INTRODUCTION TO HEALTH SECURITY IN CANADA

Drawing upon Saltman (2002) and Vohlonen et al. (2004), health security can be defined as the portfolio of health services and replacement income available to an individual who is incapacitated or ill. Health security is a measure of both the degree and effectiveness of public policy in providing both access to health care and income support during times of illness and injury.

The precise institutional forms of health security policies vary considerably from country to country, depending upon the historical trajectory of a given polity in terms of welfare and public health care. Recently, a number of countries have attempted to improve the coordination of their health security programming for a host of reasons that include the increasing mobility and migration of population, rising public healthcare costs, change in patient expectations, absenteeism from work, decreasing labour productivity, competitive pressure on states and sub-states to improve tax competitiveness, cost-shifting between and among governments, and the growing ambiguity between unemployment and incapacity policies. In some countries such as Finland, these concerns have prompted a major review of the players and the systems involved in health security (Vohlonen et al., 2004).

Despite the fact that Canada faces many of the same issues that have prompted reviews in other countries, health security – as defined above – has not been the focus of any major review by the federal or provincial governments. First, the concept of health security has not been part of the social policy culture in Canada. Second, as a decentralized federation, Canada's health security programmes are highly fragmented on a jurisdictional basis with a significant number of health services and income replacement programmes funded, administered or regulated in significantly varying ways by 13 separate provinces and territories (Guest, 1997). Third, while there have been major initiatives aimed at coordinating income security programmes on the one hand, and health services on the other, there have been few attempts to integrate policy across these two broad sectors.

Under the Canadian constitution, the country's provinces, rather than the federal government, have always had the primary responsibility for both welfare and health policy, although the federal government has been able to insert itself in both areas through formal constitutional amendments and the use of the spending power (Johnson, 1987). There are important exceptions to this general rule. The federal government has constitutional responsibility for First Nations peoples throughout Canada as well as the Inuit living in the arctic regions and for many of the health security programmes and services relating to these groups. Furthermore, in contrast to the 10 provinces, the three northern territories are creatures of the federal government from a strict constitutional perspective and are fiscally dependent on federal transfers to exercise their delegated programme and policy responsibilities. In reality, however, the territories are well on the road to becoming full-fledged provinces. They exercise many of the responsibilities of the provinces, including the administration and delivery of healthcare services, although they rely to a much more limited extent on their own-source taxation to fund such services.

As the current state of health security is most easily understood in the context of the evolution of the welfare state in Canada, the most relevant parts of this history are briefly summarized (also see Appendix). While there are a large number of social insurance,¹ categorical² and general government programmes and policies that have an impact on the health security of Canadians, there are four that are at the core of the current system: (1) provincial workers' compensation schemes; (2) public health care including universal Medicare; (3) disability pensions and (4) tax credit policy. To permit comparisons with selected countries, these policies and programmes are presented in terms of the respective responsibilities of employers, government ministries and arm's-length workers compensation boards. In addition, the different parts of the health security system are mapped out in terms of the different health conditions they address from injuries and acute or chronic diseases to counseling or treatment for mild conditions or behavioural problems. Finally, Canadian health security is examined in terms of recent initiatives in programme coordination and integration.

HISTORICAL EVOLUTION OF HEALTH SECURITY

Provincial workers' compensation schemes were among the first major social policy initiatives that would make up what we have come to know as the Canadian welfare state. Influenced by similar developments in the United States, Canadian provinces enacted workers' compensation laws before the First World War but it was Ontario's approach, first adopted in 1914, that would become the model for the rest of the country (Bellamy, 1997; Rice and Prince, 2000; Babcock, 2006). The common elements of this model included compulsory contributions by employers administered by a public (but arm's-length) workers' compensation board and income replacement provided on a no-fault basis. Although the initial focus was on income replacement, over time the provincial schemes also paid for medical care and rehabilitation. Eventually, they emphasized workplace safety and prevention.

In the absence of public health care or income support, these provincial workers' compensation regimes marked a considerable improvement in the health security of Canadian workers and their families first by providing replacement income and then by paying for direct healthcare services required to treat the illness or injury caused in the workplace as well as any necessary rehabilitation following treatment. While employees had to give up their common law rights to sue employers, no-fault workers' compensation ensured that employees could count on sufficient resources to address both health and income needs simultaneously (Guest, 1997).

