That health care has not yet emerged as an issue in the upcoming federal election campaign is strong evidence of the altered state of Canadian federalism. There are principled debates about the virtues of strong and weak federalism, and the constitutional tidiness of leaving provincial governments firmly and exclusively in charge of their health care domains. But if the theory of federalism is contestable, the state of the health care system is not. Canadian health care, once our defining social achievement, is stuck in a high-cost, low-performance rut.
Medicare became a national program because the Hall Commission, created by the Diefenbaker government, recommended it in 1964, and Lester Pearson’s minority government passed enabling legislation. The commitment to pay for half of the core hospital and medical services was a deal too sweet for even recalcitrant provinces like Quebec, Ontario and Alberta to turn down. Beginning in 1977, successive federal governments decided that co-ownership of medicare was more burden than asset, and reduced their financial and political stakes. At one point Ottawa financed 41 percent of public spending; today it is 20 percent, or 30 percent if we count the three-decades-old tax point transfers to the provinces. There are no meaningful conditions attached to federal dollars.
Despite changing demographics and new ways of delivering services, the basic architecture of medicare has remained static for four decades. We have a persistently mediocre system alongside a much diminished federal role. Whether this is a cause-and-effect relationship or mere coincidence is not subject to proof. All we know is that although we have seen the doubling of spending in real terms between 1998 and 2010, the near-doubling of medical school enrolments, regionalization (and its elimination in three provinces) and a thousand demonstration projects, none of these things have achieved the much-called-for wholesale renovation. The Commonwealth Fund ranks our system 10th among 11 high-income nations countries based on measures of access, quality, efficiency, equity, and the health of the population. Notably, we rank 11th on timeliness of care and 10th on efficiency. Compared with the systems of our European counterparts, ours is less timely, less efficient and less comprehensive. So it is at least worth considering whether there is an important role for Ottawa in improving the system. If there is, can the feds get back into the game without meddling unduly in provincial affairs? What issues should the federal parties debate in the run-up to the next election?
We have a persistently mediocre system alongside a much diminished federal role.
Federal parties should have important and useful things to say about medicare and envision roles beyond the writing of cheques. As they contemplate their health platforms, they would do well to heed the lessons of history. First, Ottawa cannot be the white night riding to the rescue of surgical patients who wait a year for new hips or old people benumbed by drug cocktails, because it has no role in managing the system beyond its constitutional responsibilities for certain groups (First Nations and Inuit, federal inmates, the RCMP and members of the armed forces). Second, it cannot hold the provinces accountable for how they spend federal dollars. Health accords and other agreements are statements of broad intent, not enforceable contracts. Once the ink is dry, the money flows to the provincial consolidated funds and there is no realistic way either to trace the dollars from their origins to their putative destinations or to tie contributions to performance. Third, the federal government cherry-picks areas in which to invest at its peril " it is the height of presumption for the federal government to substitute its judgment about what the jurisdictions need for their judgment, and it is unlikely that priorities will be identical everywhere. Fourth, there will be zero appetite for new programs like universal pharmacare without long-term, ironclad cost-sharing commitments. Fifth, Ottawa must be sufficiently humble and wise to resist oversimplified and inaccurate diagnoses of the problem (too few doctors, not enough imaging machines) that precipitate massive spending on the wrong solutions.
Applying these lessons would appear to leave Ottawa no place at the table, especially in the current environment, where federal-provincial relations are at a low ebb. But this conclusion would be premature: there are important and unoccupied niches that would best be pursued on a national basis. In a well-functioning federal state, responsibilities accrue to the level of government best positioned to fulfill them. Some should be devolved and some should be centralized. A corollary is that in some cases, uniformity doesn’t matter (indeed it may be counterproductive), while in others, it is critically important. It is essential to have a uniform railway gauge and a single census. It would serve no purpose for Ottawa to be in charge of municipal zoning by-laws or to impose uniform liquor tax rates.
