes. The area was later split into two British colonies, Upper Canada and Lower Canada. They were reunified as the Province of Canada in 1841.^[12]

Upon Confederation in 1867, Canada was adopted as the legal name for the new country, and the word Dominion was conferred as the country's title.^[13] However, as Canada asserted its political autonomy from the United Kingdom, the federal government increasingly used simply Canada on state documents and treaties, a change that was reflected in the renaming of the national holiday from Dominion Day to Canada Day in 1982.^[14]

History[link]

Aboriginal peoples[link]

Archaeological studies and analyses of DNA haplogroups have indicated a human presence in the northern Yukon region from 24,500 BC, and in southern Ontario from 7500 BC.^[15][16][17] The Paleo-Indian archaeological sites at Old Crow Flats and Bluefish Caves are two of the oldest sites of human habitation in Canada.^[18][19][20] The characteristics of Canadian Aboriginal societies included permanent settlements, agriculture, complex societal hierarchies, and trading networks.^[21][22] Some of these cultures had collapsed by the time European explorers arrived in the late 15th and early 16th centuries, and have only been discovered through archaeological investigations.^[23]

The aboriginal population is estimated to have been between 200,000^[24] and two million in the late 15th century,^[25] with a figure of 500,000 accepted by Canada's Royal Commission on Aboriginal Health.^[26] As a consequence of the European colonization, Canada's aboriginal peoples suffered from repeated outbreaks of newly introduced infectious diseases such as influenza, measles, and smallpox (to which they had no natural immunity), resulting in a forty- to eighty-percent population decrease in the centuries after the European arrival.^[24] Aboriginal peoples in present-day Canada include the First Nations,^[27] Inuit,^[28] and Métis.^[29] The Métis are a mixed-blood people who originated in the mid-17th century when First Nations and Inuit people married European settlers.^[30] In general, the Inuit had more limited interaction with European settlers during the colonization period.^[31]

European colonization[link]

Benjamin West's The Death of General Wolfe (1771) dramatizes James Wolfe's death during the Battle of the Plains of Abraham at Quebec in 1759.

The first known attempt at European colonization began when Norsemen settled briefly at L'Anse aux Meadows in Newfoundland around 1000 AD.^[32] No further European exploration occurred until 1497, when Italian seafarer John Cabot explored Canada's Atlantic coast for England.^[33] Basque and Portuguese mariners established seasonal whaling and fishing outposts along the Atlantic coast in the early 16th century.^[34] In 1534, French explorer Jacques Cartier explored the St. Lawrence River, where on July 24 he planted a 10-metre (33 ft) cross bearing the words "Long Live the King of France", and took possession of the territory in the name of King Francis I of France.^[35]

In 1583, Sir Humphrey Gilbert claimed St. John's, Newfoundland, as the first North American English colony by the royal prerogative of Queen Elizabeth I.^[36] French explorer Samuel de Champlain arrived in 1603, and established the first permanent European settlements at Port Royal in 1605 and Quebec City in 1608. Among the French colonists of New France, Canadiens extensively settled the St. Lawrence River valley and Acadians settled the present-day Maritimes, while fur traders and Catholic missionaries explored the Great Lakes, Hudson Bay, and the Mississippi watershed to Louisiana. The Beaver Wars broke out in the mid-17th century over control of the North American fur trade.^[37]

The English established additional colonies in Cupids and Ferryland, Newfoundland, beginning in 1610. The Thirteen Colonies were founded to the south soon after.^[34] A series of four French and Indian Wars erupted between 1689 and 1763.^[38] Mainland Nova Scotia came under British rule with the 1713 Treaty of Utrecht; the Treaty of Paris (1763) ceded Canada and most of New France to Britain after the Seven Years' War.^[39]

The Royal Proclamation of 1763 created the Province of Quebec out of New France, and annexed Cape Breton Island to Nova Scotia.^[14] St. John's Island (now Prince Edward Island) became a separate colony in 1769.^[40] To avert conflict in Quebec, the British passed the Quebec Act of 1774, expanding Quebec's territory to the Great Lakes and Ohio Valley. It re-established the French language, Catholic faith, and French civil law there. This angered many residents of the Thirteen Colonies, fuelling anti-British sentiment in the years prior to the 1775 outbreak of the American Revolution.^[14]

