Health Policy

HEALTH POLICY in BC over the past century has concerned itself with ensuring that all residents have access to adequate medical and hospital care. The province has been in the vanguard of health care reform, introducing both hospital and medical insurance prior to the national adoption of such plans. In 1998 BC became the second province to provide registered midwife services. BC also provides some chiropractic, naturopathic, optometric, orthoptic, podiatric, massage and physiotherapy services under the BC Medical Services Plan (MSP), and PHARMACARE pays for drugs for selected groups. In 2001–02 health services accounted for about 38% of the provincial government's total expenditures. Health costs rose from $6.3 billion in 1993 to $9.3 billion in 2001. This increase in health spending, not only in absolute terms but also relative to the population, distinguished BC from most other provinces, where health budgets shrank during the 1990s.

Origins of Public Health Insurance

The history of health policy in BC begins in 1888 with the first Health Act. It dealt with general issues of public health, including the collection of morbidity and mortality statistics, the investigation of diseases and epidemics and the monitoring of conditions likely to affect people's health. It also regulated food inspection and handling. Although physicians were regulated under a separate Medical Act, it was not until 9 years later that the first Hospital Act was legislated. Following WWI health care became an important topic of debate. In 1919 the provincial government appointed a Royal Commission on Health Insurance. Two years later it recommended a plan of limited health insurance but no action was taken. In 1929 another provincial Royal Commission was appointed to report on health insurance. As a result of this commission a medical insurance plan was almost put into place in 1937, but because of opposition from physicians the government did not implement it. In its place a non-profit society, the Medical Services Assoc (MSA), was created in 1938 with the support of the doctors. MSA was a voluntary plan involving contributions collected by employers. Public medical insurance for those not covered by a private plan was introduced in 1965 as the BC Medical Plan. In 1967 all medical insurance plans were brought under a single Medical Services Commission and the following year universal public medical insurance was introduced in BC. MSA (the private society) continued in areas such as dental insurance until 1996, when it merged with the other non-profit dental insurer, CU&C, to form Pacific Blue Cross.

In 1948 BC introduced provincial hospital insurance. The plan was originally financed with premiums heavily weighted against single people. Financial difficulties were quick to appear as premiums were not paid. In 1954 the premium system was eliminated for provincial hospital insurance and universality was introduced, funded in part by a 2% increase in the sales tax. When medical insurance was introduced in BC, it too was financed in part with a premium system. In 1999 BC and Alberta remained the only provinces that used premiums to finance part of their provincial health insurance. For the fiscal year 1998–99 premium revenues amounted to about $898 million.

Funding Medicare

Following the introduction of medicare the costs of health services increased dramatically. For example, during 1967–97 physician costs rose from 2.5% to 8.5% of the entire provincial budget, and hospital costs increased from 12% to 14.5%. In 1989 the provincial government appointed a royal commission under Justice Peter Seaton to investigate the issue of escalating health costs. The Seaton report, Closer to Home (1991), recommended decentralizing health services and a greater emphasis on home-based care. In response the NDP government announced a restructuring of the health care system. The province created 11 regional health districts for urban areas, each with its own board, and 34 community health councils and 7 community health services societies for rural areas. These bodies are responsible for the delivery of health care services in their jurisdictions. Physician services, Pharmacare, supplementary benefits and the BC AMBULANCE SERVICE continued to be funded centrally. Similar changes to the organization of health services occurred during the 1990s across Canada.

Discussions of health policy tend to focus on services provided by physicians and hospitals because they are the big-budget items. In fiscal year 1996–97 the province's 123 hospitals received a budget of almost $2.9 billion while the budget for the Medical Services Commission was over $1.7 billion. Those 2 items accounted for 64% of the budget of the Ministry of Health. MENTAL HEALTH, community health, public health and the many auxiliary services usually receive less attention. One of the objectives of the new governance structure for health care was to allow community boards to manage the entire range of health services and funding so as to achieve the best outcomes.

