CANADA’S MOST CONTROVERSIAL PUBLIC FIGURE?

GARY BETTMAN, NHL Commissioner

Health Care and Federal-Provincial Politics in Canada Gerry Boychuk, February 4 th, 2005

Overview trends in Canadian federalism trends in Canadian federalism a primer on Canadian health care a primer on Canadian health care the importance of health care in Canadian politics the importance of health care in Canadian politics First Ministers’ Health Summit, 2004 First Ministers’ Health Summit, 2004 the negotiations the negotiations the health care deal the health care deal broader implications for Canadian federalism broader implications for Canadian federalism conclusions conclusions

Overview trends in Canadian federalism trends in Canadian federalism a primer on Canadian health care a primer on Canadian health care the importance of health care in Canadian politics the importance of health care in Canadian politics First Ministers’ Health Summit, 2004 First Ministers’ Health Summit, 2004 the negotiations the negotiations the health care deal the health care deal broader implications for Canadian federalism broader implications for Canadian federalism conclusions conclusions

Trends in Canadian Federalism decentralization decentralization entanglement entanglement

Explaining Decentralization shifting importance of various enumerated powers shifting importance of various enumerated powers lack of representation of provincial interests within the federal government lack of representation of provincial interests within the federal government representation of provincial/regional interests primarily through the provincial governments representation of provincial/regional interests primarily through the provincial governments existence of Quebec existence of Quebec Quiet Revolution (1960) -- “maitre chez nous” Quiet Revolution (1960) -- “maitre chez nous” – accommodating Quebec asymmetrical federalism vs. decentralization of power to all provinces asymmetrical federalism vs. decentralization of power to all provinces –generally favoured the latter

Federal-Provincial Entanglement explaining entanglement explaining entanglement – division of powers spells out tools more than areas of responsibility – division of powers not suited to emerging policy problems – vertical fiscal disequilibrium federal spending power federal spending power prevailing views of entanglement prevailing views of entanglement – pragmatic federalism should be about ‘what works’ – “subsidiarity” federalism should be about ‘what works’ – “subsidiarity” entanglement is inefficient, ineffective entanglement is inefficient, ineffective – principled democratic deficit democratic deficit entanglement undermines the constitution entanglement undermines the constitution –basis of our division of powers is the federal deal not simply concerns about what works best

Overview trends in Canadian federalism trends in Canadian federalism a primer on Canadian health care a primer on Canadian health care the importance of health care in Canadian politics the importance of health care in Canadian politics First Ministers’ Health Summit, 2004 First Ministers’ Health Summit, 2004 the negotiations the negotiations the health care deal the health care deal broader implications for Canadian federalism broader implications for Canadian federalism conclusions conclusions

Universal Public Health Care in Canada – A Primer government role in health care in Canada government role in health care in Canada – hospital insurance Saskatchewan, 1947 Saskatchewan, 1947 federal hospital insurance, 1957 federal hospital insurance, 1957 – medical care (e.g. physician) insurance Saskatchewan, 1962 Saskatchewan, 1962 federal Medicare, 1966 federal Medicare, 1966

Universal Public Health Care in Canada – A Primer provincial role provincial role primary jurisdiction primary jurisdiction actually provide public health insurance actually provide public health insurance federal role federal role – transfers funds to the provinces federal spending power federal spending power – set and enforce national principles under Canada Health Act (CHA) comprehensive, universal, portable, accessible, public administration comprehensive, universal, portable, accessible, public administration –no province has ever been penalized under these provisions of CHA (despite obvious infractions) banned extra-billing and user fees banned extra-billing and user fees

Differences – Public Policy & Health Insurance in the US & Canada public health insurance for hospital care and medical care is universal in Canada (and categorical in the US) public health insurance for hospital care and medical care is universal in Canada (and categorical in the US) public health insurance in Canada is compulsory public health insurance in Canada is compulsory –private provision of insurance for publicly-insured health services is prohibited in Canada (but not in the US) important differences in funding (single-public- payer in Canada, and multiple-payer in the US), less significant differences in modes of delivery important differences in funding (single-public- payer in Canada, and multiple-payer in the US), less significant differences in modes of delivery

