Association for Public Policy Analysis & Management

To date efforts to expand Medicare have been fragmented, with services such as prescription drugs and mental health vying for priority. This competitive approach has limited the political base of support for reform and left those least able to afford care most likely to face the highest costs. Through a more systematic examination the range of services that fall outside of the Medicare basket in at least one province, this study aims to lay the foundation for more comprehensive reform. First, the mix of public and private coverage for services such as dental, mental health, and vision care are identified, including how much of the costs are covered, for what range of care, and for what part of the population. This analysis is then extended to consider the extent and nature of interactions between insurance models for different services, and the contributing policy factors. Data is drawn from provincial government sources, professional associations, and benefit plans. Anticipated findings include variations in insurance models and a tendency to opt for targeted reforms, with different patchworks of employment-based benefits, targeted public insurance, limited direct public funding, and private care that is paid for out of pocket. Anticipated contributing policy factors include competition between service sectors, physician dominance, fiscal federalism, a segmented electorate, and an ideological orientation toward targeted approaches typical of liberal welfare states. Comprehensive reforms would be more costly for governments but may be the only way to grow large enough political base to truly expand the Medicare basket.