Canadian Health Reform: A Gender Analysis

Abstract

We analyze the gender impact of the current Canadian system of first-dollar health insurance by examining the use of physicians' services and acute-care hospital services in the Canadian province of Manitoba from April 1, 1997, to March 31, 1999. First, we describe the use by age and sex of healthcare resources offered with universal access at no cost to individuals. Second, we argue that women have a particular interest in maintaining single-payer insurance, because women are moderately high users of healthcare resources, while men tend to be low or catastrophic users who would be shielded from the full force of market-oriented reforms. Third, we attempt to refocus the debate about the gender implications of market-oriented health reform by noting that medicare transfers resources to women of reproductive age from the rest of society, a form of social wage paid as in-kind compensation to women for nonpaid reproductive labor.

Keywords:

• Health and administration data
• women's health
• healthcare costs
• population health
• single-payer
• social wage
• first-dollar coverage
• Canada

ACKNOWLEDGMENTS

We are grateful to Nancy Folbre and two anonymous referees for their very helpful comments. Manitoba Health provided access to the administrative data used in this paper (Project No.: 2000/01-47). The study's endorsement by Manitoba Health is not intended, nor should it be inferred. We are pleased to acknowledge the financial support of the Canadian Institute for Health Research (Grant No.: CIHR MOP-68888 2002-4).

Notes

JEL Codes: I18, H51, H42

For links to many of these proposals and our responses, see our website: http://www.umanitoba.ca/centres/mchp/hot_topic/msa.html. The Fraser Institute submitted a discussion paper to the Romanow Commission (see Roy J. Romanow 2002) that encapsulates many of these themes (Migué 2002).

Sex-specific conditions are those that impact differentially as a consequence of the biology of men and women, such as breast cancer, even if social aspects of gender influence these conditions and their treatment. Men do not have hysterectomies, and therefore these are sex-specific, even though many argue that practice patterns that result in a proliferation of hysterectomies are a consequence of a particular gendered society.

Manitoba typically ranks in the middle of the ten Canadian provinces with respect to major socio-economic and demographic variables. The population is slightly older and has a moderately higher proportion of aboriginal people than the Canadian average, both groups tending to have slightly poorer health status on average. But for the purposes of our study, the province is broadly representative of Canada.

A PubMed search using the keywords “Manitoba administrative” yielded seventy-four hits (thirty-two since 1999), ranging from the New England Journal of Medicine, Social Science and Medicine, the Canadian Medical Association Journal, the Milbank Quarterly, and The American Journal of Public Health, to such condition-specific journals as Cancer and the American Journal of Urology. Note that this search would not find articles that identify the same data using other words, such as “claims registry” or “physician-claims file,” nor would it uncover research reports that use these data but are not indexed in PubMed. The linked database is widely used by clinician scientists, epidemiologists, and population health researchers in Canada.

We captured and allocated to individual patients approximately 58 percent of the total amount the province claims to spend on hospital funding. The remaining 42 percent of hospital expenditures fall in the following categories: services to nonresidents of Manitoba, outpatient services (including emergency department care but excluding day surgery), physician remuneration (both physicians delivering direct services and those providing administrative services), building capital costs, and the “overhead” costs associated with each of these categories. The fees paid to physicians who provided services in hospitals were reported as part of the physician services costs. Our data do not capture salaries paid to trainees, such as house officers.

During the period 1997 – 99, when these data were generated, the Canadian dollar hovered about C$1 = US$0.64.

For further discussion of the relationship between our analysis and the RAND health insurance results, see “Medical Savings Accounts in a Universal System: Wishful Thinking Meets Evidence” (Raisa B. Deber, Evelyn L. Forget, and Leslie L. Roos 2004).

There have typically been three “have” provinces – Ontario, Alberta, and British Columbia – and Manitoba has always been a “have not.” The distinction is based upon gross domestic product per capita, with those generating less than the national average receiving equalization payments in order to provide residents of these poorer provinces with roughly comparable public services.

Additional information

Notes on contributors

Evelyn L Forget

JEL Codes: I18, H51, H42