1 See Sharmila L., Mhatre & Raisa B., Deber, From Equal Access to Health Care to Equitable Access to Health: A Review of Canadian Provincial Health Commissions and Reports, 22 Int'L J. Health Serv. 645, 645 (1992).Google Scholar For further discussion of citizen satisfaction, see Robert J., Blendon et al., Satisfaction With Health Systems In Ten Nations, Health Aff., Spring 1992, at 185;Google Scholar Robert J., Blendon & Humphrey, Taylor, Views On Health Care: Public Opinion In Three Nations, Health Aff., Spring 1989, at 149.Google Scholar

2 See, e.g., General Accounting Office, Report to the Chairman, House Comm. on Gov't Operations, Canadian Health Insurance: Lessons for the United States (1991) [hereinafter GAO Report]; Robert G., Evans, We'll Take Care of It For You: Health Care In the Canadian Community, Daedalus, Fall 1988, at 157;Google Scholar Robert G., Evans, Split Vision: Interpreting Cross-border Differences In Health Spending, Health Aff., Winter 1988, at 17;Google Scholar Morris L., Barer & Robert G., Evans, Interpreting Canada: Models, Mindsets and Myths, Health Aff., Spring 1992, at 44, 45–46;Google Scholar Robert G., Evans, U.S. Influences On Canada: Can We Prevent The Spread Of Kuruf, in Restructuring Canada's Health Services System: How do we get there from Here? 143, 145 (Raisa B., Deber & Gail G., Thompson eds., 1992)Google Scholar [hereinafter U.S. Influences On Canada]; David U., Himmelstein & Steffie, Woolhandler, Cost Without Benefit: Administrative Waste In U.S. Health Care, 314 New Eng. J. Med. 441, 445 (1986);Google Scholar Steffie, Woolhandler & David U., Himmelstein, The Deteriorating Administrative Efficiency Of The U.S. Health Care System, 324 New Eng. J. Med. 1253 (1991)Google Scholar [hereinafter Deteriorating Administrative Efficiency].

3 See George K. Bryce, Medicare On The Ropes, 82 Can. J. Pub. Health 75 (1991). For suggested reforms, see Raisa B. Deber, Regulatory and Administrative Options for Canada's Health Care System, (Aug. 27, 1991) (unpublished manuscript prepared for The Health Action Lobby (“Heal“), on file with the American Journal of Law & Medicine).

4 See Canada Department of Finance, Cost of Government and Expenditure Management Study: Review of Federal and Provincial Cost-Containment Initiatives (1992) [hereinafter Ottawa Report]. See also British Columbia Royal Commission on Health Care and Costs, Closer to Home: Summary of the Report of the British Columbia Royal Commission on Health Care and Costs 10-11 (1991) [hereinafter Closer to Home].

5 This argument was popularized by Victor R. Fuchs. See Victor R. Fuchs, who Shall Live? Health, Economics, and Social Choice 6 (1974). See also Robert G. Evans & Greg L. Stoddart, Producing Health, Consuming Health Care 23-28 (May 1990) (Centre for Health Economics and Policy Analysis Working Paper No. 90-6, on file with the American Journal of Law & Medicine); Michael Rachlis & Carol Kushner, Second Opinion: What's Wrong with Canada's Health Care System and How to Fix it 4, 17-18 (1989).

6 See, e.g., Closer to Home, supra note 4, at 15, 19-20; Rachlis & Kushner, supra note 5, at 4-5.

7 Richard B. Saltman & Casten Von Otter, Planned Markets and Public Competition: Strategic Reform in Northern European Health Systems 81-82 (1992).

8 As described below in Part II, Canada's health care system is heavily intertwined with federal- provincial relations and, as such, is vulnerable to any constitutional changes in the distribution of power among levels of government. Deber, supra note 3, at i.

9 Press Release, President Bush's Plan for Comprehensive Health Care Reform (Aug. 2, 1992) (on file with the American Journal of Law and Medicine).

