Published in The Hill Times on November 17, 2014
By Åke Blomqvist
Åke Blomqvist is an adjunct research professor at Carleton University and a health policy scholar at the C.D. Howe Institute.
With a 2015 federal election on the horizon, many political strategists are wondering if there is a way they can leverage Canadians’ concern for their health care system into more votes. But these strategists and their parties should be wary of the pitfalls when trying to score points with federal health policy initiatives. Their success depends heavily on getting the provinces on side, and our system of federal-provincial cooperation in managing health care remains a work in progress, at best.
That health care is a major concern for Canadians is not surprising. With an aging population, increasing numbers are approaching the years when they may need costly drugs and long-term care—two areas of health spending not fully covered under our current system. While there are provincial programs that help seniors with these costs, they vary from province to province, and, in some cases, leave users with heavy out-of-pocket expenditures. Proposals for nationwide programs or standards in these areas, particularly for some kind of pharmacare, could be attractive platform planks for a federal party, and would no doubt attract a lot of support.
But people’s worries about health care are not just about spotty and uneven coverage of outpatient drugs and long-term care. They are also about things like wait lists for many kinds of surgery and about having to rely on overcrowded hospital emergency departments for urgent primary care. These problems were flagged at the time of the federal-provincial Health Accord in 2004, and lots of money was spent on trying to fix them. Ten years later, the problems are still with us, and they are part of the reason Canada typically doesn’t fare particularly well in international comparisons of health system performance.
The disappointing results from the 2004 Health Accord showed once again how hard it is to manage health-care resources efficiently in the Canadian federal system where provinces are constitutionally responsible for delivering health care, but where the federal government is anxious to be seen as a key player in responding to the public’s demand for better health care and to get some political return for its financing contributions.
The result is a system where accountability is not clearly defined. When problems arise, politicians at both levels deflect complaints to those at the other level. When hospitals and doctors fret about underfunding, it is easier for the provincial politicians to blame the feds than to raise additional revenue on their own. More importantly, they spend more energy on bickering with the federal government about money or the restrictions it tries to enforce on the provinces, than on pushing through reforms that could make the system perform better.
Managing the health-care system is difficult at the best of times, as it involves powerful interest groups like medical associations and unions representing nurses and other hospital employees. If the provinces try to drive cost-saving reforms that these groups don’t like, they can find a ready audience among federal politicians who are eager to be seen as defenders of the Canada Health Act, especially when they can say that a reform is, as the saying goes, “the first step on the slippery slope to an American-style health-care system.” Interest groups have a strong influence on health policy everywhere, but other countries seem to have been more successful than Canada in keeping them at bay and implementing policies that have made their systems perform better.
Canadians should realize that meaningful health policy reform is unlikely to happen if we don’t define political accountability for making the system work more clearly. Unless we want to rewrite the Constitution, it is the provincial governments that must be responsible. The only significant role for the feds should be to ensure that each province manages its system in ways that meet the requirements of the Canada Health Act and, when strictly interpreted, the CHA does not impose tight restrictions on what the provinces can do. The federal government will continue to transfer some of its revenue to the provinces, but the amounts should be fixed in advance, and be otherwise independent of provincial health policy and spending decisions.
Federal politicians in the past have been reluctant to challenge the passionate defenders of the status quo in Canadian health policy, especially against proposals that would allow more scope for public-private competition in health insurance and health services production. If more Canadians come to believe that some of these reforms can be carried out without the dire consequences that alarmists warn against, there may be votes to be won by a party whose stance is that provinces should be free to try them out, with little or no federal interference.
