By Sean Speer and Brian Lee Crowley, Oct. 6, 2016
Negotiations between Ottawa and the provinces on health care tend to follow a similar script. Health ministers initially talk about the need for “structural reform,” then begin squabbling about more funding. The new funds eventually buy more of the status quo and reform is put off, yet again.
Federal Health Minister Jane Philpott is set to meet her provincial and territorial counterparts in Toronto in coming days. Early signals from provincial officials about the need for more federal funding suggest that the meetings are likely to revert to the same old script.
Canada’s health-care system is an expensive underperformer.
Yet we can no longer postpone reform in the face of mounting evidence that Canada’s health-care system is fiscally unsustainable and performing poorly in a host of measures related to access and quality of care. It is up to Ottawa to resist calls for more money, and instead grant the provinces and territories the flexibility to reform how health care is financed and delivered.
That the health-care system is in need of reform is widely accepted by all but the most hard-core Medicare activists. Canadian health-care spending is among the highest in the world and several provinces are now approaching or exceeding 40 per cent of their total spending on health care. Several projections — including from the Parliamentary Budget Office and the Macdonald-Laurier Institute — show that this trend is unsustainable.
Canada’s health-care system is an expensive underperformer. Which brings us back to the upcoming meeting between Philpott and her provincial and territorial counterparts, and the need for a new script.
The minister recently told the annual general meeting of the Canadian Medical Association that we have the means to improve the system if we’re prepared to “think big” and “do things differently.” We wholeheartedly agree. The key is to determine how best to drive reform and here the minister would be wise to learn the lesson from the last federal-provincial health accord in 2004.
That accord, which involved the adoption of top-down federal priorities in exchange for massive new funding, was supposed to “mark a turning point in our efforts to renew health care for the 21st century.” Yet the accord did not lead to reform. It essentially bought stasis. Spending increased; wait-times grew; the relative performance of Canada’s health-care system fell; and time was lost. The lesson is that big rhetoric and big money do not equate to big reforms.
And it should come as no surprise. As Janice MacKinnon, a former Saskatchewan finance minister, has said, “Why would you make a tough decision if somebody is going to give you more money to keep the status quo? … The money did not go to change.”
“Big” reform will only occur when the provinces and territories are given the flexibility to experiment on how to do things differently and have the incentives to do so. Ottawa’s role should involve fewer strings, not more. This should include repealing the sections of the Canada Health Act that prohibit patient cost-sharing.
Philpott seems to have partly adopted this prescription by signalling, much to the provinces’ dismay, that the Canada Health Transfer will not increase. But she has also talked about tougher enforcement of user fees and extra billings, and threatened to cut Quebec’s transfer payment by about $80 million a year unless the province eliminates its auxiliary fees.
Ottawa’s role should involve fewer strings, not more.
This does not amount to “big thinking.” Centralizing reform out of Ottawa risks repeating the same mistakes as the past and failing to produce the improvements to affordability, universality and health-care quality. More provincial experimentation, not less, is the path to get there.
It’s time therefore for a new script in which the federal government provides the provinces with the flexibility and incentives for them to test reforms. That would represent big thinking.
Brian Lee Crowley is managing director and Sean Speer is a Munk senior fellow at the Macdonald-Laurier Institute.