There is a word you will likely not hear uttered in Finance Minister Jim Flaherty's budget speech on Thursday: health.
There may be passing references to the health of the economy, and a little braggy reminder that Ottawa has boosted health transfers to the provinces. But don't expect new initiatives or any leadership on the health-care front. Don't expect the level of passion you will hear on, say, mortgage rates.
This wash-my-hands-of-health approach from the Finance Minister – and the government of Stephen Harper more generally – is disquieting.
It's as if health care didn't matter to Canadians. But it does.
Let's start with the economics: After all, this is the budget.
Health care accounts for 11.6 per cent of the gross domestic product. The $207-billion in total spending on health services this year will account for one in every $9 spent in the economy.
It's strange that a government concerned with employment and economic stability is indifferent to a sector that employs one in 11 workers. Health care directly employs 1.6 million Canadians, and 500,000 indirect jobs depend on the sector. Most are stable, good-paying jobs. (Read: They pay a good chunk of taxes.)
It's even more difficult to understand why a pro-business government couldn't care less about the state of medicare, given that publicly funded health insurance offers Canadian business such a great economic advantage, particularly over its U.S. competitors.
Last, but not least, it seems politically reckless for a government (and a political party) to turn its back on an issue that is consistently identified as the No. 1 concern in public opinion polls – well ahead of the economy.
But Mr. Harper, and his loyal sidekick Mr. Flaherty, while politically moderate on most issues, have a pretty big dogmatic streak, and it's rearing its head on the health file.
The lack of initiative, the seeming inability to utter the word "health," is a manifestation of a dogmatic belief in decentralization, the notion that the federal government has few responsibilities other than national defence, international relations and the economy. Virtually everything else is perceived as the sole responsibility of the provinces and territories.
To back this world-view, the constitutional division of powers is cited. According to the British North America Act of 1867 (the cornerstone of the Constitution) health is a provincial responsibility.
At least that's the party line. The reality is a little more complex. Provinces are responsible for oversight of health care delivery to most of their citizens. Ottawa has overlapping responsibilities, including delivery of health care to first nations, Inuit and Métis peoples, as well as the armed forces, the RCMP, veterans and refugees, and oversight of public health.
Let's not forget that the division of powers was fashioned almost 150 years ago, when there was no health system to speak of, and the role of the state was very different from what it is today.
The Constitution, while important, is not the be-all-and-end-all. In a confederation, the federal government has a key role as a unifier and a leveler of the playing field, economic, social and otherwise.
That role, while not spelled out in the Constitution, is well-established. It's why we have a House of Commons and Senate with representation from all regions, and a tradition of regional representation in cabinet. It's also why we have complex systems of equalization and transfer payments.
In the coming year, the Canada Health Transfer, the tax money Ottawa gives the provinces for health, will reach $30.3-billion – about 15 per cent of total health spending, and it will grow by 6 per cent a year until 2017.
Writing a cheque – or, in this case 13 cheques, one to each province and territory – is bookkeeping. It's not leadership.
Ottawa should be putting strings on that money, targeting it to initiatives that bolster medicare. The federal government has done this for more than half a century, prioritizing everything from hospital construction to reducing waits for surgery.
That kind of priority-setting is desperately needed now, in one area in particular – pharmacare.
Medicare covers all hospital and physician services, but not drugs, which are often essential to good care. It makes no sense and everyone knows it.
All provinces have programs to make drugs available to those in need, like seniors, people on social assistance or with expensive health conditions. But the system lacks coherence, and the practical result is growing inequalities in access to health care across the country.
It's unfair and unacceptable and undermines medicare. It's also a problem that Ottawa can and should solve. It doesn't necessarily require more money, just earmarking money. And it doesn't even offend the notion of provincial autonomy in health care, because a national pharmacare program can be voluntary, with some sweet cash incentives.
Making essential drugs available to all Canadians is the kind of announcement that should be the centrepiece of a federal budget, the kind of move that creates a legacy.
What will be the legacy of Thursday's budget? In health care, it will be another opportunity lost.
Talking about the health of the economy without paying any attention to the health of the people is not good economics, good stewardship or good politics.
It's barely a job half done.