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What should Ottawa's role be in medicare?

Joey Smallwood, the legendary Father of Confederation, purportedly said that he never had a conversation about health care that didn't lose him votes.

That attitude, common among politicians of all stripes, has led to destructive paralysis.

Since medicare was created in the 1960s, health care delivery and the needs/demands of the public have changed markedly.

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But policies - particularly those related to how the public insurance system is funded - have not kept pace. Canada's elected leaders - ever-fearful that discussing health care is a lose-lose proposition - have largely avoided debating its underlying tenets.

The one brief exception was the mid-1980s, when Parliament passed the Canada Health Act. That law (adopted unanimously, by all parties, it should be noted) is long on principles but, since then, politicians - federal and provincial alike - have failed to formulate a vision and practical policies to deliver on them.

Instead, we have seen governments lurch from crisis to crisis, cobbling together makeshift (and often contradictory) short-term policies to extinguish the flames of public anger. Last week's crisis was overcrowding in Alberta emergency rooms, this week's is funding of cancer drugs in Quebec, and next week it will be lack of nursing home beds in B.C. (or some such thing).

Two fundamental matters are at play in every one of these crises: Money and priority-setting.

When you don't have a vision, it's hard to have priorities. And when you have a funding model that is archaic, you will never have enough money or, more to the point, enough money in the right places.

Which brings us to the negotiations related to the Canada Health Transfer: This year, Ottawa will transfer $25.4-billion in cash and $13.1-billion in tax points to the provinces and territories, and that amount will increase 6-per-cent annually until the deal expires in 2014.

With negotiations set to begin on a new deal, the political posturing has begun. The provinces and territories, naturally enough, want more money. Ottawa wants to hold the line, citing the recession, the need to eliminate the deficit and so on.

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Instead of merely bickering over how many bucks will be transferred under a flawed process, why don't we debate fundamental questions like which services should be paid for by medicare, and which should be paid by private insurance or out-of-pocket? Why don't we give some good hard thought to Ottawa's place in health care?

Constitutionally, health is provincial responsibility. Technically, Ottawa is responsible only for the health care of status Indians and members of the Canadian Forces and RCMP.

Why don't the provinces just pay the full health bill? It would mean an increase in provincial taxes but that would, presumably, be offset by a drop in federal taxes.

When medicare began, Ottawa paid 50 per cent of hospital and physician services. It did so on the understanding that services offered would be similar from province-to-province.

That principle of equity was enshrined in the Canada Health Act. The federal law sets out five criteria provinces must meet to get health funds from Ottawa: public administration, comprehensiveness, universality, portability and accessibility.

Essentially, under the CHA, Ottawa's role was to provide moral leadership and to enforce that morality with a combination of penalties and cold, hard cash.

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But, over the years, federal funding has fallen and the CHA is, for all intents and purposes, no longer enforced.

In Canadian health care, Ottawa is more spectator than player, aside from the occasional cheque-writing exercise.

The pointed question that should be asked during the negotiations surrounding the Canada Health Transfer: What should the federal government's role be in medicare?

Is it merely a banker? Or a leader? Does Ottawa dare throw off the shackles of the Canada Health Act? Or, conversely, will it embrace the spirit as well as the letter of the law?

There is no right or wrong answer to these questions. But national leaders need to take a firm position on these issues so we can have a real debate.

That would be a welcome first step in reforming and shaping medicare beyond 2010.

As Joey Smallwood said: "It's not where you are, it's where you're headed that matters."

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About the Author
Public health reporter

André Picard is a health reporter and columnist at The Globe and Mail, where he has been a staff writer since 1987. He is also the author of three bestselling books.André has received much acclaim for his writing. More

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