10 Can. Const. (Constitution Act, 1867) pt. VI (Distribution of Legislative Powers), § 92(7). Canada was established as a loose confederation of 4 provinces. The British North America (“BNA“) Act of 1867, now known as the Constitution Act, 1867, set up an organizational structure for the new nation and divided powers between the provincial governments and the new national (federal) government in Ottawa. See generally id. The BNA Act assigned all matters of national concern, plus those endeavors likely to be costly, to the federal government, which had the broadest tax base. Id. § 91. Ottawa was given jurisdiction over such items as railways, canals, coinage, and, in the health area, quarantine, marine hospitals, and health services for native peoples and the armed forces. Id. The provinces were given authority for those local concerns thought to be relatively inexpensive — including roads, education, and “[t]he Establishment, Maintenance and Management of Hospitals, Asylums, Charities, and Eleemosynary Institutions in and for the Province, other than Marine Hospitals.” Id. § 92(7). Municipal governments were given only such powers as the provinces would delegate to them. The federal role in health policy was, thus, formally limited to: (1) those few activities specified in the BNA Act (for example, health services for the armed forces, residents of the territories, and the native population, and powers over quarantine); and (2) the “health protection” concerns of food and drug safety, deemed to be under federal jurisdiction through its criminal law, trade and commerce, and “peace, order and good government” powers. See Peter W. Hogg, Constitutional Law of Canada 476-77 (3d ed. 1992).

11 See, e.g., Malcolm G. Taylor, Health Insurance and Canadian Public Policy 381, 415 (1987); Eugene, Vayda & Raisa B., Deber, The Canadian Health-Care System: A Developmental Overview, in Canadian Health Care and the State: A Century of Evolution 125, 127 (C. David Naylor ed., 1992).Google Scholar

12 Hospital Insurance and Diagnostic Services Act, ch. 28, §§ 4, 5(2), 1956-1957 S.C. 155 (Can.).

13 Medical Care Act, R.S.C., ch. M-8, §§ 2, 5 (1970) (Can).

14 Federal-Provincial Fiscal Arrangements and Established Programs Financing Act, ch. 10, 1976-1977 S.C. 301 (Can.), renamed by the Federal-Provincial Fiscal Arrangements and Federal Post-Secondary Education and Health Contributions Act, R.S.C., ch. F-8, § 4 (1985) (Can.).

15 See Alistair Thompson, Financing Health Care 17 (Aug. 30, 1991) (unpublished manuscript, on file with the American Journal of Law & Medicine). Under the formula used for HIDS and the Medical Care Act, provincial governments received matching funds from the federal government for “shareable” expenditures, although the formula included provisions (e.g., using national cost data), which meant that federal payments amounted to slightly more than 50 percent of the costs of the poorer provinces. EPF altered the formula so that provinces would no longer have to compute eligible expenditures. Instead, the federal government divided its contribution into two pieces: (1) a direct grant, which became part of provincial general revenues; and (2) the federal lowering of federal tax rates for personal and corporate tax, which allowed provincial governments to increase their tax rates without increasing the total tax burden. The payments would increase, indexed to population growth and growth in GNP. Subsequent unilateral decisions by the federal government to reduce the growth rate have meant that an increasing proportion of the transfer arises from the imputed value of the tax points. It is estimated that, if current trends continue, the cash portion of federal revenue-sharing will completely disappear within two decades. Michael Rachlis, The Impact of the 1991 Federal Budget on Health Care, Public Health Programs and the Health Status of Ontario Citizens 3 (May 8, 1991) (unpublished manuscript, on file with the American Journal of Law and Medicine); Bryce, supra note 3, at 75-76; Mhatre & Deber, supra note 1, at 646-47, 652-53.