Workers' compensation was not intended to cover those workers who were injured or incapacitated outside of work. Nor did it cover the unemployed or the self-employed. Such individuals were left to fend for themselves and those with few private resources – in particular the poor and the old – had correspondingly little health security. This would change in postwar period through the introduction of welfare, unemployment insurance, a guaranteed payment to seniors and a social insurance pension scheme. Although these programmes were not aimed directly at improving health security, they would act as a security net for those who were not caught by the main health security programmes and policies of the 20th century.

The provinces introduced social assistance plans largely in response to the exigencies of the Great Depression and the failure of municipal relief to deal with the chronically unemployed as well as impoverished farmers and small merchants who lost their property in the upheaval of the 1930s. 'Welfare', as it became known, provided a very minimal level of income support to individuals, and these 'last-resort' and means-tested programmes were very similar to the municipal relief payments that they replaced (Boychuk, 1998). In 1940, the federal government introduced unemployment insurance (now know as Employment Insurance, or EI) after obtaining a constitutional amendment that permitted it to enter a provincial policy domain. In 1951, the federal government followed this up with yet another constitutional amendment allowing it to introduce Old Age Security (OAS), a national programme to improve the then-meager incomes of many older Canadians – a form of income replacement that was substantially enhanced with the introduction of the Canada Pension Plan (CPP) and the Quebec Pension Plan (QPP) in 1965 (Bryden, 1974). To the extent that unemployment insurance included a provision for short-term sick leave and OAS and CPP/QPP provided older individuals with failing health the financial capacity to retire, they directly improved health security.

Going beyond old age pensions, CPP/QPP also provided income replacement for 'severe and prolonged' disability, wherever and however acquired, for the first time. Based on a social insurance plan requiring contributions from both employers and employees, the disability pension (like the main retirement pension portion) of CPP/QPP was intended to fill in the gaps left by provincial workers' compensation, social assistance programmes and private health insurance (Bryden, 1997). Indeed, many of the beneficiaries would turn out to be individuals suffering from chronic diseases or severe and prolonged physical or mental disability. In addition to the disability pension, CPP/QPP provided a disability benefit to the children of contributors as well as a national vocational rehabilitation programme together with return-to-work incentives and support services (Prince, 2002; Torjman, 2002).

The introduction of universal medicare covering medically necessary hospital and physician services was a major step towards more comprehensive health security in that it replaced a system in which most Canadians paid for their healthcare services directly out-of-pocket, or for those who could afford the premiums, through private medical insurance plans.

Financed through general taxation, universal hospitalization was first introduced by the province of Saskatchewan in 1947. This was followed by hospitalization plans, similarly financed though differently administered, in the provinces of Alberta and British Columbia. The federal government then encouraged other provinces to adopt universal hospitalization on the Saskatchewan model by agreeing to cost-share funding if the provinces agreed to certain national standards and principles as set out in series of bilateral agreements as well as a federal law known as the Hospital Insurance and Diagnostic Services Act of 1957. By 1961, all provinces had adopted a similar system of provincial hospitalization (Taylor, 1987). To the extent that all governments relied on taxes rather than user fees to fund hospital and diagnostic care, and access to such care became unconditional, the health security of Canadians, particularly those in lower income brackets, was considerably enhanced (Marchildon, 2005a).

In 1962, the province of Saskatchewan added physician services to the basket of universally available hospital and diagnostic services. The federal government again used its fiscal clout to entice other provinces into adopting the Saskatchewan model as long as those provinces agreed to operate under a set of national principles defined in the Medical Care Act of 1966. By 1972, all 10 provinces and two territories were insuring physician services in universally accessible single-payer systems, again adding to the health security of all Canadians. As in the case of hospitalization, almost all the funding for medicare came in the form of taxation, although some user fees were initially tolerated. With the rise in user fees in the late 1970s and early 1980s, however, the federal government replaced the two older pieces of federal legislation with a new law – the Canada Health Act (1984) – that financially penalized provinces that permitted physicians or health facilities to charge patients user fees. Henceforth, access to medicare services were to be based solely on medical need rather than ability to pay thereby ensuring a high degree of health security for all Canadians (Taylor, 1987).

In the 1970s, the provinces and territories set up public healthcare programmes and subsidies that went well beyond medicare services. These included drug subsidy programmes mainly targeting mainly poor and elderly (65 and older) residents. Provinces also began to provide or subsidize long-term care, especially nursing home care for the elderly as well as institutional care for the physically and mentally disabled and varying degrees of home care services. These largely means-tested programmes were financed through taxation supplemented by user fees including co-payments and deductibles. Some of this new activity had a direct impact on health security by making a broader range of health services, therapies and prescription drugs more accessible to ill or injured individuals, although the impact on outpatient rehabilitation services was limited.

