The Canada Health Act is often considered a third rail of Canadian politics. Politicians who dare speak of reforming, let alone repealing, it are labelled radical at best or anti-Canadian at worst. We are stepping into that breach by arguing it is time to replace the act with a more responsive series of provincial laws. This will strengthen accountability and allow provinces seeking more autonomy in Confederation, like Alberta, to lead and not leave.
In the current situation, provinces blame Ottawa for insufficient funding, Ottawa blames provinces for poor delivery, and citizens are left trying to determine which level of government is responsible for which failure in a system both claim to run but neither fully controls.
Universal public health care is a fundamental part of Canada’s political culture. But the Canada Health Act is not the paragon of public health care its defenders make it out to be. It is a funding statute with narrow scope and weak enforcement. In practice, it does not guarantee timely access, cover all important services or hold governments responsible when care models break down. Defending quality health care in Canada means kicking our dependence on the Canada Health Act and insisting on a higher level of accountability and decentralized authority than the legislation can provide.
Canadians started down this path decades ago.
Federal transfers have already become more decentralized
Under prime ministers Jean Chrétien and Stephen Harper, Canada moved toward a more decentralized, mature model of fiscal federalism. Reforms to major federal-provincial transfers increasingly recognized that provinces have different priorities, socio-demographic pressures and approaches to delivering public services. The federal government’s role became less about directing provincial policy or establishing one-size-fits-all national programs and more about ensuring that Canadians, wherever they live, benefit from a fair distribution of federal funds and comparable levels of service.
Chrétien and Harper reforms were all good things for a more decentralized Canada – and they gave all provinces, including Alberta, more autonomy over their own programs. Reducing conditions on federal transfers in areas of provincial jurisdiction is one way in which Alberta has found a way to lead, not leave Canada. This spirit of open federalism was abandoned during the years Justin Trudeau was prime minister. But the underlying logic remained reflected in equalization. Have-less provinces continue to receive equalization payments without any federal conditions on how the money must be spent. We trust provincial governments to make those decisions, and we empower legislatures, citizens and courts to hold those governments accountable for the results.
While Canadians may disagree with how particular provinces use those funds, the principle is clear: accountability flows primarily through provincial democratic institutions, so it’s not for the rest of us to judge. Ottawa has no more say over how Quebec spends its equalization dollars than Alberta does. And that’s a good thing.
The same principles should apply to other federal transfers. The Canada Health Transfer and Canada Social Transfer are intended to help provinces fund and deliver services that fall squarely within provincial jurisdiction. Yet these programs continue to carry federal expectations and conditions that imply Ottawa knows best how those services should be designed and delivered.
Those apron strings are from a bygone era, not one defined by co-operative federalism.
A more coherent approach involves allocating all health and social transfers on a transparent per capita basis and allowing provinces the flexibility to meet the needs of their own populations. No strings, conditions or paternalistic oversight. A recognition of the current realities facing health care in this country.
Canada already has different health-care systems
Canada has 10 provincial health care systems, not one national one. The systems share some common elements, and they all operate in the shadow of the Canada Health Act. Nonetheless, they differ considerably in what they cover, how they pay for it and how much private provision they tolerate. If the CHA was meant to create a single system across the country, it has failed.
Hospital and physician services remain at the core of what Canadians think about when they imagine medicare. These are the services most directly covered by the CHA. But what Canadians actually experience as health care sits mostly outside these services or only partially within them. Dental care is still mostly private, as are prescription drugs. And access to those services varies widely by province, age, income and employment status.
Mental health care may be public when delivered in hospital, but outside those facilities it is often private, limited and difficult to access. Provincial workers’ compensation systems operate with their own rules, sometimes sending injured workers to private clinics for procedures unavailable to other residents on the same terms and even to other jurisdictions, as in the case of British Columbia.
