During the House of Commons debates over hospital insurance in the 1950s, members of the Co-operative Commonwealth Federation accused the federal government, including the Minister of pensions and nation- al health, Paul Martin, Sr., of playing ”œpolitical football” with the provinces over health care. Half a century later, football is still the metaphor of choice to describe the political minefield that is health reform. And, ironically, a football contest served as the actual venue for the kickoff of what could become a new game in federal-provincial relations in Canada, as the provincial premiers met with Liberal Party leader Paul Martin at the Grey Cup game in Regina last month.

Health care has come to define the good, the bad and the ugly of Canadian federalism. So the winning smiles between Martin and the premiers that replaced the warring spectacle of the past few years between the prime minister and provincial leaders are probable grounds for cheer for fed- eralism and health reform. The positive vibrations are not just about the changing of the guard at the federal level, they also reflect important changes in provincial leadership. Eight of the ten provinces held elections this year, most of which were fought on health reform issues. Several provincial gov- ernments changed their political stripes, and those that sur- vived were given a wake-up call in democratic governance.

Paul Martin and the Liberal Party may not face a close contest in the next general election, but they will face an electorate that has grown rather cynical about the potential for meaningful change in the politics of health care. Canadians have now lived through a decade of a near constant state of ”œcrisis” about the delivery and financing of health care services. The extent of the crisis may be real or imagined, but the considerable erosion of the public’s confidence in health care has certainly been exacer- bated by the interminable blame game between the federal government and the provinces, and the seeming incapac- ity of political leadership in Canada to take on responsibility for sustaining the health care system.

What can we expect Paul Martin to do about health reform? Has health care become ”” as some suggest ”” the ”œthird rail” in Canadian politics that is better left untouched for safety’s sake? Or does the health care dossier offer a real oppor- tunity to rethink the shape of social pro- grams in this country, and at the same time repair the federal-provincial rela- tionship now defined ”” and to a large extent, consumed ”” by the issue?

A little over a year ago, two impor- tant reports were presented to parlia- mentarians in Ottawa and to the Canadians they serve. Both the Kirby report and the Romanow report acknowledged the unease Canadians felt about the state of the health care system and the anxieties about the future sustainability of the public sys- tem. The two reports went on to make dozens of practical recommendations about how to address the major prob- lems in the delivery of health care services and the hard questions of health care financing. The Romanow report, which was unveiled under an intense media barrage, was particularly directive in insisting that the public system was sustainable and worth sav- ing, with the injection of new money and the accord of provincial premiers to be accountable for the money.

In the year since, Canadians have witnessed more political gamesman- ship of health reform. In February 2003, the premiers and the prime min- ister met to ”œhammer out” a health accord, a process for which, according to accounts by provincial leaders, the hammer metaphor was particularly apt. Once again, Canadians watched as their political leaders gathered around a table not playing football but rather something akin to high stakes poker. The accord that was signed was not just about a new injection of money into provincial budgets for health care by the federal government, but more importantly specified that govern- ments would now have to account for the money by agreeing to the creation of a Health Council.

A central recommendation of the Romanow report, the council was conceived as a mechanism for public voice in health reform, and to ensure accountability in the health care sys- tem. Almost immediately, tensions arose over the definition of the Council’s mandate and membership. Alberta Premier Ralph Klein balked at any such initiative that could jeopard- ize provincial authority in health care matters, while Jean Charest’s new gov- ernment in Quebec reiterated the PQ’s position that Quebec had its own such council in place and wouldn’t have to sign on to this one.

The Health Council, as the centrepiece of the Romanow report, is less about fixing the political relationships essential to health reform, than it is about shoring up support for and pro- tecting the public health care model in Canada. It has a different function, but one that could potentially exacerbate federal-provincial tensions, especially if the Health Council is designed as a watchdog that grows sharp teeth. There must be a political dialogue about responsibility in financing and sustaining health care before there can be effective accountability.

While the provinces pondered the Council, other reform initia- tives were moving along. Almost all of the provinces had commissioned their own health reviews prior to Romanow and Kirby, and several common themes emerged. Relatively unheralded in the public eye, but hotly debated in health care milieus, primary care initiatives were being developed as a way of directly addressing concerns about the access of care to citizens. In Quebec, such Family Medicine Groups were considered part of the unfinished busi- ness of the original health and social services legislation that emphasized prevention and primary care in the health system; in other provinces practice- and community-centered pilot projects represented an important step forward in ensuring the integration of health care services.

