What’s the deal with Canadian healthcare?

One question I am often asked by my American friends is “Explain Canadian healthcare to me.” (I guess that is more of a statement!). I consider myself fortunate—most of the time—to live in Canada. Sure, there are occasionally (read: often) really long waits for certain medical tests, like medical imaging such as an MRI or CT scan, but the reality is, if you need those tests urgently, you will get them faster. I would presume—hopefully—the same to be for long specialist waits. Barring those things, here is how the Canadian healthcare system functions:

Canadian healthcare is not free—the pay is just built into your life.

Let’s clear this one up right now: healthcare here is not free. Instead, we pay—in most provinces and territories—two types of tax on just about everything. The first is the federal Goods and Services Tax, 5% that heads back into the government. The second is, in most provinces, the Provincial Sales Tax—in some provinces these are combined as harmonized sales tax or HST. These rates vary from province to province. Essentially, this is mostly how healthcare is funded. You can’t exactly avoid paying for healthcare, so it feels free.

What’s paid for?

Doctor’s visits, emergency room visits, surgery, hospitalizations, medication received in the hospital, medicine received in the doctors office (like if they do an in-office procedure, you don’t pay for say freezing injections), some physical therapy (I’d refer to it as “non-elective”—sports injury? You pay. Congenital or hospital-based? They pay), occupational therapy, medical imaging, lab tests like blood work or spirometry or anything of that nature.

What do Canadians actually pay for?

 I’m fortunate that at this stage in my life everything related to my asthma care is paid for—well, just about. I pay a small fraction of it as my “Pharmacare deductible”. I’ll explain Pharmacare in the next point.
Mental health is questionably covered: a psychiatrist, being a medical doctor, would be covered by the provincial health plan, but a psychologist is not (with the exception of some community clinics that, as you’d expect, typically have long wait lists).

In some situations, you may be able to pay to have certain surgeries done for pay—once again, “elective” surgeries that are often covered if you wait a long time. I know three people, for example, who have paid for gastric bypass surgery out of pocket to avoid long waits and health complications developing before they got the surgery. Ambulances are not covered, dental care is not covered, durable medical equipment is questionable and I would presume your choices may vary depending on your province. For instance, I paid out of pocket for my nebulizer and compressor (and it cost double what the Pari Trek S would have cost in the US—but you can’t order medical supplies from across the border. Many medical supplies are not covered, but some are.

Oh, and the good old doctors note and almost any forms—depending on your physician, I think specialists are less likely to charge for these services—that’ll cost you at least $25.

Dental care is not covered which has caused me the most annoyance, honestly. Orthodontics are not covered. Crutches, canes, braces and orthotics aren’t usually covered (some provinces have some programs for these things. Also, I’m sure crutches are readily available on Kijiji if you don’t want to pay the $25-30 the hospital will charge. But with that said, you probably also have a friend with a pair in their basement that they’ll let you borrow…)

These “gaps in coverage” as they are called—this is where insurance matters, or might matter.

Pharmacare?

Medication being covered is a slippery slope. Pharmacare works for a few populations: the very young, the old, and people who don’t make a lot of money. Pharmacare is “paid for” by a deductible based on your income—I spend 4% of my income from 2 years prior out-of-pocket, after which point most medications are covered. In some provinces, I must point out, the pharmacare system is better and 100% of medication costs are covered with no deductible. The cost of the generic only is covered unless a generic does not (yet) exist. Once I meet my deductible, the province pays the rest. Many medical supplies are also covered, with some maximums per year (which are, at least in Manitoba, pretty generous). Pharmacare also pays for, in Manitoba, one AeroChamber if prescribed by your doctor per year once you’ve met your deductible which I always take advantage of!

How about insurance? What’s the deal with that?

For the past two years, I have been uninsured. Because of various factors, this has not taken a significant toll—I have paid less in healthcare expenses than I would have paid out of pocket for insurance being primarily self-employed. Often, insurance plans are part of the benefits package offered by a person’s employer, and the group insurance plans are often better than individual ones. To pay out of pocket, it’s a delicate balance for me: within the next year, I’ll make the flip where paying for insurance costs less than paying out of pocket based on my upcoming Pharmacare deductible and what I have paid for dental care this year. There are also some benefits—like athletic therapy (I think they’re also known as athletic trainers in the US)—that I would have taken advantage of if I had insurance, but chose to go without.

Supplemental insurance plans essentially “fill the gaps” between provincial medical care expenses. Plans that cover dental care are available at varying rates of coverage and rates of cost. Same with medications, durable medical equipment, semi=private hospital accommodations (which, I’ll note, is in m experience what is most often assigned anyways). The un-covered durable medical equipment or mobility aid costs may be covered by insurance plans as well.

And yes, some insurance plans do require a medical summary prior to enrolment, although the pre-existing condition clauses are variable. Ultimately, insurance companies here know you aren’t dependent on them, so (like sans-Obamacare) it’s harder to get denied, I’d imagine.

Okay what about traveling?

My health benefits do not leave the province I live in. So, for me, travel insurance is a must. This usually only covers emergency care in another province. For instance, I had stitches in January that I needed removed, but that timeframe overlapped a time when I was traveling out of province but within Canada. I did call my travel insurance provider to pose the question of if they’d pay for my stitches to be removed (I didn’t think so), and while he had to do some digging for the answer, ultimately my specific plan didn’t cover it (I presume most would not). However, had I been a part of a different Blue Cross plan that was not limited to travel insurance, it likely would have been authorized. However, had I needed to get the stitches when I was away or had any other sort of medical escapade, that would have been covered.

I consider the Canadian healthcare system to be moderately efficient and very helpful to me. I think there are benefits and drawbacks to each country’s system (although I have heard Sweden is magical?) and there are, I am sure, some gaps in my explanations here. Have questions on specific things I haven’t covered? Let’s chat—leave me a comment and I’ll fill you in!

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