Saturday, April 16, 2011

At least you have your health...

With a little more than two weeks to go before voting day, the issue of health care has been generating more and more attention. This should not be surprising.

- Health care has remained near or at the top of the list of issues Canadians have deemed the most important to them.

- At a time where government austerity of some sort is going to be needed to address the deficit, how government spending on health care might be affected is a topic that needs to be on the table.

- With two weeks to go and the Conservatives still polling strongly, the Opposition parties will look to tap into public concerns about health care and possible funding cuts to gain support.

Let me start with the following observation: it should not take an election to prompt discussion of our health care system, how it is funded and the upcoming challenges we are facing.

This is already the single largest draw on provincial revenues. And transfers to the provinces from the federal government related to health care represent the largest share of government transfers.

Canadians value it. Provinces are responsible for it. All governments pay for it.

Add to that the demographic realities we are facing and the only surprise is that it took nearly three weeks for health care to "rise up" to the top of list of issues being discussed in #elxn41. Yet there it is, featuring in attack ads and duelling talking points and tweets. Here are some of my thoughts.

1. I would start by noting that the Health Accord - the agreement struck between the Martin Liberal government and the provinces - will expire in 2014. As I noted in a blog post last year, if you thought saving GM and Chrysler were expensive wait until the bill comes in for the next iteration of this accord.

The fact that this Accord is: (a) soon to expire; and (b) the big ticket of big ticket items was apparently not sufficient for it to feature prominently in the platforms of the Conservatives and Liberals. As a result, we have seen the parties simply reaffirm their commitment to the Accord and its funding during scrums. As Andrew Coyne has noted, we are essentially making policy on the fly.

While I favour a commitment to funding, I have to admit that I am dismayed by the lack of discussion about how Canada is going to address the challenges demographics will present to our system. In effect, we are committing funding without having really discussed the demand, the needs of tomorrow. This is not the best way to make policy, and all parties are guilty of going down this path.

2. Despite this being identified as their most important issue, I am not sure Canadians really understand how the system works and how it is funded. In a 2009 posting on this blog (*sigh* has it been that long?), I wrote about the division of powers and how we have the system we have -

We have a system in which responsibility for delivering health care resides with the provinces, but the core means for generating the funds necessary for running it reside with the federal government. One has the responsibility, the other the cash.

Over the years, this has been addressed through funding agreements (cash and tax points) from Ottawa to the provinces. Unfortunately, from my perspective previous discussions and the subsequent agreements have focused on cash being the solution. The dialogue almost seems to be along the lines of: "If there was more money available, the current problems (wait times, access to equipment, etc.) would go away."

Money is only a solution to problem if you have properly and honestly considered the problem, and discussed all solutions. I am not sure that this has been done.

The result? Commitments to funding, accusations focusing on past behaviour and warnings about future agendas. Sadly, none of this will do anything to address health care. None of this is showing the public that there is a real willingness to do something about the area we have said matters most to us.

3. Building on the point above, we also have the Canada Health Act which essentially lays out the principles the federal government expects the provinces to adhere to in exchange for federal money.

But do Canadians really understand the Act, what it says, how the provinces interpret it? Again, I am not sure they do. Yet this is what is raised to them during campaigns and speeches. It would be more meaningful when one says they will "defend the Canada Health Act" if the audience knew what that meant.

So at the end of all of this, here is what I see:

- it's valued;
- it's expensive;
- different levels of government are responsible for it; and
- it's about to face some serious challenges - in the context of our fiscal position and more importantly in the context of our changing demographics.

In the end, we have to talk about it. Together. It can't be a line in a scrum intended to take the issue of the table. It can't be an attack ad. It has to be a discussion.

Are we prepared for it?


  1. IMO, this is a big elephant in the room and people don't understand it.

    They have to revise the Canada Health Act to make a sustainable health care reform for all.

    One of the reasons I am attracted to a Harper government is his desire to make a small federal government. They would have to transfer more taxation power to the provinces and gradually eliminate federal programmes which intrude on provincial jurisdiction (health care, education, etc) gradually phasing-out the equalization programme and the federal government can concern itself only with Defence, external affairs, trade and economic union, citizenship and monetary policy.

    Federal and provincial boundaries have to be untangled, it won't be an easy task to delineate the boundaries.

    I believe health care delivery and its needed changes are best looked by the province because they operate in closer contact with specific needs because we have different needs.

  2. This is an interesting post. Our healthcare system is so important to us, but yet we do not really understand how it works. We just know it's there when we need it. I am guilty of such.

    I plan on getting myself up to speed on how are system works - federal/provincial split. Until then I cannot effectively be a part of an intelligent conversation on the direction we need to go in. But I can say, I lived in the US and was in need of healthcare. It was scary to not have it. I realized how much we take it for granted in Canada.

    Secondly, in regards to Claudia's comment... I understand the point of letting the provinces manage healthcare, giving them more jurisdiction. But from personal experience I think there is a need for universal guidelines. Being admitted to a Quebec hospital was more complicated than it needed to be. It felt like I was in another country. When you're sick, you really do not appreciate that.

  3. Kendall but Quebec is another country, or rather planet : ) even with universal guidelines they do their own stuff, remember Quebec is its own nation.

    I lived in 3 different provinces and they are the same, but Saskatchewan (yes, I had to live there 2 years!) was by far the best, less waiting time and excellent service. But it is Tommy Douglas nation so they are the example.

  4. First of all, wow. My hope has always been that people would read, comment and that we would have dialogue. You have helped us get there, so thanks!

    The notion of national standards is a difficult. It became part of the Meech discussions and has remained an important part of any consideration of new social programs.

    The feds have the cash. The provinces have the responsibility. Bottom line = they need one another to make it work. They also both want credit. So where do we go from here?

    Portability is critical. A Canadian should expect the same service at the same "cost" province to province. At the same time, our system should be flexible enough to account for differences within province and the needs these differences may place on the health care system (e.g. more retirees in BC, more children being born in Ontario).

    It's a tough nut to crack - all the more reason we should be discussing it. Essentially, we are squabbling over the bill before we have even sat down and looked at the menu. Does that make sense?

  5. That's a valid point. I guess my fear is that by giving the provinces more power over healthcare, it would erode such consistency across the board (excluding Quebec).

    I know Newfoundland is just chomping at the bit to be declared a distinct nation, I have visions of 'foreigners' having to be 'screeched in' before seeing a doctor.

    I kid, of course.

  6. Newfoundland is the only province I have not visited. Getting Screeched In is on my list of things to do...

  7. I could arrange that. Would you prefer to kiss a cod or kiss a puffin's arse?

    I highly recommend you visit. Best place on earth. I am totally biased.


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