Any provincial premier would tell you, however, that any such initiatives have to be considered within the larger picture of sustainable funding for the health care system as a whole. As the debate over fiscal imbalance suggests, we are still at square one of the peren- nial conundrum of Canadian federal- ism: how to resolve the jurisdictional autonomy of the provinces with the fiscal capacity of the federal govern- ment. (In historical terms, this is the essential crossover question from Paul Martin pé€re to fils.) In this respect, the proposed Council of the Federation is probably more important to the long- term health of the federation ”” and by extension, health care, one of the most important fiscal issues ”” than the Health Council. The Council of the Federation is a structure that could allow provincial governments to have constructive political voice and oppor- tunity ”” not simply be the whining section in the bleacher seats. While the money issue may scuttle provincial goodwill in short order, in the context of a new Martin regime, the Council of the Federation has the potential to soften the bashing ”” on both sides of the fed-prov divide ”” and allow both sides to engage in some meaningful dialogue on more even ground.

The current honeymoon between provincial premiers and Paul Martin is odd if considered in the con- text of recent history: a little less than a decade ago, he was pilloried as the finance minister who introduced the infamous Canada Health and Social Transfer and reduced fiscal transfers that greatly affected the provincial budgets that pay for health care. Since that time, premiers have been bemoaning the loss of revenue that these uni- lateral funding decisions entailed.

But the underlying message of Paul Martin’s attitude toward social programs in general, and health care in particular, is one that many provincial govern- ments share: namely, that we can only fund social programs that allow us to live within our means, fiscally speaking; and that governments have to consider their responsibilities as larger and more varied than one single program, regardless of how important or expensive it may be. Extrapolated in the long run, this attitude says that, while a health care sys- tem that ensures universal coverage is a worthy ”” perhaps even essential ”” public good, it has to be considered within the bigger picture of public goods that governments can provide.

So it would be unlikely to expect that, as prime minister, Martin would be interested in engaging in the types of initiatives that would tie up even more public funds in the health care sector, such as national pharmacare or home care programs. But one of the ways that the place of health care in a larger context of the public good would be to emphasize that other types of social investment ”” such as housing and education, or the reduction of income inequalities ”” are also impor- tant to overall health outcomes. The evidence on the social determinants of health makes abundantly clear that economic and social productivity are greatly affected by a population’s healthiness, and that that relies on more than health care services per se.

But the message that Paul Martin has so far sent about health care and investment ”” and one that has found a receptive audience in business circles ”” has to do with health care technology as a gen- erator of economic growth (as opposed to simply consuming revenues). This was an important theme of his break- through 2000 budget that described research innovation an investment in the Canadian economy. Basically, the idea is that Canadians should be encouraged to think of the health care sector as an important part of the economy, in particular in terms of the incubation, creation and commercial- ization of health care technologies.

These investments are lofty but essen- tially long-term; it is unlikely that the majority of Canadians would have the patience to be serenaded on the virtues of such ventures while still having to queue for routine procedures or emer- gency waiting rooms.

The SARS outbreak reminded us that health care is, in fact, more inte- grated than we realize into our social fabric and economic foundations, and that population health and public health are often inextricably linked in a global age. It also reminded us that political cooperation is the crucial link in responding effectively to public health crises. Public health is the one area where federal leadership is not only acceptable in jurisdictional terms but also essential, since it requires a national, coordinated effort to be able to prevent, prepare and manage public health crises. The Naylor report on the SARS fiasco was particularly critical of Health Canada for its inaction and the absence of the national voice and capacity needed to interface with other countries and international agencies in a global age of disease management.

Here is an area, then, where federal leadership can be exercised with the lowest political costs, although the coordination efforts between levels of government will have to be consider- able. While the biggest gains in public health are usually non-newsworthy ”” successful prevention makes fewer headlines than treating outbreaks ”” an agency for disease control and preven- tion is an important long-term investment in public health that a new feder- al government could undertake. Even in the European Community, where EU activity in health care is lim- ited due to national jurisdic- tions, movement toward a disease control coordination mechanism is a highlight of EU health policy.

Health care poses a dilemma that political lead- ers in Canada since Paul Martin Sr. have had to grapple with: how to engage in meaningful reform while following the medical adage that requires you to ”œdo no harm” ”” either to the health of the federation or the economy, or the health of Canadians themselves. This dilemma is even greater as confidence in the health care system remains relatively uneasy, while expectations for Paul Martin remain high. Health care has become the lens through which intergovern- mental relations, the new economy, and even Canada’s international repu- tation, can be evaluated, and the inno- vative ideas that can be brought to bear here will, to a considerable extent, determine how this new regime will be judged, at least in the short term.

The political football game around health care will continue to be played out, but the stakes are considerably higher than in the past. The secret to success in this policy area is to think through the rules and policy that would allow the game to be played with strategy and finesse ”” rather than as a bunch of players colliding into one another on a muddy field.

Vous pouvez reproduire cet article d’Options politiques en ligne ou dans un périodique imprimé, sous licence Creative Commons Attribution.

Creative Commons License

More like this