Hostname: page-component-78c5997874-m6dg7 Total loading time: 0 Render date: 2024-11-10T14:50:27.586Z Has data issue: false hasContentIssue false
  • English
  • Français

User Fees for Health Care: Why a Bad Idea Keeps Coming Back (Or, What's Health Got to Do With It?)

Published online by Cambridge University Press:  29 November 2010

Robert G. Evans ,
Morris L. Barer  and
Greg L. Stoddart
Robert G. Evans
Affiliation:
University of British Columbia
Morris L. Barer
Affiliation:
University of British Columbia
Greg L. Stoddart
Affiliation:
McMaster University
Get access Rights & Permissions [Opens in a new window]

Abstract

Calls for user fees in Canadian health care go back as far as the debate leading up to the establishment of Canada's national hospital insurance program in the late 1950s. Although the rationales have shifted around somewhat, some of the more consistent claims have been that user fees are necessary as a source of additional revenue for a badly underfunded system, that they are necessary to control runaway health care costs, and that they will deter unnecessary use (read abuse) of the system. But the real reasons that user fees have been such hardy survivors of the health policy wars, bear little relation to the claims commonly made for them. Their introduction in the financing of hospital or medical care in Canada would be to the benefit of a number of groups, and not just those one usually thinks of. We show that those who are healthy, and wealthy, would join health care providers (and possibly insurers) as net beneficiaries of a reintroduction of user fees for hospital and medical care in Canada. The flip side of this is that those who are indigent and ill will bear the brunt of the redistribution (for that is really what user fees are all about), and seniors feature prominently in those latter groups. Claims of other positive effects of user fees, such as reducing total health care costs, or improving appropriateness or accessibility, simply do not stand up in the face of the available evidence. In the final analysis, therefore, whether one is for or against user fees reduces to whether one is for or against the resulting income redistribution.

Résumé

Les appels à l'utilisation de tickets modérateurs dans le système de soins de santé canadien remontent au débat qui a donné naissance au programme national d'assurance-hospitalisation vers la fin des années 1950. Même si les raisonnements soutenant une telle mesure se sont quelque peu modifiés depuis, on la justifie généralement en maintenant que les tickets modérateurs serviront de source additionnelle de revenu à un système mal en point quant à son financement, qu'ils sont nécessaires pour maîtriser les coûts de soins de santé galopants, et qu'ils décourageront une utilisation inutile (voire même abusive) du système. Toutefois, les vraies raisons qui ont permis aux tickets modérateurs de survivre à toutes les controverses touchant la politique en matière de santé partagent peu de liens avec ces justifications générales. Leur mise en application dans le financement des soins hospitaliers et médicaux au Canada avantagerait nombre de groupes, et non seulement ceux qui nous viennent habituellement à l'esprit. Cet article démontre que les personnes en santé et bien nanties bénéficieraient directement, et dans une même mesure que les prestateurs de soins de santé (et peut-être même les assureurs), d'une réintroduction de tickets modérateurs dans les soins hospitaliers et médicaux au Canada. Par contre, les personnes indigentes et malades devront porter le poids de la redistribution (car voilà les conséquences réelles des tickets modérateurs), et les personnes âgées font majoritairement partie de ce groupe. Les affirmations à l'effet que les tickets modérateurs auraient d'autres effets positifs, comme la réduction du coût des soins de santé ou l'amélioration de la pertinence ou de l'accessibilité des services, n'ont aucun fondement à la lumière des faits. En dernière analyse, par conséquent, une opinion en faveur ou non des tickets modérateurs revient à la question suivante: soutient-on ou non la redistribution du revenu qu'entraînerait leur mise en application?

Keywords

User FeesHealth Care FinancingUnderfundingAccess.Frais modérateursfinancement de soins de santésous-financementaccès.
Type
Articles
Information
Canadian Journal on Aging / La Revue canadienne du vieillissement , Volume 14 , Issue 2 , Été/Summer 1995 , pp. 360 - 390
Copyright
Copyright © Canadian Association on Gerontology 1995