16 Canada Health Act, R.S.C., ch. C-6, §§ 7-13 (1985) (Can.). The Canada Health Act replaced HIDS and the Medical Care Act and reaffirmed the terms and conditions that provincial plans must meet to receive federal funding under EPF. Id. § 32.

17 See S., Heiber & R., Deber, Banning Extra Billing in Canada: Just What the Doctor Didn 't Order, 13 Can. Pub. Pol'v 62, 66–67 (1987).Google Scholar

18 Rachlis, supra note 15, at 3.

19 The model is applied in Raisa B. Deber et al., International Healthcare Systems: Models of Financing and Reimbursement (May 5, 1993) (unpublished manuscript, on file with the American Journal of Law & Medicine) [hereinafter Models of Financing]. Certain elements of “private” systems are discussed in Paul Starr, The Meaning of Privatization 1-6 (1985) (Project on the Federal Social Role, National Conference on Social Welfare Working Paper No. 6, on file with the American Journal of Law & Medicine).

20 See Models of Financing, supra note 19, at app. A, i-xx.

21 Marc Bendick, Privatizing the Delivery of Social Welfare Service 21 (1985) (Project on the Federal Social Role, National Conference on Social Welfare Working Paper No. 6, on file with the American Journal of Law & Medicine).

22 W.A. Glaser, Health Insurance in Practice: International Variations in Financing, Benefits, and Problems 193-95 (1991).

23 Models of Financing, supra note 19, at 86.

24 Glaser, supra note 22, at 399-400.

25 Saltman & Von Otter, supra note 7, at 25.

26 See, e.g., GAO Report, supra note 2, at 18; Stephen M., Shortell, A Model For State Health Care Reform, Health Aff., Spring 1992, at 108Google Scholar (Shortell's reform model features health promotion and accountability regions (“HPARs“), which are organized public and private partnerships at the state level that include benefit packages and financing options, and link the functions of planning, insurance, payment, delivery, and evaluation); Stephanie, Woolhandler, Reforming Health-Care Financing in the United States, in Health Care Innovation, Impact and Challenge 111, 128 (S. Mathwin, Davis ed„ 1992).Google Scholar

27 For information on the higher economic efficiency of single-payer systems, see generally Organization for Economic Co-Operation and Development, Health Care Systems in Transition: The Search for Efficiency (1990) (presenting a comparison of international health care expenditures) [hereinafter Health Care Systems].

28 See supra note 10 and accompanying text.

29 For example, the prohibition of direct charges to patients for insured services means that managed care programs in Canada cannot “lock in” their patients. See Mariann. Lam. Et al., Managed Care in Canada: The Toronto Hospital's Proposed Comprehensive Health Organization 67-69 (1991). Indigent care is also not an issue in a system with universal coverage. Patients have free choice of providers, without any limitations based on income or insurance coverage.

30 A primary cause for Canadians’ going to the United States arises from Canada's universal system. In general, providers attempt to give priority to those with the highest medical needs. This may, on occasion, disgruntle wealthier individuals whose health would not be impaired by waiting, but who find it more convenient to “jump the queue.” If such individuals choose to go to the United States at their own expense to make use of their neighbor's underutilized facilities, most Canadians have not regarded this as a policy disaster. Other pressure points can arise in border communities with insufficient population to warrant specialized facilities. Since individuals in those communities must travel for care, they may often prefer to go the shorter distance. Windsor, Ontario is a classic example, since the Detroit hospitals just across the river have considerable excess capacity and have actually tried to attract Canadian patients. In our view, neither explanation constitutes a structural weakness of the Canadian model.

31 C. David, Naylor, A Different View of Queues in Ontario, Health Aff., Fall 1991, at 110, 114Google Scholar [hereinafter A Different View]; Rachlis & Kushner, supra note 5, at 60-61.