The 1783 Treaty of Paris recognized American independence and ceded territories south of the Great Lakes to the United States. New Brunswick was split from Nova Scotia as part of a reorganization of Loyalist settlements in the Maritimes. To accommodate English-speaking Loyalists in Quebec, the Constitutional Act of 1791 divided the province into French-speaking Lower Canada (later Quebec) and English-speaking Upper Canada (later Ontario), granting each its own elected legislative assembly.^[41]

Robert Harris's Fathers of Confederation (1884), an amalgamation of the Charlottetown and Quebec conferences of 1864.^[42]

The Canadas were the main front in the War of 1812 between the United States and Britain. Following the war, large-scale immigration to Canada from Britain and Ireland began in 1815.^[25] Between 1825 and 1846, 626,628 European immigrants reportedly landed at Canadian ports.^[43] Between one-quarter and one-third of all Europeans who immigrated to Canada before 1891 died of infectious diseases.^[24]

The desire for responsible government resulted in the abortive Rebellions of 1837. The Durham Report subsequently recommended responsible government and the assimilation of French Canadians into English culture.^[14] The Act of Union 1840 merged The Canadas into a united Province of Canada. Responsible government was established for all British North American provinces by 1849.^[44] The signing of the Oregon Treaty by Britain and the United States in 1846 ended the Oregon boundary dispute, extending the border westward along the 49th parallel. This paved the way for British colonies on Vancouver Island (1849) and in British Columbia (1858).^[45]

Confederation and expansion[link]

An animated map showing the growth and change of Canada's provinces and territories since Confederation in 1867.

Following several constitutional conferences, the 1867 Constitution Act officially proclaimed Canadian Confederation on July 1, 1867, initially with four provinces – Ontario, Quebec, Nova Scotia, and New Brunswick.^[46][47][48] Canada assumed control of Rupert's Land and the North-Western Territory to form the Northwest Territories, where the Métis' grievances ignited the Red River Rebellion and the creation of the province of Manitoba in July 1870.^[49] British Columbia and Vancouver Island (which had been united in 1866) joined the Confederation in 1871, while Prince Edward Island joined in 1873.^[50] Prime Minister John A. Macdonald and his Conservative government established a National Policy of tariffs to protect the nascent Canadian manufacturing industries.^[48]

To open the West, the government sponsored the construction of three transcontinental railways (including the Canadian Pacific Railway), opened the prairies to settlement with the Dominion Lands Act, and established the North-West Mounted Police to assert its authority over this territory.^[51][52] In 1898, during the Klondike Gold Rush in the Northwest Territories, the Canadian government created the Yukon Territory. Under the Liberal Prime Minister Wilfrid Laurier, continental European immigrants settled the prairies, and Alberta and Saskatchewan became provinces in 1905.^[50]

Early 20th century[link]

Canadian soldiers and Mark II tank at the Battle of Vimy Ridge in 1917.

Because Britain still maintained control of Canada's foreign affairs under the Confederation Act, its declaration of war in 1914 automatically brought Canada into World War I. Volunteers sent to the Western Front later became part of the Canadian Corps. The Corps played a substantial role in the Battle of Vimy Ridge and other major engagements of the war.^[53] Out of approximately 625,000 Canadians who served in World War I, around 60,000 were killed and another 173,000 were wounded.^[54] The Conscription Crisis of 1917 erupted when conservative Prime Minister Robert Borden brought in compulsory military service over the objections of French-speaking Quebecers. In 1919, Canada joined the League of Nations independently of Britain,^[53] and the 1931 Statute of Westminster affirmed Canada's independence.^[4]

The Great Depression of the early 1930s brought great economic hardship to Canada. In response to the downturn, the Co-operative Commonwealth Federation (CCF) in Saskatchewan introduced many elements of a welfare state (as pioneered by Tommy Douglas) in the 1940s and 1950s.^[55] Canada declared war on Germany independently during World War II under Liberal Prime Minister William Lyon Mackenzie King, three days after Britain. The first Canadian Army units arrived in Britain in December 1939.^[53]

Canadian troops played important roles in many key battles of the war, including the failed 1942 Dieppe Raid, the Allied invasion of Italy, the Normandy landings, the Battle of Normandy, and the Battle of the Scheldt in 1944.^[53] Canada provided asylum for the monarchy of the Netherlands while that country was occupied, and is credited by the Netherlands for major contributions to its liberation from Nazi Germany.^[56] The Canadian economy boomed during the war as its industries manufactured military materiel for Canada, Britain, China, and the Soviet Union.^[53] Despite another Conscription Crisis in Quebec, Canada finished the war with a large army and strong economy.^[57]

Modern times[link]

At Rideau Hall, Governor General the Viscount Alexander of Tunis (centre) receives the bill finalizing the union of Newfoundland and Canada on March 31, 1949.