Overview trends in Canadian federalism trends in Canadian federalism a primer on Canadian health care a primer on Canadian health care the importance of health care in Canadian politics the importance of health care in Canadian politics First Ministers’ Health Summit, 2004 First Ministers’ Health Summit, 2004 the negotiations the negotiations the health care deal the health care deal broader implications for Canadian federalism broader implications for Canadian federalism conclusions conclusions

The Symbolism of Health Care in Canada “We want a Canada where our universal health care system is a proud example of our national values at work… Health care is the nation’s first priority. Quality care; timely care. Care that is accessible regardless of income; portable right across Canada; and publicly funded. We are committed irrevocably to the principles of the Canada Health Act. They are part of who we are — a moral statement about fundamental fairness — that all Canadians should stand equal before our health care system.” Prime Minister Paul Martin Reply to the Throne Speech January 2004 “We want a Canada where our universal health care system is a proud example of our national values at work… Health care is the nation’s first priority. Quality care; timely care. Care that is accessible regardless of income; portable right across Canada; and publicly funded. We are committed irrevocably to the principles of the Canada Health Act. They are part of who we are — a moral statement about fundamental fairness — that all Canadians should stand equal before our health care system.” Prime Minister Paul Martin Reply to the Throne Speech January 2004

The patron saint of Canada is Tommy Douglas. Any time someone has a new idea about the health-care system, someone else invokes the sacred memory of St. Tommy and that's the end of it.” “The patron saint of Canada is Tommy Douglas. Any time someone has a new idea about the health-care system, someone else invokes the sacred memory of St. Tommy and that's the end of it.” Margarent Wente’s “Guide For Expat Americans” G&M, Nov.9th 2004

Health Care and National Identity How important are the following to the Canadian identity … Canada’s health care system? Source: Environics Focus Canada Survey, March 1996

Why is Health Care So Politically Important? the provision of health services touches every individual Canadian directly the provision of health services touches every individual Canadian directly – “The federal government has few direct touch points with individual Canadians. So whenever it has an opportunity to deal directly with its citizens, it should do so, to increase the federal government’s relevance to their daily lives. The more Ottawa becomes involved with Canadians, the more individuals are likely to see the value of the national government, nationalism and our federation.” (Goldfarb, 2004)

Why is Health Care So Politically Important? the provision of health services touches every individual Canadian directly the provision of health services touches every individual Canadian directly other spheres of government competence increasingly limited other spheres of government competence increasingly limited – federal government –trade policy and tarriffs –industrial development –monetary policy –fiscal policy (taxing and spending) what is left for the federal government to do?? what is left for the federal government to do??

Overview trends in Canadian federalism trends in Canadian federalism a primer on Canadian health care a primer on Canadian health care the importance of health care in Canadian politics the importance of health care in Canadian politics First Ministers’ Health Summit, 2004 First Ministers’ Health Summit, 2004 the negotiations the negotiations the health care deal the health care deal broader implications for Canadian federalism broader implications for Canadian federalism conclusions conclusions

Health Care in the Federal Election, 2004 Prime Minister Martin promised to... Prime Minister Martin promised to... – “fix health care for a generation” – undertake negotiations with the provinces and not abandon talks until a deal was struck – to negotiate in an open, televised forum

First Ministers’ Meeting on Health Care, September 2004 PM Martin The Premiers

Overview trends in Canadian federalism trends in Canadian federalism a primer on Canadian health care a primer on Canadian health care the importance of health care in Canadian politics the importance of health care in Canadian politics First Ministers’ Health Summit, 2004 First Ministers’ Health Summit, 2004 the negotiations the negotiations the health care deal the health care deal broader implications for Canadian federalism broader implications for Canadian federalism conclusions conclusions

Health Summit -- The Negotiations... federal-provincial diplomacy and the ‘democratic deficit’ federal-provincial diplomacy and the ‘democratic deficit’ federal provincial gamesmanship federal provincial gamesmanship democratic deficit – closed door negotiations democratic deficit – closed door negotiations Health Summit Health Summit televised negotiations televised negotiations –decrease the level of acrimony (public grandstanding) –enrich the substantive debate about health care –transparency

Media Reports “Health Care’s Gong Show,” National Post, 14 September 2004, A18. “Health Care’s Gong Show,” National Post, 14 September 2004, A18. “Premiers Blast PM’s ‘Silly’ Offer,” Globe and Mail, 14 September 2004 “Premiers Blast PM’s ‘Silly’ Offer,” Globe and Mail, 14 September 2004 “This process has been a farce. Federal negotiating tactics have been disgusting.” Newfoundland Premier Danny Williams “This process has been a farce. Federal negotiating tactics have been disgusting.” Newfoundland Premier Danny Williams John Ibbotson, “Amid All the Acrimony, They Could Still Cut a Deal,” Globe and Mail, 14 September John Ibbotson, “Amid All the Acrimony, They Could Still Cut a Deal,” Globe and Mail, 14 September 2004.