Where, then, is the promising federal space in health care? The biggest unmet need is intelligence: the provision of meaningful, real-time information to help clinicians, patients, managers, and governments make better decisions. Health care systems are immensely complex, with thousands of moving parts. They are all vulnerable to major and unjustified variations in what is done, how it is done, and what all the activity achieves. In my city, Saskatoon, a woman who has breast cancer and is operated on at Royal University Hospital will most likely have a lumpectomy. If she goes to St. Paul’s Hospital she will almost certainly have a radical mastectomy. Patient-centred and self-aware systems are alarmed by unwarranted variation and use high-quality information to support improvement. In Canada, clinical practice is highly autonomous. Few clinicians know whether their practices differ from their peers’, and no one is responsible for examining, let alone reducing the variations.
National agencies like the Canadian Institute for Health Information (CIHI), the Canadian Patient Safety Institute, Canada Health Infoway and the Canadian Foundation for Healthcare Improvement have mandates to make the system smarter but their impact is limited, for reasons beyond their control. CIHI is a classic product of a dysfunctional federalism. It is funded mainly by Ottawa but governed mainly by provincial public servants or their nominees. The provinces’ agreement to send data to CIHI is always contingent, and the quid pro quo is to take blunt and fearless truth-telling off the table. Canadian governments’ reluctance to disclose and publicize the sobering truth about health care performance weakens the case for the transformative change to which they routinely pay lip service, but never achieve.
We need a federal political debate around health care that speaks to the government’s role in telling the truth to Canadians about its performance and strategically investing in culture change. Whether cash transfers to the provinces escalate by 6 percent, 4 percent or 0 percent annually will not make one whit of difference to the quality, timeliness or efficiency of care if the culture remains intact. The mantra and core strategy of high-performing systems is data-driven, continuous improvement. Clinicians seek and use data to refine their practices, eliminate useless and harmful interventions, and improve patients’ experiences. System leaders align policies and incentives to quality and efficiency goals. Hierarchy, tradition and the convenience of providers count less; evidence and the needs of patients count more. Nothing is sacred, and transparency trumps the sensitivities of insiders. An open health information culture is to health care what the fourth estate is to democracy.
If promoting such a culture is Ottawa’s principal job, it will have to reconceive its partnership with the provinces and rethink its investment strategy. Its cash transfers should be conditional on the provinces agreeing to a new charter that ushers in a new world of health-information-system development, analysis and enhanced public reporting. Federal agencies should be liberated to describe reality as it is and be governed by champions of transparency. The government should invest substantially in health intelligence centres across the country and user-friendly information portals accessible to providers and the public. Ottawa should aspire to lead the world in ensuring that the public and patients have access to all relevant information to help them make informed decisions about their own care. Unencumbered by the responsibility to deliver health care beyond its constitutionally mandated obligations, Ottawa is uniquely positioned to talk directly to the citizenry. Its commitment to seeking truth and disclosing it unvarnished has the potential to generate what has hitherto been lacking: an engaged and informed public that demands better.
Ottawa should lead the world in accessibility of information so patients can make informed decisions about their care.
The party that throws down the intelligence gauntlet with skill and passion will begin to reframe health care federalism. That would be a public service in itself. The health information debate is an entry point to the larger discussion of the role of science in policy-making, the relationship of government with the research community, and whether governments or the citizens are the rightful owners of government-held data. If health information is vital infrastructure, its architecture and use should be thoughtfully designed, continuously improved and standardized. Canada generates a lot of health care data but not much actionable health information. Sunk costs are high and returns are low. A system steeped in ignorance of its performance, denial about its defects and overconfident in its ability to self-correct cannot spend its way to greatness. The federal government should be the system’s microscope, mirror and confessor. To the extent that it works at all, the health care system succeeds in spite of its information system. Only with federal leadership, resolve and investment will it improve because of it.
Steven Lewis is president of Access Consulting Ltd. and adjunct professor of health policy at Simon Fraser University. He is the co-author of Bending the Cost Curve in Health Care (IRPP, 2013).