David McLaughlin is the president and chief executive officer of the Institute on Governance. He has been a deputy minister of intergovernmental affairs in New Brunswick and Manitoba.
The health care funding carousel is returning to Ottawa this week in the form of a first ministers’ meeting. The FMM is the first in-person gathering of the Prime Minister and premiers in more than four years, and the first to discuss health care in more than two years. That should not be the case.
Up until the beginning of the COVID-19 pandemic, there have been 82 FMMs in Canadian history. More than 60 of these have occurred since 1963, after which gatherings of premiers and prime ministers began to multiply. Contemporary Canada, with its national pension plan, medicare, equalization, natural resources ownership and a Charter of Rights and Freedoms, are all products of FMMs – a unique Canadian practice.
Two topics have dominated intergovernmental agendas in this modern era: the Constitution and health care. Today, the first remains unfinished and untouchable; the second is sacred and ungovernable. That the country’s leaders are gathering yet again in crisis mode to “fix” health care underlines the weak federalist governance that underpins it.
To change this, we need to distinguish between federalism and its governance. Fights of fancy over jurisdiction – the matter of who does what – are the stuff of federalism. Fights of form – how decisions are made and accountability is rendered – are the stuff of governance.
Unfortunately for Canadians, who are sick to death – literally – of a poorly performing health care system delivering inadequate services, this seems like a distinction without a difference. Yet, it matters. Health care federalism is a different beast than the typical day-to-day intergovernmental architecture buttressing regular federal/provincial/territorial discourse. But we don’t treat it that way. It’s time we did.
If we are to secure something that’s more than just another temporary financial fix to what ails our less-than-national health care system, then a closer alignment between health care jurisdictional federalism, Canada Health Transfer (CHT) funding and health care intergovernmental governance must be on the FMM agenda, too.
We must begin by recognizing that the pandemic ravaged our health care systems to the point that there are truly national interests at stake. Health care professional training, credentials and the mobility of doctors and nurses is a cross-Canada issue, not a provincial one. Bidding wars to recruit – poach, let’s admit it – these professionals will benefit some provinces while beggaring others. Record-high wait lists for surgeries and other procedures will fester without concerted, co-ordinated action across the federation. Systemic Indigenous health issues identified during the pandemic require far better co-ordination than what we have experienced.
And what of the looming mortalities and morbidities wrought by COVID-19′s impact on postponed tests, diagnostics and preventative health measures? Do we really think this can be whittled down through business-as-usual? The federal government has called for 1.5 million new immigrants over the next three years to grow our economy. A greying, growing population simply cannot be taken care of by today’s health care system.
We must also depersonalize health care. A peculiar feature of Canada’s “executive federalism” is the primacy of premiers and prime ministers in deciding what’s important, when. It is personality-driven federalism subject to the political interests of leaders and the landscape of the moment. Former prime minister Stephen Harper, for example, convened premiers exactly twice during his tenure; in private and only on the economy. Prime Minister Justin Trudeau refused to meet premiers on health care for more than two years until he deemed the time right.
COVID-19 hit pause on this arbitrary model. Emergency measures called for a form of emergency federalism, with regular FMM calls week after week, then month after month, as the pandemic wore on. First ministers got stuff done largely because they had to. Political posturing was politically risky. But, with the pandemic largely in our rear view, traditional executive federalism has reverted to its old habits.
We must build an accountability superstructure to govern any new CHT funding. This means a regular series of FMMs for the next two years, minimum, to track and report on health care improvements. The mutual sharing of data, results and best practices should help to break down pan-Canadian barriers to reform and innovation, align funding with need and spotlight inefficiencies and professional vested interests in the health care system that hamper needed change.
If first ministers are honest this week, they will remind Canadians that truly fixing health care is a long-haul exercise and that they are now going to do things differently. They will admit that better care sooner will not emerge from a one-day, headline-grabbing, intergovernmental demand-fest.
A true fix for health care. Now, wouldn’t that be a headline to read?