The federal government started funding hospital services on roughly a 50% basis with the provinces under the authority of the Hospital Insurance and Diagnostic Services Act of 1957. Medical services also received 50% federal funding when provinces qualified under the Medical Care Act of 1966. The 50% federal sharing was changed in 1977 with the introduction of the Established Programs Financing Act (EPF), covering cost sharing for both health and advanced education. In order to obtain provincial agreement to the change, funding on a per capita basis for extended health care was added, resulting in increased provincial coverage of nursing homes. Under EPF, federal funding was to increase according to a formula tied to the growth of the population and the economy, but with no ties to actual provincial spending on health care. By the early 1980s some provinces, though not BC, were experiencing increased "extra billing" by physicians. (Extra billing is when physicians ask their patients for money in addition to what the provincial plan pays.) Canada responded by adopting the Canada Health Act, which restored the federal government's authority to financially penalize provinces that failed to meet certain national standards. In BC this resulted in the end of user fees for standard ward acute care hospital beds. In 1996 federal funding was further changed with the implementation of the Canada Health and Social Transfer (CHST) to replace EPF. CHST combines federal funding for health, education and social services in one block grant (see TRANSFER PAYMENTS).

Hospital Services and Medical Care

Hospital services in BC are funded, on a non-profit basis, by the Regional Programs of the Ministry of Health (MOH). The Medical Services Plan (MSP) is administered and operated on a non-profit basis by the Medical Services Commission (MSC). The Commission is responsible to the provincial government for the administration and operation of the Plan. Regional programs and the MSC are subject to audit of their accounts and financial transactions by the AUDITOR GENERAL of BC. All residents, excluding members of the Canadian Forces and the RCMP, inmates of federal penitentiaries and refugee claimants, and those eligible for compensation from another source, are entitled to hospital and medical care insurance coverage. Enrolment in the MSP is mandatory and payment of premiums is ordinarily a requirement for coverage. However, failure to pay premiums is not a barrier to access to care for those who meet the basic enrolment eligibility criteria. Residents of limited means are eligible for premium assistance. The Medical Care Plan provides for all medically required services of medical practitioners' claims and specified dental/oral surgery when it is necessary for it to be performed in hospital by a dental/oral surgeon. Services not insured are those covered by the Workers' Compensation Act or by other federal or provincial legislation. Payment for medical services delivered in the province is made through the MSP to individual physicians, based on billings submitted. The patient is not normally involved in the payment system. Compensation for medical practitioners is based on a fee schedule established by the MSC, with the advice of the BC Medical Assoc. Other health-care practitioners offering insured services have individual fee schedules approved by the appropriate co-managed tripartite special committees. The MSC also funds certain medical services through alternative payment arrangements. An Alternative Payments Branch provides funding to some 300 health-care agencies that retain physicians to deliver approved programs. Approximately 1,800 physicians have voluntarily entered into alternative payment arrangements with these agencies and receive part or all of their income through salaries, sessions or service agreements.

The Regional Programs of the MOH fund a comprehensive range of community-based supportive care services to assist people whose ability to function independently is affected by long-term health-related problems or who have acute care needs that can be met at home. Continuing Care services are not federally mandated services and are funded at the sole discretion of the provincial government, through the MOH. Services are delivered at the community level through the health authorities.

Public Health

The Public Health Protection Branch consists of 2 program areas—Food Protection and Environmental Health Protection—and is responsible for the development and implementation of legislation, policies and programs. This activity supports regional health authorities that are responsible for the delivery of these programs and the prevention of disease that may arise from unsanitary practices or exposure to environmental health and safety hazards. Public health protection programs are administered locally by medical health officers and environmental health officers, who are responsible for direct service delivery in health authorities throughout the province. Environmental health officers provide surveillance and monitoring of specific activities and premises that may affect the public's health, and provide appropriate interventions to minimize health and safety hazards. Among its services are a food safety program, including inspection of food service (in restaurants, for example) and other food-processing and food-sale facilities (food stores, butcher shops, dairy plants, schools, hospitals, etc); food safety advice and information to the public and industry; communicable disease investigations related to drinking water, food and other vectors; on-site sewage disposal monitoring, assessments and permits; recreational water inspection and sampling (at public pools, beaches, etc); public drinking-water supply inspection and monitoring; institutional environmental health inspection (at summer camps, schools, etc); tobacco sales enforcement; personal services facilities monitoring (at tattoo parlours, tanning salons, hairdressing salons, etc); and other public health-related activities such as rodent control and investigation of unsanitary conditions. The Preventive Health Branch is responsible for the development of provincial standards, policies and priorities for public health and for prevention issues. These include population health and adult services for public health NURSING, speech, audiology, nutrition, dental, tobacco reduction, heart health, injury prevention, non-communicable disease epidemiology and health services for community living programs. See also COMMUNITY DEVELOPMENT; HUMAN CARE SERVICES; MEDICAL PROFESSION.