It was supposed to be the deal that fixed Canadian health care for a generation.
In 2004, then-prime minister Paul Martin and the premiers signed a 10-year, $41.3-billion agreement to strengthen the system. They committed to a 10-point plan that promised shorter waits for surgery, better access to primary and home care, and the creation of health human-resource and national pharmaceutical strategies.
Nearly 20 years later, none of the problems that spurred the 2004 accord are considered fixed, and a new generation of premiers is once again asking the federal government for a major increase in health spending, this time in the shadow of a devastating pandemic.
As Prime Minister Justin Trudeau and the premiers prepare to gather in Ottawa on Tuesday for a “working meeting” on health care, the country’s top doctors, nurses and health care executives are urging all sides to heed the lessons of the past.
The health care system was struggling to meet the needs of a growing and aging population even before COVID-19 struck. This new deal, advocates say, must recognize that the system requires a fundamental overhaul, not small or short-term fixes.
“My big fear is that if you put enough money into it, you can put off any hard decisions for another couple of years,” said Michael Gardam, the chair of HealthCareCan, a group that represents hospitals and health organizations across the country. He’s also the chief executive officer of Health PEI, the province’s health authority. “You can have an old clunker of a car and if you sink enough money into it, you can keep it on the road for a few more years.”
The premiers have been lobbying the federal government for a gargantuan boost to the Canada Health Transfer. They want Ottawa to raise its share of health costs to 35 per cent, up from what they say is about 22 per cent today. That would mean an immediate increase of approximately $28-billion to Ottawa’s transfer to the provinces and territories, which amounted to $45.2-billion this fiscal year.
The Trudeau government takes issue with the premiers’ accounting, and regularly reminds the public that Ottawa transferred tax points to the provinces in 1977 to make more room for the level of government that actually delivers health care to increase taxes to pay for it.
The provinces and territories initially wanted more money without any strings. A November meeting of federal and provincial health ministers fell apart when the parties couldn’t agree to improve national health data. Some provinces have since softened that stance, with Ontario’s Health Minister declaring on Thursday that her province is “all in” on collecting more data and sharing it with Ottawa.
Data collection might seem like small potatoes in a fight over billions of dollars and the future of a pandemic-battered health system, but those who’ve been through the wringer of previous health-funding negotiations say improvement isn’t possible without clear targets and the data to determine whether they’ve been met.
“As I reflect over the years as to when we’ve actually seen significant change, it’s when those commitments are as specific as possible,” said Jane Philpott, dean of the school of medicine at Queen’s University.
Dr. Philpott was federal health minister in 2017, when the Trudeau Liberals negotiated bespoke deals with every province and territory for mental-health and home-care funding, rather than satisfying the premiers’ demands for a higher across-the-board increase to the Canada Health Transfer.
She still believes the targeted deals were a good idea, but in retrospect wishes her government had been more specific about the progress it expected in return. Precise wait-time benchmarks for a handful of surgeries were one of the best things to emerge from Mr. Martin’s 2004 accord, she said.
The core of that deal was an increase to the Canada Health Transfer, along with a promise that the fund would grow by 6 per cent a year for a decade. The deal also included a separate $5.5-billion fund to address wait times, $500-million for medical equipment and $850-million for Indigenous health and health in the territories.
Of the accord’s 10 priorities for reform, wait times are the most straightforward to evaluate. The parties agreed to set wait-time goals for five procedures: cataract surgery (16 weeks), hip replacements (26 weeks), knee replacements (26 weeks), emergency surgery for broken hips (48 hours) and radiation therapy for cancer (four weeks.)
The Canadian Institute for Health Information continues to publish those indicators nationally and by province. There was steady improvement nationally in the early years of tracking, although progress varied significantly from province to province. At the same time, demand for the procedures kept rising and, eventually, the system wasn’t keeping pace on cataracts or joints.
For example, in 2010, 80 per cent of knee replacements were done within the benchmark waiting time of 26 weeks after a specialist and patient agreed to proceed with surgery. By 2019, the figure had dropped to 70 per cent. Over that decade, the number of knees replaced in the country annually grew by about 50 per cent, according to CIHI.
When the pandemic halted elective surgeries for part of 2020, the share of knee replacements done within six months fell to 47 per cent.
In 2012, a Senate committee published an evaluation of the 2004 accord that summed up testimony this way: “Witnesses provided exciting examples of reforms occurring at the front lines of health care delivery in Canada. However, they indicated that systemic change had stalled. … They feared that health care reform in Canada would never evolve beyond a pilot project.”
Neither the 2004 accord nor the 2017 bilateral deals included mechanisms to claw back federal funds if provinces fell short of the targets. Dr. Philpott urged Ottawa to use both carrots and sticks this time. “And the important thing is that the stick has to be used,” she said.
Gregory Marchildon, professor emeritus at the University of Toronto’s Institute of Health Policy, Management and Evaluation and the executive director of the Romanow Commission on the Future of Health Care in 2001-02, said crafting a claw-back mechanism would be difficult, though not impossible. The premiers would be certain to object, he predicted.
His knock against the 2004 accord is that it wasn’t bold enough. “What I think went really wrong is that there was an opportunity to truly transform, with that amount of money, the terms of medicare,” he said. “That was our historic opportunity to introduce universal pharmacare and medically necessary home care.”
Nobody expects Tuesday’s meeting to culminate in such a big swing. But Alika Lafontaine, president of the Canadian Medical Association, is still hoping for concrete progress.
For him, that would mean guaranteeing all Canadians access to team-based primary care within a 30-minute drive of their homes and creating a national physician licence that would give doctors the flexibility to provide care across provincial borders. The CMA is urging the federal government to increase its share of health funding, but it hasn’t said by how much.
“I don’t think that physicians and nurses and other providers across the country need a grand bargain,” Dr. Lafontaine said. “What we need is to see that things are starting to change.”
Editor’s note: An earlier version of article incorrectly referred to a $41.3-million health care agreement, rather than the correct $41.3-billion.