Health and education are provincial matters under the Canadian Constitution, i.e., they are, in American terms, not “Federal” but rather “State's rights” matters. Universal Health Insurance is therefore a provincial scheme, i.e., developed by each province. It began when the Federal Government offered to reimburse 50% of the cost of any provincial plan, provided it had two features: (1) “Universality”, defined as covering at least 90% of the population, and (2) “Public Administration”. The ten provincial schemes have these features, and all provinces have had health insurance for nine to ten years.
In the Province of Quebec, psychoanalysis was originally left out of their plan by a deliberate government decision (largely on the advice of a Quebec psychoanalyst and politician). Later, it was partially included, in that it was made available, at low levels of government reimbursement, only at specific teaching hospitals that taught many aspects of psychiatry, including psychoanalysis, and that had analysts on their staffs. Thus psychoanalytic treatment is only available at public expense in Quebec, if done at the few selected hospitals and at the low government rates of pay. Most of the analysts in Montreal and in Quebec City offer psychoanalytic treatment largely outside of the health scheme, their fees paid by the patient.
The rest of Canada (particularly Ontario with its large number of analysts), operates under health schemes that include psychoanalysis as one of the insured services. All Canadian health insurance offers a fee-for-service system of individual payment for each “medical act”, affecting those analysts in Toronto, Ottawa, London, Ont., Edmonton, Saskatoon, Winnipeg, and Vancouver.
In the province of Ontario, for example, psychoanalysis is paid at the same rate as other psychotherapeutic medical acts. The current Ontario rate is $68.80 for a psychiatric consultation (done by a “Psychiatric Specialist”) and $65.40 an hour for 45 minutes of psychotherapy, including psychoanalysis. Fees are higher in the Canadian West. There are no limits as to number of treatments, which is determined by the needs of the patient's clinical condition.
Such unlimited coverage works because there is a normative population base to the health insurance scheme, in that the entire population, not just a middle-class
section, is covered. In more fragmentary private schemes, where only the well-to-do (those that can afford private insurance) and likely better educated receive the benefits, these individuals make a disproportionately high demand for psychoanalysis, driving up its overall cost in the plan.
Psychoanalysis does not cost a disproportionately large amount of the money allotted for psychiatric services in an insurance plan that insures everybody, because only a small proportion of patients receive this highly specialized treatment.
Psychoanalysis under such health insurance is made available to a much broader socio-economic spectrum of patients, although the indications for psychoanalysis remain what they have always been. When the power figures in the health delivery system value psychoanalytic treatment, they make it available, and the entire population is educated as to its availability. Thus in the Adult Psychiatric OPD Clinics at the Ottawa General Hospital, a considerable number of patients who would never have had the opportunity, were it not for health insurance, have been offered psychoanalysis.
In Ontario and the western provinces, physicians may participate in the provincial health plan (be “opted in”) or may elect not to participate (be “opted out”). In Ontario, if “opted out”, the patients pay the doctor directly, receive a receipt, and are then reimbursed by the Ontario Health Insurance Plan at the fee set by it. Those psychoanalysts who work essentially in private practice are often “opted out”, while those who are geographic full-time university personnel in hospitals or universities often accept the standard health insurance fees as payment.
Lay analysis is accepted in Canada. Lay analysts in Ontario constitute a minority of the analysts, as is so in the rest of Canada, with the possible exception of the French psychoanalytic group in Montreal. However, psychoanalysis done by a lay analyst is not covered under normal health insurance, since only “medical acts” are insured and lay analysts must charge their patients directly.
Thus psychoanalysis, as an accepted insured fee-for-service medical act in most of Canada, works well. The Canadian experience demonstates that psychoanalysis functions successfully under universal health insurance schemes when careful planning for its inclusion and proper functioning is provided.
Gerald J. Sarwer-Foner, M.D.
Ottawa, Canada