Federal and provincial governments have also directly shaped health security policy through their respective tax systems. The federal government first introduced medical expense and disability tax credits in the 1940s. Beginning in the 1980s, these tax credits were significantly enriched while their scope was broadened considerably through periodic amendments and adjustments (Prince, 2001). Since the early 1980s, the provinces have also been administering tax assistance for their residents with temporary or permanent disabilities. These measures include retails sales tax exemptions for medical care and aids, property tax exemptions as well as other tax deductions (Prince, 2001). While it would be extremely difficult to calculate the aggregate value of these provincial measures, it is likely that they pale in comparison to the aggregate value of federal medical and disability tax expenditure subsidies, which together were worth C$0.9 billion in 2000 and projected to be worth almost C$1.6 billion by 2008 (Canada, 2006a).³

PRINCIPAL PROGRAMME AND POLICY CLUSTERS IN HEALTH SECURITY: INTEGRATION CHALLENGES

For analytical purposes, it is useful to isolate the public programme and policy clusters that have had (and were intended to have) a direct impact on health security in Canada as illustrated in Figure 1. Public healthcare services can be divided into two distinct clusters. The first cluster is made up of medicare services that are available on a universal basis free of any user fees. These are governed by the federal Canada Health Act (CHA) and provincial medicare laws, funded through general taxation by the federal, provincial and territorial governments, and administered and delivered through 13 individual provincial and territorial single-payer health systems. The second cluster is made up of non-CHA healthcare services including public subsidies and supports for long-term care, home care and prescription drug therapies. This group of public healthcare services is funded and administered solely by the provinces and territories. Funded by the provinces through general tax revenues, the terms of access to these goods and services vary considerably from province to province (Marchildon, 2005a).

Figure 1.

Public sector health security in Canada.

Full figure and legend (44K)

Income replacement in the event of illness or injury is provided through three principal clusters of provincial and federal programmes. As social insurance plans funded by employers and employees (and the self-employed), CPP and the QPP disability benefits make up the first cluster of programmes. The second cluster is made up of workers' compensation (WC) programmes funded by employers but administered and delivered by the provinces and territories and governed at arm's length through WC boards and agencies.⁴ Finally, the third cluster involves a range of tax expenditure subsidies, the most important of which are the federal medical expense and disability tax credits.

In theory, there are many potential benefits in terms of integrating – or at least better coordinating – the health security programmes and policies illustrated in Figure 1. These benefits include lowering administrative costs, reducing inappropriate use and improving overall health security. At the same time, however, there are important structural and jurisdictional impediments to integration or improved coordination.

The first impediment is the different ways in which governments fund public programmes and policies. These diverse funding models not only shape the design of such programmes and policies but they also influence the very objectives they are capable of achieving. Based upon a model of contributory payments, for example, social insurance programmes benefit from earmarked funding but suffer from a lack of universality unlike some general tax-funded programmes. Another example involves tax expenditure subsidies that can permit individuals considerable latitude in health security supports but often tend to benefit those with more substantial incomes. The funding for the five main health security policy and programme clusters is set out in Table 1. Three quite different funding models can be observed. The first is general taxation, the second is social insurance and the third involves tax policy. While policy coordination across three such disparate funding models is conceptually possible, it poses enormous challenges for governments.

Table 1 - Funding sources: five main health security policy and program clusters.

Full table

A second impediment to integration is the silo factor. Once established, public programmes tend to be delivered in isolation of other public programmes, even those that have similar or overlapping objectives. In the case of health security, this is exacerbated by the gulf that separates the health services and programme clusters from the income replacement programme and policy clusters. In Canada, as shown in Table 2, different government ministries and agencies are responsible for health services on the one hand and income replacement on the other.

Table 2 - Division of responsibilities among main health security players, Canada.

Full table

Health security focuses on the effectiveness of public health and income replacement policy for individuals who become incapacitated or ill. Another aspect of the silo challenge is that the nature of the incapacity or illness and the impact this might have on the public policy ultimately deployed. Thus, the categorization of the health problem may have an important impact on how it is managed from a public policy standpoint. Table 3 attempts to capture this dimension of the silo problem.

Table 3 - Health security responsibilities for different health problems.

