Canada has a complex health delivery system which is a conglomeration of 13 public plans--10 provincial and three territorial as well as a number of federally administered plans serving special populations such as Aboriginals and Veterans--all providing full coverage for most hospital and physician services as well as partial coverage for many services that vary among plans. The importance of this study is that it examines how the public/private sector relationship in health care delivery--particularly that of the for-profit sector--has developed both historically and in recent years, in three subnational provincial jurisdictions within a federal system. The case study provinces are Ontario, Quebec, and Alberta. The study examines both similarities and differences in this development. These provinces are highly distinct in their political culture and political history affecting health care delivery. Ontario and Quebec are Canada's most populous provinces and Alberta is an increasingly populous prairie state. Alberta is unique in its long-time governance of the Progressive Conservative party and its predecessor the Social Credit Party. Ontario has had a more variable political history with periods of Progressive Conservative, New Democratic Party and Liberal leadership and in recent years Quebec governance has shifted between the Parti Qu becois and the Liberal Party. In this study, one dimension that the authors examine are political dispositions to act regarding public/private initiatives in health care delivery and how this affects health care delivery in these provinces. Provincial medical and hospital plans are constrained by the Canada Health Act of 1984. For necessary medical and hospital services, the provinces and territories must adhere to the five principles of the Act in order to receive federal funding. However for other extended health care and health care-related services, there are federal contributions that are not constrained by these principles--although subject to reporting obligations. Another factor providing some flexibility in provincial Medicare plans is that necessary hospital and medical services are not enumerated in the Canada Health Act. This has allowed some "delisting" of services which is discussed in the case studies. In the provincial case studies, the authors examine how the federal/provincial dynamic in the delivery of health care services has worked out in the three provinces, with respect to similarities and differences regarding the involvement of the for-profit sector both within and outside the respective Medicare systems. They also examine how the fiscal setting has affected both political and economic sustainability pressures with respect to inclusion of private commercial initiatives in these three provincial settings. The authors note that these initiatives occur both within and external to Canadian provincial Medicare systems and that there is a need to see that such initiatives are held publicly accountability to meet equity and access goals. The study utilizes government documents, press reports and personal interviews to draw a picture of health delivery developments within the Canadian federal context. This study adds to the comparative health policy literature by applying a comparative approach to subnational provincial cases. It is also noteworthy to note that globally, many nations' health insurance plans incorporate a mixed public and private health delivery system, albeit that the mixes of for-profit and not-for-profit organizations will vary with respect to the ideological, political, cultural and historical characteristics of various nations. This is an important book for collections in Canadian studies, political science, and public health.

The Fiscal Sustainability of Health Care - the first of a three-volume set of selected papers from the Romanow Commission - comprises the most influential discussion papers on the fiscal sustainability of public health care in the future. The subjects covered include the current and potential cost drivers of the system, the financing and delivery of health care, fiscal federalism, and international trade regimes. While some of the contributors are among Canada's best known and respected figures in the field, others are relatively new scholars from Canada and abroad who bring fresh perspectives and new insights to the issue of fiscal sustainability. Presenting divergent diagnoses and policy prescriptions, the papers collectively highlight the many factors that governments and health care sector managers must confront to keep the Canadian health care system viable in the 21st century.

The health systems we enjoy today, and expected medical advances in the future, will be difficult to finance from public resources without major reforms. Public health spending in OECD countries has grown rapidly over most of the last half century. These spending increases have contributed to ...

Private for-profit activities in the health care sector in Canadian provinces have moderately shrunk the definition of "necessary medical and hospital services" that must be provided under conditions of public administration. "Necessary health care services" that include all necessary hospital services, physician services and surgical dental services must also be provided without copayments or user fees - or the provinces in violation would be subject to financial penalties by the federal government. (Also such extensions have occurred among other "extended" health care services such as diagnostic imaging and in-home as well as long-term care facility services not subject to the same restrictions.) A number of Canadian health policy analysts have contended that economic factors are not involved in decisions to reduce the notion of "necessary services" but rather that political sustainability is the driving factor in these decisions (Boychuk, 2004; Evans, 2004; Flood, Stabile & Tuohy, 2008). We maintain that the development of new technologies (Berenson & Abelson, 2008; Fleury, 2008), pharmaceutical innovations, competing (non-health) demands on the federal dollar and some factors related to an aging population, together create an environment where economic, as well as political sustainability drivers are leading to some peripheral erosion with regard to the basket of necessary medical and hospital services in Canada's provincial health care delivery systems (Yakabuski, 2004), as well as the extension of commercial enterprises in the extended care area. Our presentation will examine the distinct governmental, linguistic, religio/cultural background as well as the distinctive political process, political symbolism and ideologies, and political differences that exist in the three provinces of Alberta, Ontario, and Quebec. After discussing these differences in some depth, we conclude that a combination of political and economic sustainability factors have led to increased growth of for-profit private enterprises at the margins of the Canadian provincial health systems and usually in a manner that integrates or relates these operations into the framework of Canada's public health insurance and the health care programs in the three provinces of Alberta, Ontario and Quebec. Furthermore, we conclude that essentially this growth is related to maintaining the public health insurance in Canada in an atmosphere of increasing financial demands on public revenues both within and outside of the arena of health care.

Universal healthcare, perhaps the most distinguishing feature of Canada's public policy, is under fire, criticized for its heavy expense and questionable sustainability. In Where to From Here?: Keeping Medicare Sustainable, Stephen Duckett defends Canadian Medicare, addressing key concerns and refuting criticism, while also acknowledging flaws in the system and room for improvement. Duckett argues that while the fundamentals of Medicare are sound, a great deal of change is necessary to keep it sustainable. This book envisions a Medicare that is not static and simply responsive to problems, but an active, shifting system that keeps up with the evolving needs of a rapidly changing time. Duckett systematically lays out proposals for incremental change across a range of areas including primary care, hospitals, and the health workforce. Where to From Here? Presents an unflinching defense of one of Canada's iconic policies, while keeping a clear eye on the future of the nation's health.

"Health and health care are at the pop of the public agenda, not only in Canada but throughout the world. Canada's most cherished social program -- health care -- is being transformed in many ways, some highly visible and others hidden from public view."--Cover.