5. FEDERALISM AND THE POLITICS OF HEALTH CARE POLICY IN CANADA Gerard W. Boychuk Department of Political Science University of Waterloo Political Science 321 March 6 th, 2007

6. Federalism and Health Care constitutional division of powers provides different orders of government with different policy tools constitutional division of powers provides different orders of government with different policy tools

7. Health Care and the Constitutional Division of Powers provincial jurisdiction provincial jurisdiction S.92 (7) “The Establishment, Maintenance, and Management of Hospitals…in and for the Province…” S.92 (7) “The Establishment, Maintenance, and Management of Hospitals…in and for the Province…” exceptions exceptions gives provinces the power to legislate in regard to health care gives provinces the power to legislate in regard to health care

8. Health Care and the Constitutional Division of Powers federal policy tools federal policy tools the federal spending power the federal spending power “…the power of [the federal] Parliament to make payments to people or institutions or governments for purposes on which it [Parliament] does not necessarily have the power to legislate.” “…the power of [the federal] Parliament to make payments to people or institutions or governments for purposes on which it [Parliament] does not necessarily have the power to legislate.” not explicit in the Constitution Act, 1867 not explicit in the Constitution Act, 1867 formally recognized (and limited) in the Social Union Framework Agreement, 1999 formally recognized (and limited) in the Social Union Framework Agreement, 1999

9. The Federal Role – The Canada Health Transfer Canada Health Transfer (CHT) Canada Health Transfer (CHT) block-funding transfer from the federal government to the provinces block-funding transfer from the federal government to the provinces the conditions for funding are set out in the Canada Health Act the conditions for funding are set out in the Canada Health Act not directly legislating – simply sets the terms for federal transfers not directly legislating – simply sets the terms for federal transfers

10. The Federal Role – The Canada Health Act Canada Health Act (CHA) Canada Health Act (CHA) the five principles the five principles universality, comprehensiveness, accessibility, portability, public administration universality, comprehensiveness, accessibility, portability, public administration universal availability of public health insurance (on uniform terms and conditions) for all medically necessary hospital and physician services universal availability of public health insurance (on uniform terms and conditions) for all medically necessary hospital and physician services without financial barriers to access without financial barriers to access no extra-billing on insured services no extra-billing on insured services no user/facility fees on insured services no user/facility fees on insured services

11. The Federal Role – The Canada Health Act Canada Health Act (CHA) Canada Health Act (CHA) penalties penalties non-discretionary penalties for extra-billing/user fees non-discretionary penalties for extra-billing/user fees discretionary penalties for other violations of five principles discretionary penalties for other violations of five principles no province has ever been penalized for violation of the five principles no province has ever been penalized for violation of the five principles

12. The Federal Role – The Canada Health Act Canada Health Act (CHA) Canada Health Act (CHA) non-requirements non-requirements no legal prohibitions on private provision of services no legal prohibitions on private provision of services no legal prohibitions on private insurance no legal prohibitions on private insurance

13. Federalism and Health Care constitutional division of powers provides different orders of government with different policy tools constitutional division of powers provides different orders of government with different policy tools the operational division of powers in health care is determined politically the operational division of powers in health care is determined politically

14. The Politics of the CHA “There’s nothing that says you have to stay in the Canada Health Act.” Premier Ralph Klein, June 2004 “There’s nothing that says you have to stay in the Canada Health Act.” Premier Ralph Klein, June 2004 …so…why do provinces abide by the CHA? …so…why do provinces abide by the CHA? provinces need the money? provinces need the money? CHT (cash) equals roughly… CHT (cash) equals roughly… 36% of total federal transfers to provinces 36% of total federal transfers to provinces 19% of provincial health expenditures 19% of provincial health expenditures 6.5% of total provincial revenue 6.5% of total provincial revenue

15. Ipsos-Reid, CFNU, January 2006.

17. The Politics of the CHA “There’s nothing that says you have to stay in the Canada Health Act.” Premier Ralph Klein, June 2004 “There’s nothing that says you have to stay in the Canada Health Act.” Premier Ralph Klein, June 2004 …so…why do provinces abide by the CHA? …so…why do provinces abide by the CHA?

18. The Politics of the CHA “There’s nothing that says you have to stay in the Canada Health Act.” Premier Ralph Klein, June 2004 “There’s nothing that says you have to stay in the Canada Health Act.” Premier Ralph Klein, June 2004 …so…why do provinces abide by the CHA? …so…why do provinces abide by the CHA? the CHA is politically popular the CHA is politically popular

19. The Politics of the CHA “There’s nothing that says you have to stay in the Canada Health Act.” Premier Ralph Klein, June 2004 “There’s nothing that says you have to stay in the Canada Health Act.” Premier Ralph Klein, June 2004 …so…why do provinces abide by the CHA? …so…why do provinces abide by the CHA? the CHA is politically popular the CHA is politically popular the CHA is enforced politically the CHA is enforced politically