Full table

In order to provide a general picture of the division of responsibilities, Tables 2 and 3 obscure the important federal-provincial division of authority and responsibility within individual programme and policy clusters. Both federal and provincial governments and their ministries and arm's-length agencies are involved in the funding, administration, regulation and delivery of health care, income replacement and tax relief that make up health security. This division between the two constitutionally recognized orders of governments, along with the separate policy trajectories of individual provincial governments, poses a major challenge to the coordination of health security, and prevents the formal integration of health security programmes across the board. It is probably true that horizontal governmental coordination – either federal-provincial or inter-provincial – is more difficult to achieve in Canada than vertical programme and policy integration by a single government.

All of the above-mentioned funding, silo and jurisdictional factors have led to some overlap and duplication. In addition to producing some inefficiency, this has also created a policy tension given the different, and at times conflicting, policy objectives of the overlapping programmes. I now turn to an examination of two of these areas of overlap in health security.

THE WORKERS' COMPENSATION-MEDICARE INTERFACE

An illustration of the challenges faced by governments involves the interface between medicare on the one hand and health benefits paid for by provincial workers' compensation on the other. The area of overlap shown in Figure 1 represents public healthcare services that are paid for by WC social security contributions rather than through general taxation. Based upon Canadian Institute for Health Information (CIHI) expenditure data, WC payments for healthcare services were C$1.4 billion in 2006, which amounts to less than 1.0% of total health expenditures of C$148 billion (CIHI, 2006).⁵ Although this appears to be a small percentage share, the clash in principle between the policy objectives of WC (to get workers back into the workplace as quickly as possible) and medicare (where urgency alone is to determine an individual's position in the queue for medically necessary services) has emerged as a major policy issue.

In the early to mid-1990s, provincial governments throughout Canada restrained programme spending to eliminate deficit spending (Richards, 2000). Healthcare cuts were large enough to produce a negative growth rate in real health expenditures during these years (Marchildon, 2005a; Tuohy, 2002). With a decline in the purchase of new capital equipment, including advanced diagnostic imaging, and a decline in the number of nurses and family physicians, bottlenecks developed and wait times increased. Trying to get workers treated and rehabilitated as quickly as possible, WC boards and agencies were prepared to pay a premium to gain preferential access to public facilities and health human resources. In some provinces such as British Columbia, WC boards paid for physicians who welcomed the opportunity to work outside the public system (Campolieta and Lavis, 2000).

Before the 1990s, WC patients and 'regular' medicare patients had access to the same basic diagnostic, physician and hospital services on largely the same terms and conditions despite the fact that WC was exempt from the Canada Health Act and its five principles of public administration, universality, portability, comprehensiveness and accessibility. WC clients did have greater access to a broad range of rehabilitation services but this was largely understood in a context where governments expected and encouraged WC clients to return to work as soon as possible. With the budget cuts of the 1990s, however, the challenge posed by WC to medicare policy became more direct. The vaunted 'one-tier' feature of Canadian medicare was under increasing strain as WC funding allowed WC clients faster access to hospital and physician services, a form of 'officially sanctioned queue-jumping in the public system' (quoted in LeBourdais, 1999).

Added to the fact that WC expenditures generally have been growing faster than the rate of medicare expenditures since at least the early 1970s, this differential access translated into a growing problem for both levels of government (Campolieta and Lavis, 2000). As a consequence, the recent Commission on the Future of Health Care in Canada recommended that the WC exception to the Canada Health Act be reviewed by both orders of government in an effort to eliminate this public source of queue-jumping (Canada, 2002).

Such a review would require the support of 13 provincial and territorial governments to expend time and political capital on the problem (assuming they even agree on the nature of the policy problem), an agreement on an intergovernmental advisory body to conduct such a review as well as the willingness to act in concert on the recommendations of the advisory body. In the current political environment, even getting to step one would be extremely difficult. At least one provincial government has suggested that the WC exception to medicare, and the private clinics it has spawned, has actually been a positive development. Another provincial government has continually expressed its concern about the universality principle of medicare and has openly endorsed a recent Supreme Court of Canada decision that puts into question that ability of provinces to prohibit private insurance challenges to provincial single-payer medicare (Flood and Archibald, 2001; Marchildon, 2005b).