Ralph “I’m Outta Here” Klein, Premier of Alberta

Alberta Premier Ralph Klein

Manitoba Premier Gary Doer

“Paul, I am not your son...I am the Premier of Quebec.” Jean Charest (reportedly to Paul Martin during closed door negotiations)

Health Summit -- The Negotiations... federal-provincial diplomacy and the ‘democratic deficit’ federal-provincial diplomacy and the ‘democratic deficit’ federal provincial gamesmanship federal provincial gamesmanship democratic deficit – closed door negotiations democratic deficit – closed door negotiations Health Summit Health Summit televised negotiations televised negotiations –decrease the level of acrimony (public grandstanding) –enrich the substantive debate about health care –transparency

Overview trends in Canadian federalism trends in Canadian federalism a primer on Canadian health care a primer on Canadian health care the importance of health care in Canadian politics the importance of health care in Canadian politics First Ministers’ Health Summit, 2004 First Ministers’ Health Summit, 2004 the negotiations the negotiations the health care deal the health care deal broader implications for Canadian federalism broader implications for Canadian federalism conclusions conclusions

Health Summit, 2004 – The Health Care Deal federal financial contribution federal financial contribution – $41 billion over 10 years close short-term Romanow gap close short-term Romanow gap –i.e. federal contribution = 25% of provincial costs 6% escalator 6% escalator no change in structure of funding no change in structure of funding

Health Summit, 2004 – The Health Care Deal – Wait Times Reduction Fund setting targets setting targets –comparable indicators to be established by each jurisdiction and wait times reported to citizens (Dec. 2005) –medically-acceptable wait times established (Dec.2005) –targets established by each jurisdiction (Dec.2007) –by 2008, provinces to begin to report in progress in meeting wait time targets strategy to lower waiting times? strategy to lower waiting times? –to be determined by each province

Health Summit, 2004 – The Health Care Deal primary care reform primary care reform duplicates commitment of HCRA, 2003 duplicates commitment of HCRA, 2003 offer 24/7 access to 50% of the population by 2011 offer 24/7 access to 50% of the population by 2011 home care home care duplicates commitment of HCRA, 2003 duplicates commitment of HCRA, 2003 coverage for up to 2 weeks of homecare of various types coverage for up to 2 weeks of homecare of various types Pharmacare Pharmacare commit to establishing a Ministerial Task Force (June 2006) to “develop, assess and cost options for catastrophic pharmaceutical coverage commit to establishing a Ministerial Task Force (June 2006) to “develop, assess and cost options for catastrophic pharmaceutical coverage HCRA, 2003: commitment to “ensure that Canadians have reasonable access to catastrophic drug coverage by the end of 2005/06” HCRA, 2003: commitment to “ensure that Canadians have reasonable access to catastrophic drug coverage by the end of 2005/06”

Health Summit, 2004 – The Health Care Deal Strategic Health Human Resource Action Plans – provs. agree to set targets for training, recruitment and retention public by Dec – federal gov’t commits to... accelerate integration of international health care practitioners reduce financial burden on students in specific health education programs (unspecified)

Health Summit, 2004 – The Health Care Deal emphasized symbolism over substance emphasized symbolism over substance demonstrates the degree of entanglement demonstrates the degree of entanglement

Overview trends in Canadian federalism trends in Canadian federalism a primer on Canadian health care a primer on Canadian health care the importance of health care in Canadian politics the importance of health care in Canadian politics First Ministers’ Health Summit, 2004 First Ministers’ Health Summit, 2004 the negotiations the negotiations the health care deal the health care deal broader implications for Canadian federalism broader implications for Canadian federalism conclusions conclusions

“...the most important federal-provincial deal since the constitution...” Globe & Mail “...a triumph for Canadian federalism” Globe & Mail “...a debacle...” National Post REACTIONS TO THE HEALTH SUMMIT AGREEMENT...