32 A Different View, supra note 31, at 110, 115-16.

33 See Dale A., Rublee, Medical Technology in Canada, Germany, and the United States, Health Aff., Fall 1989, at 178.Google Scholar

34 Geoffrey, Anderson et al., Hospital Care for Elderly Patients with Diseases of the Circulatory System: A Comparison of Hospital Use in the United States and Canada, 321 New Eng. J. Med. 1443 (1989).Google Scholar For a comparison of admissions, length of stay, and costs between United States and Canadian hospitab, see Donald A., Redelmeier & Victor R., Fuchs, Hospital Expenditures in the United Stales and Canada, 328 New Eng. J. Med. 772 (1993).Google Scholar

35 See, e.g., Robert G., Hughes et al., Hospital Volume and Patient Outcomes, 26 Med. Care 1057, 1067 (1988).Google Scholar

36 Theodore R., Marmor, Commentary on Canadian Health Insurance: Lessons for the United States, 23 Int'L J. Health Services 45, 57 (1993).Google Scholar

37 See Anderson et al., supra note 34, at 1448.

38 Robert G., Evans et al., Controlling Health Expenditures: The Canadian Reality, 320 New Eng. J. Med. 571, 571, 572 (1989)Google Scholar [hereinafter Controlling Health Expenditures]; George J., Schieber & Jean Pierre, Poullier, International Health Care Expenditure Trends, Health Aff., Fall 1989, at 169, 172.Google Scholar See generally Health Care Systems, supra note 27 (presenting a comparison of international health care expenditures).

39 GAO Report, supra note 2, at 6-7, 63.

40 See Charles J., Wright, Physician Remuneration: Fee-for-Service Must Go, But Then What?, in Restructuring Canada's Health Services System: How do we get there from Here?, supra note 2, at 35, 37–38;Google Scholar Morris L., Barer et al., Fee Controls as Cost Control: Tales from the Frozen North, 66 Milbank Q, 1, 25, 32 (1988).Google Scholar

41 See Deteriorating Administrative Efficiency, supra note 2, at 1253; GAO Report, supra note 2, at 39-41. The extent of administrative savings is a contentious issue; for obvious reasons, the private insurance industry has challenged these estimates, but the direction is clear.

42 See, e.g., Carolyn, Tuohy, Conflict and Accommodation in the Canadian Health System, in Medicare at Maturity 393, 406-07, 422-23Google Scholar (Robert G. Evans & Greg L. Stoddart eds., 1986); Carolyn J., Tuohy, Medicine and the State in Canada: The Extra-billing Issue in Perspective, 21 Can. J. Pol. Sci. 268, 294 (1988).Google Scholar

43 See Controlling Health Expenditures, supra note 38, at 472-73.

44 The Management Information System Project is a cooperative effort to determine standards for hospital information systems.

45 The Clinton/Gore Health Care Plan, U.S. Newswire, Sept. 24, 1992, available in Lexis, Nexis Library, U.S. Newswire File.

46 See, e.g., Ross M., Mullner et al.. Rural Community Hospitals and Factors Correlated with Their Risk of Closing, 104 Pub. Health Rep. 315, 315 (1989)Google Scholar (noting that as many as 600 of the remaining 2700 rural hospitals in the U.S. appear likely to close).

47 See Mhatre & Deber, supra note 1, at 662-64.

48 See U.S. Influences On Canada, supra note 2, at 144.

49 George J. Schieber & Jean-Pierre Poullier, Overview of International Comparisons of Health Care Expenditures, in Health Care SYSTEMS, supra note 27, at 11.

50 Schieber & Poullier, supra note 38, at 171.

51 See generally Health Care Systems, supra note 27 (presenting a comparison of international health care expenditures).

52 Barry R. Furrow Et al., Health Law 466 (2d ed. 1991).

53 For an excellent analysis of the many meanings inherent in the concept of equity, see Deborah A. Stone, Policy Paradox and Political Reason 30-48 (1988).

54 For a thorough discussion of moral hazards, see Carol A. Heimer, Reactive Risk and Rational Action: Manacing Moral Hazards in Insurance Contracts 8-9 (1985).