THE INCOME REPLACEMENT OVERLAP: PROVINCIAL WORKERS' COMPENSATION AND FEDERAL DISABILITY PENSIONS

While a portion of WC funding flows into health services, the majority of WC funds are earmarked for income replacement payments. In 2003, roughly $4.5 billion – or 70% of total WC benefits – were earmarked for income replacement. This compares to the roughly $3 billion that was paid out in CPP disability benefits that year.⁶ Thus, approximately $7.5 billion in total was transferred to Canadians by a combination of provincial agencies and the federal governments as income replacement for both short-term and long-term incapacity caused by illness or injury.⁷ Both groups of policies are predicated on the assumption that individuals have a social and legal responsibility to minimize programme benefit and social costs. Individuals are expected to provide accurate information, participate fully in rehabilitative efforts and return to work as quickly as possible, even if this requires substantial retraining efforts. Throughout treatment and rehabilitation, individuals are monitored by physicians and other health providers as well as case managers, and reports are filed by these professionals concerning eligibility for future benefits (Canada, 2004b).

There are, however, significant differences between the two sets of programmes. The purpose of WC is to provide compensation 'for earnings loss in the event of work-related accident or injury', while CPP/QPP pays 'benefits in the presence of severe and prolonged disability that prevents a person from working at any job, regardless of cause' (Torjman, 2002, p. 52). This produces overlap and, in theory, a worker could receive benefits under both WC and CPP/QPP. In practice, however, only a few provinces permit WC benefits to be added to CPP benefits; in most, CPP disability benefits are deducted from WC payments. In Quebec, where both regimes are administered provincially, workers with job-related injuries or illnesses must first rely on WC and, only if they are ineligible for WC, are then permitted to apply for disability benefits under QPP (Torjman, 2002).

INTEGRATION OF HEALTH SECURITY

Given the enormous funding, silo and jurisdictional challenges to health security integration in Canada, it is hardly surprising that the federal, provincial and territorial governments have not embarked upon a comprehensive reform of health security. At the same time, however, governments have initiated major reviews aimed at integrating or better coordinating aspects of health security including health services on the one hand and income replacement on the other. On the heels of major reviews of their respective health systems, almost all provinces created geographically based regional health authorities to better integrate medicare services with other public healthcare services (Marchildon, 2005a). The federal government has periodically reviewed its income replacement programmes in an effort to not only integrate federal income policies but to dovetail them with provincial income replacement programmes (Johnson, 1987).

Given the constitutional division of responsibility among jurisdictions in Canada, perhaps the most effective approach is one of coordination in which existing federal and provincial programmes remain in place but they share some common functions. One of these could be the assessment and rehabilitation of disabled individuals. As Torjman (2002) points out, the CPP, which is administered by a federal department (Human Resources and Social Development Canada), has tested a model of integrated assessment and rehabilitation with the Workers' Compensation Board of British Columbia, the British Columbia Ministry of Labour and the federal government's own regional Employment Insurance office.⁸

Using a case management methodology, this pilot project required that each claimant be assigned to one organization (on behalf of both governments) – the British Columbia Paraplegic Association – which then completed a needs assessment, a rehabilitation potential assessment, a rehabilitation plan and a training programme. This same case worker then assisted the disabled individual to find a work placement. While Torjman (2002) does not indicate the outcome of the pilot project, she does indicate that the administrative complexities would necessitate a province-by-province approach in the future. Given the jurisdictional authorities and responsibilities of the provincial governments in particular, a province-by-province approach to this type of integration would also be necessary from a constitutional standpoint.

The federal government has made some major strides in rationalizing its tax policies as they relate to disability. In 2003, an independent advisory committee was appointed to improve the effectiveness and, in particular, the fairness of the existing system (Canada, 2004a). In response to the Committee's recommendations, the federal government initiated three major changes. These included clarifying (and broadening) eligibility for the disability tax credit while improving the administration of the tax, introducing a disability deduction for education and training, and doubling the limit of the medical expenses claimable for dependents from C$5,000 to C$10,000 (Torjman, 2005). Following a recent World Health Organization report which captured an emerging trend of viewing disability as the interaction between impairment and 'externally imposed limitations on activity', the Committee recommended that future policy be based upon a social model of disability. This will lead to a 'broader list of functions for the disability tax credit' including mental functions such as 'diseases and conditions affecting memory, problem solving, judgment, perception, learning, attention, concentration, verbal and non-verbal comprehension and expression, and the regulation of behaviour and emotions' (Canada, 2004a, p. 114).

