A bit more than a decade ago, Canada’s first ministers struck what they grandly billed as a health accord designed to “fix medicare for a generation.”
Twelve years and billions of public dollars later, new players are headed back to the negotiation table this fall.
They might as well be starring in a remake of Groundhog Day. For, while the faces are fresh, the issues are the same. The promised big fix has failed to materialize.
Most Canadians have, at best, seen only modest progress on homecare and pharmacare. In far too many places, unacceptable wait times for medical services are still the norm.
There is little cause to believe that the upcoming talks will make a real difference.
Here are some reasons why:
Don’t hold your breath waiting for someone to pull a rabbit out of a hat. The future of Canada’s public health system was the top-of-mind social-policy issue of the decade that preceded the 2004 accord. One could fill a bookshelf with the reports – provincial and federal – commissioned over that period.
They include the report of a royal commission headed by former Saskatchewan premier Roy Romanow. It served as the template for Paul Martin’s health accord. It has failed to have a transformative impact on the system.
Yet, its premise that a critical amount of money can buy change remains the dominant conventional wisdom at both levels of government.
Few Canadians can readily recall the name of the federal minister in charge of the health file at the time of the negotiation of the last accord. Ujjal Dosanjh is best remembered for having served as premier of British Columbia.
That’s because when it comes to health care, the buck stops with the minister of finance and the prime minister, not the minister in charge of the portfolio.
Almost a year in, Health Minister Jane Philpott is widely seen as one of the promising rookies of Trudeau’s cabinet. But for all the talk about a federal leadership role, the fact is that Ottawa’s main contribution to the health system takes the shape of transfer payments to the provinces. The health minister has no authority over those.
In this, as in many federal-provincial matters, the real action tends to be where the prime minister is. That’s why this week the provinces called for a first ministers meeting on health care.
When it comes to dealing with the provinces, money is Ottawa’s top bargaining chip. The health budget accounts for close to half of all provincial spending. Given the billions the federal government puts into it, one would expect it to have some leverage.
But the reality is that this pot of federal gold has almost always been used more effectively to facilitate trade-offs with the provinces on other files of interest to Ottawa than to buy substantive reform in the health system.
As it happens, the Trudeau government is opening two federal-provincial fronts this fall. One involves health care and the other carbon pricing (and pipelines.) It is highly unlikely that one file can be dealt with in isolation from the other.
Since 2004, the federal health transfer to the provinces has increased by 6 per cent a year. Under a formula advanced by Stephen Harper, that rate is about to fall to 3 per cent. Trudeau intends to stick to the Conservative plan but has also promised to spend another $3 billion on home care.
Most provinces are wary of having strings attached to health-care funding. That’s not just a whim on their part. A $3-billion start-up fund could get more home-care initiatives up and running, but once the federal money is spent, the funds to keep the new services going would have to be found within existing provincial budgets.
By and large, the provinces have balked at Trudeau’s approach to health-care funding.
Quebec’s Liberal health minister, Gaétan Barrette, has even said he would leave the money on the table rather than accept federal conditions as to how it is spent.
Before dismissing the provincial protests as par for the course in the day-to-day life of the federation, consider that this is the most Liberal-friendly group of premiers Trudeau can ever hope to deal with and draw your own conclusions as to whether the next chapter of the health-care debate will be that different from the costly inconclusive ones of the recent past.
Chantal Hébert is a national affairs writer.