The spending patterns tell the same sort of story. Per capita health expenditures vary substantially across provinces even after taking into account structural pressures such as an aging population and geographic dispersion. Canadian Institute for Health Information (CIHI) attributes these differences in part to provincial choices about how services are organized and financed. The public-private mix varies considerably: CIHI data reveal large interprovincial differences in both public- and private-sector health spending per person.
Quebec illustrates the scope for provincial variation
Take Quebec, for example. As a result of the Supreme Court’s 2005 Chaoulli decision, which upheld Quebecers’ unique set of rights to health care in that province, non-participating doctors can operate outside the public system, set their own fees and bill patients directly. Quebecers can purchase private insurance for services in private facilities in ways that most provinces prohibit. Public hospitals can contract with private facilities under certain conditions. The result has not been the collapse of medicare, but something more basic: a distinct provincial model operating largely outside the parameters of federal oversight and with the approval of the courts.
These are not small administrative differences within a single national model. They are evidence of a highly decentralized set of health systems. That is not a bad thing, and if it were federal governments of various stripes would have clamped down years ago. In practice, federal oversight has been minimal, inconsistent and politically selective. Ottawa rarely enforces the Canada Health Act in ways that reshape provincial systems, and the CHA is not a hard deterrent for provincial experimentation as we have demonstrated in the case of Quebec.
In short, even with the CHA, the federal government lacks the capacity and political will to standardize health care across Canada. This gives us the worst of both worlds: federal conditions that are strong enough to confuse Canadians about accountability and too weak to ensure conformity or uniformity.
To make it clear: the Canada Health Act and the associated Canada Health Transfer are not standardizing health care in Canada in any meaningful sense. But their presence gives the veneer of a nationalized system, creating a real problem with accountability. The CHA perpetuates a longstanding myth: that Ottawa can and should attach broad national principles to a limited category of insured services and thereby oversee a national system of universal health care. But the real systems Canadians use every day are much more varied and complex than that.
Quebec’s system is not necessarily better than Manitoba’s or Alberta’s or New Brunswick’s. It is different, and its performance should not be hampered or judged by anyone other than the residents of Quebec. Canada’s health care systems already reflect different provincial political cultures, priorities, fiscal capacities, geographies, demographics and public expectations. The CHA has not prevented this variation; it has simply made the variation harder to justify and clarify for Canadians.
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All of this makes accountability more opaque than it needs to be. When Ottawa attaches conditions to health transfers, it asserts federal responsibility for the shape and performance of provincial systems. But Ottawa does not run hospitals, negotiate contracts and fees, manage surgical wait times or decide how mental health services are run. Provinces do those things.
Yet the presence of federal conditions allows everyone to escape accountability with finger pointing all round, leaving citizens struggling to understand what level of government is responsible for the failures.
The case for eliminating federal conditions on health transfers is not a case against public health care. It is a case for clearer responsibility. The CHA is doing little to produce a common health care system across Canada. Instead, it is preserving the illusion of federal control while obscuring provincial accountability.
Put responsibility where the decisions are made
A better model would see provinces fully defining the principles of health care within their jurisdictions, putting legislators and residents in charge of holding them accountable. Some provincial governments may choose to replicate the CHA in their jurisdictions as indeed B.C., Alberta and Ontario have already done, others to expand its principles to be even more progressive, still others to refine or redefine what good health care looks like in their part of the country. All of them would be under immense provincial, rather than federal, pressure and scrutiny in doing so.
Are provincial populations any less capable of holding their governments responsible for delivering health care than a distant federal government? We think not. In fact, this would force all provinces to accept responsibility for defining their own priorities rather than abdicating responsibility or throwing blame on the federal government.
Eliminating the Canada Health Act is just Step 1. An Alberta government promoting this idea at the next meeting of federal-provincial-territorial health ministers would be leading, not leaving, Confederation.
The authors are both members of Lead Not Leave, a policy initiative advocating for a stronger Alberta within a united Canada.