55 Rashi Fein, Medical Care, Medical Costs: The Search for a National Health Policy 30 (1986).

56 Most Flex Plans Have ‘Opt-Out’ Provisions, Natl. Underwriter, June 18, 1990, available in Lexis, Nexis Library, Natl. Underwriter File (quoting Stephen Fein).

57 Fein, supra note 55, at 187-88.

58 See, e.g., Marmor, supra note 36, at 45, 46-47; Woolhandler, supra note 26, at 114.

59 Malcolm G. Taylor, Health Insurance and Canadian Public Policy 4 (1978).

60 Robert G. Evans, Strained Mercy: The Economics of Canadian Health Care 43 (1984).

61 Saltman & Von Otter, supra note 7, at 8.

62 Robert G., Evans et al., The 20-Year Experiment: Accounting for, Explaining, and Evaluating Health Care Cost Containment in Canada and the United States, 12 Ann. Rev. Pub. Health 481, 513-14 (1991).Google Scholar See also Glaser, supra note 22, at 71-73; Richard B. Saltman, Recent Health Policy Initiatives in Nordic Countries, Health Care Financing Rev., Summer 1992, at 157.

63 U.S. Influences On Canada, supra note 2, at 148.

64 Aaron Wildavsky, Speaking Truth to Power: The Art and Craft of Policy Analysis 58 (1989).

65 See Evans & Stoddart, supra note 5, at 54-56. See generally Ontario Premier's Council on Health Strategy, Nurturing Health: A Framework on the Determinants of Health (1991) (summarizing how social, economic, and environmental factors outside the health care system play key roles in our individual and collective well-being).

66 See Jonathan Lomas Et al., The Price of Peace: The Structure and Process of Physician Negotiations in Canada 3 (Aug. 1992) (Centre for Health Economics and Policy Analysis Working Paper No. 92-17, on file with the American Journal of Law 6f Medicine).

67 See, e.g., Donald M., Berwick, Continuous Improvement as an Ideal in Health Care, 320 New Eng. J. Med. 53–56 (1989)Google Scholar [hereinafter Continuous Improvement]; see also Donald M. Berwick, Curing Health Care (1990).

68 Heiber & Deber, supra note 17, at 66-67.

69 Data provided by the Policy, Planning and Information Branch of National Health and Welfare, Canada, indicates that the proportion of national health expenditures borne privately had increased from 23.6% in 1975 to an estimated 27.8% in 1990. Health and Welfare Canada Policy, Planning and Information Branch, Health Expenditures in Canada Fact Sheets (1993) (Table I). National health expenditures as a proportion of GDP had increased from 7.2% to 9.4% in that same period. Id.

70 Felicity Barringer, Florida Enacts Law Seeking Insurance for All Employees, N.Y. Times, Mar. 26, 1992, at B12.

71 See Continuous Improvement, supra note 67, at 54.

72 Mhatre & Deber, supra note 1, at 662-63.

73 See Louise B. Russell, Is Prevention Better than Cure? (1986) (discussing the limitations of prevention).

74 William G., Weissert, Cost-effectiveness of Home Care, in Restructuring Canada's Health Services System: How do we get there from Here?, supra note 2, at 89, 91.Google Scholar

75 The Clinton Administration reversed this ruling, granting Oregon a Medicaid waiver that cleared the way for its rationing experiment, but with major revisions of the plan's details. Robert, Pear, U.S. Backs Oregon's Health Plan for Covering All Poor People, N.Y. Times, Mar. 19, 1993, at A8.Google Scholar

76 Evans, supra note 60, at 249.

77 Barringer, supra note 70, at B12.

78 David P., Fan & Lois, Norem, The Media and the Fate of the Medicare Catastrophic Extension Act, 17 J. Health Pol., Pol'y & L. 39, 54 (1992).Google Scholar