"What's in, what's out": stakeholders' views about the boundaries of Medicare

The Canada Health Act requires that provincial insurance plans provide universal coverage without co-payments for all "medically necessary" services delivered by hospitals and doctors, but allows care delivered by other providers in other locations to fall outside of the boundaries of Medicare. Discussion about the sustainability of medicare at both the national and provincial levels has called for the revisiting of these boundaries. The M-THAC (Medicare to Home and Community) Research Unit attempted to clarify the areas of consensus and controversy as to what key stakeholders thought should be "in" or "out" of Medicare. Using a non-experimental, cross-sectional design, a self-administered survey (in both English and French, constructed in consultation with our partners) was distributed between January and April 2002 to policy elites of key stakeholder groups. The results are based on 2,523 responses. Much of the current "debate" is mired in discussing issues where consensus already exists. We found strong support for in-hospital care. However, there is considerable resistance, across all groups, to full funding for similar services in private clinics or in the home, and almost no support for full funding for non-medical home-based services. The vision of many policy elites remains heavily linked to the current system of guaranteed public funding only for acute care in hospitals or by physicians. Successful reform will need to address, rather than assume, a broader view of healthcare.