The Canadian health care system is often held up as an example to model or to avoid at all costs in the debates on health care in America, and elsewhere.  Yet there are a startling number of misconceptions — on both sides of the partisan divide — about how the Canadian health system actually works, often from experts who should know better.  Here are the facts.

1. Doctors are self-employed, not government employees. Canada has a publicly funded health care system, but the vast majority of doctors do not work for the government.  A patient is free to choose which doctor they wish to visit, and they are entitled to essential physician health services without charge.  Doctors are self-employed, which means they can determine their own hours and work location, and they are responsible for paying their employees, for office space and other overhead expenses.  Doctors earn money by billing their provincial government for the services they provide to patients.

The Canadian health system is often referred to as “socialized” medicine, but it is actually a mix of private providers billing governments for publicly funded services.

2. Canada has 15 different health care systems. People often refer to the “Canadian health care system,” when in reality, it has distinct health systems for each of the provinces and territories.  The Canada Health Act outlines the basic tenets for health care to be universal and accessible for essential physician and hospital health services across the country.  However, the details of how each system operates, including what is covered and how, is determined provincially.  In addition, the federal government has responsibility for Aboriginal and Veteran health care.

Add it together, and Canada has a whopping 15 unique health care systems. On the plus, this means provinces can tailor health services to the particular needs of their residents; the downside is that coordinating health reforms across the country remains a significant challenge.

3. Funded health care services are not provided equally across the country. The Canada Health Act guarantees that essential physician and hospital services are paid for by the government, but there is variation across provinces for what is considered an “essential health service” — and even who delivers the care or where care is delivered.

For example, Quebec’s publicly funded system includes fertility treatments, while most other provinces do not.  Some provinces, including British Columbia, Ontario and Quebec, pay for births delivered by licensed midwives, while several provinces and territories do not.  Eligible funded therapies for autism vary widely across the country.    Abortion services are not equally accessible across the country.  The Canada Health Act does not cover prescription drugs, home care or long-term care, and as a result, there are widely different approaches for these services in each province.

4. User fees charged to patients are not permitted. Canadians cannot be charged a “user fee” when a physician provides an insured service (something already covered by the publically funded health system).  But some physicians get around the letter of the law by charging “annual fees” as part of a comprehensive package of services they offer their patients.  Such charges are completely optional and can only be for non-essential health options.

In some provinces, doctors may charge a small fee to the patient for missed appointments, for doctor’s notes and for prescription refills done over the phone — all items for which a doctor receives no payment from the province.

5. Canada does not truly have a “single payer” system meaning a significant portion of Canadian health care comes from both public and private financing. Canada has extensive public financing for essential physician services and hospital care — among the highest rates in the world.  But most Canadians have to pay for eye and dental care out-of-pocket, and more than 60% of prescription medications are paid for privately in Canada.

Canada is the only country with a universal health care system that does not include prescription drugs.  This means that Canadians still pay for approximately 30% of their health care directly or via private insurance with only 70% of health costs paid for publicly.  In fact, Canadians are as likely to hold private health insurance as Americans.

Kathleen O’Grady is a research associate, Simone de Beauvoir Institute, Concordia University, Montréal, Québec. Noralou Roos is a professor of community health services, faculty of medicine, University of Manitoba, Canada.  They are managing editor and director, respectively, Evidence Network.