The Dominion of Newfoundland (now Newfoundland and Labrador) was unified with Canada in 1949.^[58] Canada's post-war economic growth, combined with the policies of successive Liberal governments, led to the emergence of a new Canadian identity, marked by the adoption of the current Maple Leaf Flag in 1965,^[59] the implementation of official bilingualism (English and French) in 1969,^[60] and the institution of official multiculturalism in 1971.^[61] Socially democratic programs were also instituted, such as Medicare, the Canada Pension Plan, and Canada Student Loans, though provincial governments, particularly Quebec and Alberta, opposed many of these as incursions into their jurisdictions.^[62] Finally, another series of constitutional conferences resulted in the 1982 patriation of Canada's constitution from the United Kingdom, concurrent with the creation of the Canadian Charter of Rights and Freedoms.^[63] In 1999, Nunavut became Canada's third territory after a series of negotiations with the federal government.^[64]

At the same time, Quebec underwent profound social and economic changes through the Quiet Revolution of the 1960s, giving birth to a modern nationalist movement. The radical Front de libération du Québec (FLQ) ignited the October Crisis in 1970,^[65] and the sovereignist Parti Québécois was elected in 1976, organizing an unsuccessful referendum on sovereignty-association in 1980. Attempts to accommodate Quebec nationalism constitutionally through the Meech Lake Accord failed in 1990.^[66] This led to the formation of the Bloc Québécois in Quebec and the invigoration of the Reform Party of Canada in the West.^[67][68] A second referendum followed in 1995, in which sovereignty was rejected by a slimmer margin of just 50.6 to 49.4 percent. In 1997, the Supreme Court ruled that unilateral secession by a province would be unconstitutional, and the Clarity Act was passed by parliament, outlining the terms of a negotiated departure from Confederation.^[66]

In addition to the issues of Quebec sovereignty, a number of crises shook Canadian society in the late 1980s and early 1990s. These included the explosion of Air India Flight 182 in 1985, the largest mass murder in Canadian history;^[69] the École Polytechnique massacre in 1989, a university shooting targeting female students;^[70] and the Oka Crisis of 1990,^[71] the first of a number of violent confrontations between the government and Aboriginal groups.^[72] Canada also joined the Gulf War in 1990 as part of a US-led coalition force, and was active in several peacekeeping missions in the late 1990s.^[73] Canada sent troops to Afghanistan in 2001, but declined to send forces to Iraq when the US invaded in 2003.^[74] In 2011, Canadian forces participated in the NATO-led intervention into the Libyan civil war.^[75]

Geography[link]

A satellite composite image of Canada. Boreal forests prevail on the rocky Canadian Shield, while ice and tundra are prominent in the Arctic. Glaciers are visible in the Canadian Rockies and Coast Mountains. The flat and fertile prairies facilitate agriculture. The Great Lakes feed the St. Lawrence River in the southeast, where lowlands host much of Canada's population.

Canada occupies a major northern portion of North America, sharing land borders with the contiguous United States to the south and the US state of Alaska to the northwest. Canada stretches from the Atlantic Ocean in the east to the Pacific Ocean in the west; to the north lies the Arctic Ocean.^[76][77] Greenland is to the northeast, while Saint Pierre and Miquelon is south of Newfoundland.

By total area (including its waters), Canada is the second-largest country in the world, after Russia. By land area alone, Canada ranks fourth.^[77] The country lies between latitudes 41° and 84°N, and longitudes 52° and 141°W.

Since 1925, Canada has claimed the portion of the Arctic between 60° and 141°W longitude,^[78] but this claim is not universally recognized. Canada is home to the world's northernmost settlement, Canadian Forces Station Alert, on the northern tip of Ellesmere Island – latitude 82.5°N – which lies 817 kilometres (508 mi) from the North Pole.^[79] Much of the Canadian Arctic is covered by ice and permafrost. Canada has the longest coastline in the world, with a total length of 202,080 kilometres (125,570 mi);^[77] additionally, its border with the United States is the world's longest land border, stretching 8,891 kilometres (5,525 mi).^[80]