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Arrow, K.J. (1976). Welfare Analysis of Changes in Health Coinsurance Rates. In Rosett, R.N. (Ed.), The Role of Health Insurance in the Health Services Sector (pp. 3–23). New York: National Bureau of Economic Research.Google Scholar
Barer, M.L., Bhatia, V., Stoddart, G.L., & Evans, R.G. (1994). The Remarkable Tenacity of User Charges: A Concise History of Participation, Positions, and Rationales of Canadian Interest Groups in the Debate over “Direct Patient Participation” in Health Care Financing. Toronto: Ontario Premier's Council on Health, Well-being and Social Justice.Google Scholar
Barer, M.L., & Evans, R.G. (1986). Riding North on a South-Bound Horse? Expenditures, Prices, Utilization, and Incomes in the Canadian Health Care System. In Evans, R.G. & Stoddart, G.L. (Eds.), Medicare at maturity: Achievements, lessons & challenges (pp. 53–163). Calgary: University of Calgary Press for the Banff Centre.Google Scholar
Barer, M.L., & Evans, R.G. (1992). The Meeting of the Twain: Managing Health Care Capital, Capacity, and Costs in Canada. In Gelijns, A.C. (Ed.), Technology and Health Care in an Era of Limits, Vol. III of “Medical Innovation at the Crossroads,” Institute of Medicine Committee on Technological Innovation in Medicine (pp. 97–119). Washington, DC: National Academy Press.Google Scholar
Barer, M.L., Evans, R.G., & Labelle, R.J. (1988). Fee Controls as Cost Control: Tales from the Frozen North. The Milbank Quarterly, 66(1), 1–64.CrossRefGoogle ScholarPubMed
Barer, M.L., Evans, R.G., & Stoddart, G.L. (1979). Controlling Health Care Costs by Direct Charges to Patients: Snare or Delusion? Toronto: Ontario Economic Council.Google Scholar
Barer, M.L., Hertzman, C., Miller, R., & Pascali, M.V. (1992). On Being Old and Sick: The Burden of Health Care for the Elderly in Canada and the United States. Journal of Health Politics, Policy and Law, 17(4), 763–82.Google ScholarPubMed
Berk, M.L., & Monheit, A.C. (1992). The Concentration of Health Expenditures: An Update. Health Affairs, 11(4), 145–149.CrossRefGoogle ScholarPubMed
British Columbia. Royal Commission on Health Care and Costs (Seaton Commission). (1991). Closer to Home (Vol. 2). Victoria, BC: The Province of British Columbia.Google Scholar
Canada. Royal Commission on Health Services (Hall Commission). (1964). Report (Vol. I). Ottawa: The Queen's Printer.Google Scholar
Chassin, M.R., Park, R.E., Fink, A. et al. (1986). Indications for Selected Medical and Surgical Procedures — A Literature Review and Ratings of Appropriateness. (R-3204/2-CWF/HF/HCFA/PMT/RWJ) (May). Santa Monica, CA: The Rand Corporation.Google Scholar
Evans, R.G. (1976). Beyond the Medical Marketplace: Expenditure, Utilization, and Pricing of Insured Health Care in Canada. In Roseti, R.N. (Ed.), The Role of Health Insurance in the Health Services Sector (pp. 437–492). New York: National Bureau of Economic Research.Google Scholar
Evans, R.G. (1992). What Seems to Be the Problem? The International Movement to Restructure Health Care Systems. HPRU 92–8D (November), Centre for Health Services and Policy Research, University of British Columbia, Vancouver.Google Scholar
Evans, R.G. (1993). Health Care Reform: ‘The Issue from Hell’. Policy Options, 14(6), 35–41.Google Scholar
Evans, R.G., Barer, M.L., & Stoddart, G.L. (1994). Charging Peter to Pay Paul: Accounting for the Financial Effects of User Charges. Toronto: Ontario Premier's Council on Health, Well-being and Social Justice.Google Scholar
Evans, R.G., Barer, M.L., Stoddart, G.L., & Bhatia, V. (1994). It's Not the Money, It's the Principle: Why User Charges for Some Services, and Not Others. Toronto: Ontario Premier's Council on Health, Well-being and Social Justice.Google Scholar
Friedman, E. (1991). Insurers under Fire. Health Management Quarterly, XIII(3), 23–27.Google Scholar
Fuchs, V.R., & Hahn, J.S. (1990). How Does Canada Do It? A Comparison of Expenditures for Physicians' Services in the United States and Canada. New England Journal of Medicine, 323(13), 884–890.CrossRefGoogle Scholar
