At the very foundation of Canada's publicly funded, universally accessible health care system is a broad consensus among Canadians that medical care "is not a commodity" but a "moral enterprise," according to Roy Romanow, chair of the Commission on the Future of Health Care in Canada.

Romanow spoke about the future of Canada's medical care system during a panel discussion held at the Law School on Oct. 17. Sponsored by the Yale Center for International and Area Studies and the Canadian Consulate, the event featured a panel of experts on Canadian health care policy, moderated by Yale School of Management Professor Theodore Marmor.

Romanow discussed the history of Canada's health care system and some of the difficulties that might threaten its long-term survival in its present form. As chair of the commission studying the Canadian Medicare system, as it is known, Romanow will present a report to the prime minister next month recommending courses of action to deal with the health care "issues and debates" in Canada.

"I want to begin by clearing up a popular myth," Romanow said. "There's a misconception ... that Canada has one big public health care system." In fact, he said, Canada's public health care is made up of at least 13 systems, each governed by the country's separate provinces and territories.

Although they have automony in deciding how to administer health care, these regional governments all must meet the mandate set out by the federal government in the Canada Health Act of 1984. That law states that "all patients are entitled to receive medically necessary services delivered by doctors and hospitals," explains Romanow, and it further stipulates that all health coverage must be "universally available, comprehensive, portable, accessible and publicly administered."

Romanow described Canada's three tiered system of medical care, which depends on a loosely configured formula of public and private contribution. Slightly more than 40% of health care coverage for necessary medical treatment is paid through public funding -- that is, by taxpayers through a progressive tax system.

Drugs, home care and long-term care are among the goods and services that fall within the second tier, which accounts for 30% of health care costs. Financing at the second-tier level is provided by a blend of public and private contributions, largely established by the individual provincial governments. Most provinces provide drugs at no cost to old, disabled or poor patients, said Romanow, noting that those who don't qualify for free prescription medicine pay either through private insurance or out-of-pocket.

The third tier of the system -- accounting for the final 30% of health care costs -- includes such services as dental care, psychotherapy and optometry. This is paid for almost entirely by individuals through private insurance, out-of-pocket contributions or some combination of both, he explained.

"A few people," Romanow said, believe that the current system is too expensive and inadequate to meet current demand, let alone future needs. He dismissed this belief. "Keeping needs, services and resources in balance is a very, very tough challenge and an ongoing challenge," Romanow conceded, noting that the factors threatening the long-term sustainability of the current system include an aging population, great advances in costly medical technology and increased expectations for services.

In terms of financial resources, however, Romanow pointed to the "interesting and little reported fact" that of the three tiers of the health care system, the first -- public spending for medically necessary services -- is by far the most efficient and effective way of keeping costs down.

"Per capita spending on these publicly funded hospital and physician services is the same today essentially as it was in 1991," he said. Drug costs, on the other hand, which are funded by a mixture of private and public contributions, have doubled in the last 25 years, he noted.

Romanow cited a Harvard study estimating that Canadians spend two-thirds less than Americans on health care administration. He cited 1999 data showing that each Canadian pays $3.25 per year compared to $11.50 by each American.

Not only should Canada continue its program of publicly funded, universal health care, but it should expand the medical services that fall within the first-tier of the system, Romanow argued. Whether medical care is paid for through taxes or individual premiums in private insurance, he said, it is the individual citizen that foots the bill. Though this might cost more in public funding in the short term, he said, in the long term this offers the most cost-effective future for health care.

Romanow also acknowledged criticisms that the Canadian system is too slow to deliver services and compromises quality of care, and that there is too much "tier jumping," giving wealthier individuals who can pay for private services an advantage over most of their fellow citizens.

Without getting into the details of the proposals he will make to the Canadian government, Romanow recommended an overall increase in "wellness" programs and primary care, shifting medical services away from hospitals and individual physicians to "team" health care delivery, and an emphasis on preventive medicine.

As to the future of the Canadian system, Romanow said, "Any public health care system is as sustainable as a given society wills it to be." Canadians, he contended, would not tolerate a system that denies or compromises universal accessibility to medical care to all its citizens.

-- By Dorie Baker

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