“Health is Not the Issue” National Post Editorial Headline, Sept

“Ask your new Canadian friends to explain the ins and outs of asymmetrical federalism to you. They will be delighted at your interest. But don't ask them the words to the national anthem. They'll only be embarrassed.” Margarent Wente’s “Guide For Expat Americans” G&M, Nov.9th 2004

Health Summit, 2004 – Federalism Aspects special side-agreement with Quebec special side-agreement with Quebec – formal recognition of the principle of asymetrical federalism “…flexible federalism that notably allows for the existence of specific agreements and arrangements adapted to Québec’s specificity…” “…flexible federalism that notably allows for the existence of specific agreements and arrangements adapted to Québec’s specificity…” – criticisms may have implications for the application of the CHA principles in Quebec may have implications for the application of the CHA principles in Quebec

Health Summit, 2004 – Federalim Aspects assymetrical federalism and the context of the health care deal, 2004 assymetrical federalism and the context of the health care deal, 2004 “A Second Quiet Revolution?” National Post Editorial Headline, Sept “A Second Quiet Revolution?” National Post Editorial Headline, Sept “A Province of Private Clinics” National Post, Sept “A Province of Private Clinics” National Post, Sept “Don’t Push Quebec, PM Warned: Forced Deal Would Backfire, Report”National Post, Sept “Don’t Push Quebec, PM Warned: Forced Deal Would Backfire, Report”National Post, Sept – Andre Senikas, President Quebec Medical Association: “If other provinces tried to set up what we have, they’d have a revolt on their hands. But in Quebec, it’s accepted.” “If other provinces tried to set up what we have, they’d have a revolt on their hands. But in Quebec, it’s accepted.” “Universal health coverage is still important to Quebecers, but it’s certainly not a defining characteristic of their national identity. In places like Ontario, people talk about the health care system being public like its a religion. In Quebec, people think differently.” “Universal health coverage is still important to Quebecers, but it’s certainly not a defining characteristic of their national identity. In places like Ontario, people talk about the health care system being public like its a religion. In Quebec, people think differently.” “Mr. Klein has not suggested anything Quebec governments have not been doing for years. [...] When you hear Mr. Charest and Mr. Klein talk, they are totally on the same wavelength...” “Mr. Klein has not suggested anything Quebec governments have not been doing for years. [...] When you hear Mr. Charest and Mr. Klein talk, they are totally on the same wavelength...”

Health Summit, 2004 – Federalism Aspects special side-agreement with Quebec special side-agreement with Quebec – formal recognition of the principle of asymetrical federalism “…flexible federalism that notably allows for the existence of specific agreements and arrangements adapted to Québec’s specificity…” “…flexible federalism that notably allows for the existence of specific agreements and arrangements adapted to Québec’s specificity…” – criticisms may have implications for the application of the CHA principles in Quebec may have implications for the application of the CHA principles in Quebec may have implications for the application of the CHA in other provinces may have implications for the application of the CHA in other provinces

Overview trends in Canadian federalism trends in Canadian federalism a primer on Canadian health care a primer on Canadian health care the importance of health care in Canadian politics the importance of health care in Canadian politics First Ministers’ Health Summit, 2004 First Ministers’ Health Summit, 2004 the negotiations the negotiations the health care deal the health care deal broader implications for Canadian federalism broader implications for Canadian federalism conclusions conclusions

Health Care and Federal-Provincial Relations -- Conclusions illustrates two central trends of Canadian federalism illustrates two central trends of Canadian federalism decentralization decentralization entanglement entanglement illustrates the central problem of executive federalism (federal-provincial diplomacy) illustrates the central problem of executive federalism (federal-provincial diplomacy) transparency and the democratic deficit transparency and the democratic deficit illustrates the centrality of the politics of territorial integration in federal-provincial relations and public policy (esp.health care) illustrates the centrality of the politics of territorial integration in federal-provincial relations and public policy (esp.health care) competitive state building competitive state building –nation-building vs. province-building illustrates the central tension of Canadian federalism illustrates the central tension of Canadian federalism accommodating provincial distinctiveness (esp. Quebec) while maintaining national unity accommodating provincial distinctiveness (esp. Quebec) while maintaining national unity