Globe and Mail. (1993). Alberta Premier to press for medicare user fees. January 13, p. A3.Google Scholar
Letsch, S.W. (1993). National Health Care Spending in 1991. Health Affairs, 12(1), 94–110.CrossRefGoogle ScholarPubMed
Lohr, K.N. et al. (1986). Use of medical care in the Rand Health Insurance Experiment: Diagnosis and service-specific analyses of a randomized controlled trial. Medical Care, 25 (Supplement), 531–538.Google Scholar
Manning, W.G., Newhouse, J.P., Duan, N. et al. (1987). Health Insurance and the Demand for Medical Care: Evidence from a Randomized Trial. American Economic Review, 77(3), 251–277.Google Scholar
Miller, M.E., Zuckerman, S., & Gates, M. (1993). How do Medicare Physician Fees Compare with Private Payers? Health Care Financing Review, 14(3), 25–39.Google ScholarPubMed
Nair, C., Karim, R., & Nyers, C. (1992). Health Care and Health Status: A Canada-United States Statistical Comparison. Health Reports, 4(2), 175–183. Ottawa: Statistics Canada (cat. no. 82–003).Google Scholar
Naylor, C.D. (1991). A Different View of Queues in Ontario. Health Affairs, 10(3), 110–128.CrossRefGoogle ScholarPubMed
Naylor, C.D., Morgan, C.D., Levinton, C.M. et al. (1993). Waiting for coronary re-vascularization in Toronto: 2 years' experience with a regional referral office. Canadian Medical Association Journal, 149(7), 955–962.Google Scholar
Newhouse, J.P. (1992). Medical Care Costs: How Much Welfare Loss? Journal of Economic Perspectives, 6(1), 3–21.CrossRefGoogle ScholarPubMed
Rachlis, M.M., Olak, J., & Naylor, C.D. (1991). The vital risk of delayed coronary artery surgery: Lessons from the randomized trials. Iatrogenics, 1, 103–111.Google Scholar
Rasell, E., Bernstein, J., & Tang, K. (1993). The Impact of Health Care Financing on Family Budgets. Economic Policy Institute Briefing Paper (April). Washington, DC: EPI.Google Scholar
Redelmeier, D.A., & Fuchs, V.R. (1993). Hospital Expenditures in the United States and Canada. New England Journal of Medicine, 328(11), 772–778.CrossRefGoogle Scholar
Roos, N.P., Shapiro, E., & Tate, R. (1989). Does a Small Minority of Elderly Account for a Majority of Health Care Expenditures?: A Sixteen-year Perspective. The Milbank Quarterly, 67(3–4), 347–369.CrossRefGoogle ScholarPubMed
Rouleau, J.L., Moyé, L.A., Pfeffer, M.A. et al. (1993). A Comparison of Management Patterns after Acute Myocardial Infarction in Canada and the United States. New England Journal of Medicine, 328(11), 779–784.CrossRefGoogle ScholarPubMed
Schieber, G.J., Poullier, J.-P., & Greenwald, L.M. (1992). U.S. health expenditure performance: An international comparison and data update. Health Care Financing Review, 13(4), 1–87.Google ScholarPubMed
Stoddart, G.L., Barer, M.L., & Evans, R.G. (1994). User Charges, Snares and Delusions: Another Look at the Literature. Toronto: Ontario Premier's Council on Health, Well-being and Social Justice.Google Scholar
Toronto Star. (1993). User fee figures. Editorial, June 5, p. D5.Google Scholar
Torrey, B.B., & Jacobs, E. (1993). More Than Loose Change: Household Health Spending in the United States and Canada. Health Affairs, 12(1), 126–131.CrossRefGoogle Scholar
van Doorslaer, E., Wagstaff, A., & Rutten, F. eds. (1993). Equity in the Finance and Delivery of Health Care: An International Perspective. Oxford: Oxford University Press.Google Scholar
Welch, W.P., Katz, S.J., & Zuckerman, S. (1993). Physician Fee Levels: Medicare Versus Canada. Health Care Financing Review, 14(3), 41–54.Google ScholarPubMed
Woolhandler, S., & Himmelstein, D.U. (1991). The Deteriorating Administrative Efficiency of the U.S. Health Care System. New England Journal of Medicine, 324(18), 1253–1258.CrossRefGoogle ScholarPubMed
Woolhandler, S., Himmelstein, D.U., & Lewontin, J.P. (1993). Administrative Costs In Hospitals, U.S.. New England Journal of Medicine, 329(6), 400–404.CrossRefGoogle ScholarPubMed