Significant change in either breadth or direction of national health policy is unlikely to be driven by the next elected federal government, whether through leadership, fiscal transfers or regulation. Canadian health care federalism is notoriously complex, and the changes that Lang believes would arise for federal policy in general in the event of an outcome other than a Conservative minority are not so easily imaginable for health policy. Changes in national health policy have significant capital requirements — both political and economic — that constrain possible movement at the best of times. And, to be clear, we aren’t in one of those times. While need exists for implementation of national health policy objectives, no real change is expected in the short term. A complicated legal future for Canadian medicare further reinforces this position, though there is some hope of nation-building efforts to be undertaken with our coming 150th anniversary.
Federal involvement in Canadian health care federalism has been largely stagnant since the ending of the Martin-era Health Accords. A surprise, unilateral announcement in December 2011 by Finance Minister Flaherty signalled the nonrenewal of the Accords; the symbolic closure of the Health Council of Canada marked the end of a national attempt to combine federal fiscal power with provincial and territorial administrative power to improve health care. Much has been written, good and bad, about the outcomes of the decade-long effort to fundamentally reorient Canada’s collection of 14 different health care systems. Whatever one thinks of the Accords, the gap that was created when they expired has not been filled by any order of government working independently. Proposed health policy today seems like a confusion of echoes calling for the same objectives originally listed in the Accords. In this sense, when it comes to the prospect of health policy initiatives, even if major policy were introduced, very little would be new.
What Canada needs is well known: pharmacare, as advocated strongly now by lobby groups and some provincial ministers of health; seniors’ care, as pushed for by the Canadian Medical Association; an Aboriginal performance measurement and public reporting system, as outlined in the 94 calls to action of the Truth and Reconciliation Commission of Canada; and what of the most recent recommendations from the Advisory Panel on Healthcare Innovation? The problem isn’t a lack of familiar possibilities. Rather, directions for national health policy lack cohesion. This is where leadership from the federal government with its enormous fiscal power is needed. There needs to be a return to the collaborative health care federalism seen in the original objectives of the Accords that focused the Canada Health Transfer (CHT) beyond the basic principles of the Canada Health Act.
However, substantial collaboration on health policy is unlikely given that efforts in this area will require significant political capital. Intergovernmental relations are playing a dominant part in the battles of the current election, and whoever holds the balance of power come October 19 will be managing difficult relations with the provinces and territories.
The reelection of a Conservative government would certainly mean no significant changes in provincial and territorial relations, given the Prime Minister’s clear hands-off approach to health care federalism. There is simply no reason for Harper to change course, and many for him to hold firm, as funding changes to the CHT are to be implemented in 2017. Further, it’s hard to imagine negotiations on new health care objectives given the Prime Minister’s eye on Senate reform and his explicit redirection of this topic to the provinces and territories. One of the few imaginable policy pieces that may emerge is a national dementia strategy, given the Conservative government’s previous and demonstrated commitment to G7 efforts. But this disease-specific approach is not the large-scale change needed. If anything, this move would be more of a commitment to current international efforts around dementia than a truly Canadian initiative.
The election of a minority or a majority Liberal or NDP government would be welcomed by those who see a strong collaborative role for the federal government on issues of health policy. For example, Justin Trudeau’s proposed approach to environmental policy ahead of the UN climate change conference in Paris in December 2015 and his promise of inclusion of premiers in these discussions suggest an active desire for collaborative federalism for large-scale challenges. However, a federal government looking to improve intergovernmental relations has easier areas than health policy to pursue. What is more likely to change in the short term will be an approach to how the federal government relates to its provincial and territorial partners in advancing collaboration around health care. Expect to see a respectful and needed increase in attendance at meetings but perhaps little else.
Another reason for skepticism regarding large-scale health policy change is the barrier posed by the Canadian economy. Given the price tag of health care, it is hard to imagine that expensive new directions will be proposed in an election and a subsequent string of parliamentary sessions that will likely be partially fought over economic management.
The Innovation Fund proposed by a federal panel chaired by David Naylor
has been given a budget line suggestion of $1 billion of new money. Further, a recent comment by the Ontario Minister of Health and Long-Term Care that federal savings from bulk pharmaceutical purchasing should be redirected to the provinces and territories essentially means increased investment. To be clear, given a different economic situation, it would be more likely that significant health care announcements could occur: at the August meeting of the Canadian Medical Association in 2014, Tom Mulcair announced to Canada’s “Parliament of Medicine” that surpluses under an elected NDP government would be used to increase health care transfers.
But with a vanished surplus and a likely deficit and recession, the optics of being seen as a sound economic steward make new steps forward in health policy unlikely in the short term. The capital required to make a significant difference in health care funding is better spent elsewhere on programs with greater multiplier effects on GDP growth and greater distributional benefits. Infrastructure investments appear to stand out among policy options: given the importance of cities to securing election wins and the growing concentration of urban Canadians, increased national infrastructure will likely be a focus of budget expansion. Perhaps the best thing that could happen to Canadian health care federalism without a significant focus on a new health care accord would be a focus on economic growth. With the proposed CHT funding formulas for 2017 being tied to GDP growth, Canadian health care may benefit most when facing reticent federal governments if the economy is growing.
Another complication that will cause the federal government to proceed slowly is Cambie Surgical Centre et al. v. Medical Services Commission et al. The British Columbia Supreme Court is set to begin hearing this landmark case soon. Whatever the outcome, it is almost guaranteed to be appealed to the Supreme Court of Canada, and it seems unlikely that the Court would decline to hear it, given the magnitude of its implications. The case challenges the restriction on private billing of medically necessary health care services in Canada. A ruling in favour of private billing based on a Charter of Rights and Freedoms challenge would shake the fundamental structures of Canadian health care federalism. The federal government will want to keep an eye on this case as it weaves its way through Canada’s legal system. Until more clarity exists on the outcome of this case, expenditure of significant political and economic capital may be seen as too risky.
One argument for introduction of new or meaningful health policy would be for the sake of nation building. Let’s use the example of a national pharmacare program. The argument is something along these lines: Canadians love medicare, and advancing the dream of universal health coverage would align federal efforts with the deeply held values of the Canada Health Act that have become a form of quasi-identity. While a minority federal government may be tempted to undertake a nation-building effort to gain favour in the expectedly short-lived interval before the 43rd Canadian general election, there are other focuses for such efforts that are less historically fraught with problems. However, this argument should not be discounted and may be especially strong heading into Canada’s 150th anniversary, when whoever holds power may wish to make a bold, sentimental mark on Canadian history.
It is difficult to imagine any real progress on health care during the 42nd Parliament. If this piece had been written last summer, it would have had a different tone as economic, budgetary and voting prospects were all very different. Perhaps another year will bring more hope for the maturation and progress of Canadian health care federalism. And perhaps the provinces and territories will take steps to implement effective health policy, rather than waiting on the federal government to assume its needed role and drag the rest of the country along. This would match much of the pattern of the history of medicare in Canada.
Jesse Kancir is a resident physician and a 2014-2015 Chevening Scholar at the University of Cambridge, where he is an MPhil candidate in public policy. He has served as the president of the Canadian Federation of Medical Students (CFMS) and was a 2014-2015 Action Canada Fellow.