CONCLUSION

This study is necessarily limited by the relative lack of research and analysis concerning the interplay between income replacement benefits and pensions through WC and CPP on the one hand, and public healthcare services on the other. Despite the fact that WC financing of health services has become a centre-piece in the ongoing public–private debate in Canada, virtually no scholarly work has been published on the impact of WC sector on public health care much less than its long-term impact on health security.

While CPP disability funding does not impinge in the same way as WC on universal health services financed through general taxation, there has been relatively little study of the impact of CPP disability policies on overall health policy. At the same time, any future analyses of this issue might be more productive if they use the concept of health security as a starting point, although it must be recognized that the various impediments to programme and policy integration in health security, particularly the constitutional nature of what has become a highly decentralized federation, are enormous in the case of Canada.

Rehabilitation services that are directly connected to hospital (acute-care) services are treated in most provinces like other medicare services. At the same time, most rehabilitation services, including vocational rehabilitation, that occurs outside the hospital environment remain outside the medicare system. Outpatient rehabilition, as opposed to inpatient rehabilitation through medicare, is funded through a variety of sources including private health insurance, workers' compensation benefits, as well as public no-fault automobile insurance in some provinces and private tort-based claims in other provinces.

Overall, Canadians tend to focus more heavily on policies involving access to healthcare services rather than income replacement. This is likely a consequence of the fact that a sizeable majority of Canadians have, for decades, perceived medicare as the 'jewel in the crown' of Canadian social policy. While universal health care has become an integral part of the Canadian identity (and is regularly used to distinguish Canada from the United States), income support policies and programmes are not given such status and have received correspondingly less attention.

At the same time, numerous studies have pointed out the strong and positive relationship between more equitable income distribution and population health in high-income countries (Wilkinson, 1996; Kawachi and Kennedy, 1997). A recent time series study on income equality and mortality in Canada takes this work one step forward with results that highlight the significance of both income dispersion and unemployment on the one hand and health care spending on the other (Laporte and Ferguson, 2003). In general, these studies support the notion that properly designed income replacement policies and programmes for ill or injured individuals are central to health security.

Notes

¹ Social insurance programs include provincial workers' compensation boards, federal Employment Insurance benefits and Canada Pension Plan/Quebec Pension Plan disability pensions.

² Government-led categorical programs include criminal injuries compensation, no-fault public automobile insurance and veterans' benefits.

³ The 2000 estimate was arrived at by adding the estimated value of disability tax credit ($275 million), the medical expense tax credit (C$550 million) and the refundable medical expense supplement ($52 million). The 2008 projection was calculated by adding together Finance Canada's projections for the disability tax credit (C$475 million), the medical expense tax credit (C$995 million) and the refundable medical expense supplement ($110 million). See Canada, 2006a.

⁴ The 12 WC organizations are: Workers' Compensation Board of British Columbia; Workers' Compensation Board of Alberta; Workers' Compensation Board of Saskatchewan; Workers' Compensation Board of Manitoba; Workplace Safety and Insurance Board [Ontario]; Commission de la Santé et de la Sécurité du Travail [Quebec], Workplace Health, Safety and Compensation Commission [New Brunswick]; Workers' Compensation Board of Nova Scotia; Workers Compensation Board of Prince Edward Island; Workplace Health Safety and Compensation Commission [Newfoundland and Labrador]; Yukon Workers' Compensation, Health & Safety Board; and the Workers' Compensation Board of the Northwest Territories and Nunavut.

⁵ Total social security expenditures amounted to approximately 2.1$ billion in 2002. Most of this (minus the $700 million expended through the Quebec drug insurance fund) was for workers' compensation health benefits. See CIHI (2006).

⁶ Campolieta and Lavis (2000, p. 1152) state that total WC expenditures were $5.05 billion in 1994, most of this in the form of income replacement while WC expenditures on health services were $0.48 billion in 1994, a mere 9.5% of the total. In the case of CPP disability benefits, Prince (2002, p. 10) provides some data for 1999–2000: $2.6 billion in disability pensions paid to 287,000 CPP contributors; and $245 million in disability benefits paid to the children of contributors. However, Prince did not estimate the value of the national vocational rehabilitation program and other related return-to-work support services and incentives.

⁷ This does not include Quebec because of the separate operation of the QPP.

⁸ This pilot project also involved the private sector insurance industry since it dealt with automobile insurance as well.

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Appendices

Appendix: Chronology of public sector health security programmes and policies in Canada

Table A1

Table A1.

Full table

Acknowledgements

I have benefited greatly from the comments of Peter Allebeck, Richard Saltman and Sherri Torjman on an earlier draft.