20. The Politics of the CHA “There’s nothing that says you have to stay in the Canada Health Act.” Premier Ralph Klein, June 2004 “There’s nothing that says you have to stay in the Canada Health Act.” Premier Ralph Klein, June 2004 …so…why do provinces abide by the CHA? …so…why do provinces abide by the CHA? the CHA is politically popular the CHA is politically popular the CHA is enforced politically the CHA is enforced politically provincial violations of the CHA tend to be politically unpopular provincial violations of the CHA tend to be politically unpopular

21. Federalism and Health Care constitutional division of powers provides different orders of government with different policy tools constitutional division of powers provides different orders of government with different policy tools the operational division of powers in health care is determined politically the operational division of powers in health care is determined politically the politics of federal-provincial interaction in health care occur in a broader political context the politics of federal-provincial interaction in health care occur in a broader political context

22. Federal Involvement in Health Care nation-building nation-building origins of the CHA origins of the CHA Quebec referendum, 1980 Quebec referendum, 1980 Canada-US free trade debate, 1988 Canada-US free trade debate, 1988 continuing context continuing context 1995 Quebec referendum 1995 Quebec referendum

23. Federal Involvement in Health Care globalization globalization globalization has constrained national gov’ts more than sub-national govt’s globalization has constrained national gov’ts more than sub-national govt’s what does the federal government do in a globalized world? what does the federal government do in a globalized world? trade policy, industrial policy and regional development policy, monetary policy, fiscal policy trade policy, industrial policy and regional development policy, monetary policy, fiscal policy what do the provincial governments do in a globalized world? what do the provincial governments do in a globalized world? education education post-secondary education post-secondary education health care health care

24. Federal Involvement in Health Care vertical fiscal (im)balance vertical fiscal (im)balance definition definition federal government has excess revenues (relative to its responsibilities) and provincial governments have insufficient revenues (relative to their responsibilities) federal government has excess revenues (relative to its responsibilities) and provincial governments have insufficient revenues (relative to their responsibilities)

25. Source: Canada Institutes for Health Information, Statistics Canada

26. Federal Involvement in Health Care vertical fiscal (im)balance vertical fiscal (im)balance effects effects e.g. federal government is strongly positioned to powerfully exercise the federal spending power e.g. federal government is strongly positioned to powerfully exercise the federal spending power excess federal revenues excess federal revenues provincial demands for federal government to share excess revenues provincial demands for federal government to share excess revenues

27. Federal Involvement in Health Care constitutional politics constitutional politics formerly the preoccupation of federal- provincial relations formerly the preoccupation of federal- provincial relations shift in 1993 shift in 1993 demise of Meech Lake Accord (1988) and Charlottetown Accord (1992) demise of Meech Lake Accord (1988) and Charlottetown Accord (1992) shift to emphasis on ‘functional’ federalism (and away from constitutional discussions) shift to emphasis on ‘functional’ federalism (and away from constitutional discussions) result – health care replaced constitutional discussions as the central focus of federal- provincial relations result – health care replaced constitutional discussions as the central focus of federal- provincial relations less evident since 2004 less evident since 2004

28. Federal Involvement in Health Care context for a renewed federal role in health care context for a renewed federal role in health care health care policy has become a defining characteristic of Canadian identity health care policy has become a defining characteristic of Canadian identity globalization has weakened federal raison d’etre globalization has weakened federal raison d’etre federal gov’t has more financial resources than it knows what to do with federal gov’t has more financial resources than it knows what to do with continuing vacuum in federal-provincial relations continuing vacuum in federal-provincial relations

29. Federal Involvement in Health Care federal proposals for reinvigorated federal role (1995-20??) federal proposals for reinvigorated federal role (1995-20??) federal elections – 1997, 2000, 2004 federal elections – 1997, 2000, 2004 federal proposals federal proposals national pharmacare program national pharmacare program national homecare program national homecare program national wait times guarantee national wait times guarantee

30. Support for 5 Harper Priorities Source: IPSOS- Reid, November 26, 2006

31. Federalism and Health Care constitutional division of powers provides different orders of government with different policy tools constitutional division of powers provides different orders of government with different policy tools the operational division of powers in health care is determined politically the operational division of powers in health care is determined politically the politics of federal-provincial interaction in health care occur in a broader political context the politics of federal-provincial interaction in health care occur in a broader political context federal-provincial interaction has important impacts on the dynamics driving the politics of health care federal-provincial interaction has important impacts on the dynamics driving the politics of health care

32. Effects of Federalism on Health Care health as a ‘watertight’ jurisdictional compartment vs. federal-provincial interpenetration? health as a ‘watertight’ jurisdictional compartment vs. federal-provincial interpenetration? dynamics resulting from interpenetration dynamics resulting from interpenetration intergovernmental competition has driven expansion of public health insurance intergovernmental competition has driven expansion of public health insurance interpenetration has undermined transparency and accountability interpenetration has undermined transparency and accountability blame avoidance blame avoidance

33. Effects of Federalism on Health Care different jurisdictional arrangements different jurisdictional arrangements ‘watertight’ federal jurisdiction ‘watertight’ federal jurisdiction access to public health care would be more nationally uniform access to public health care would be more nationally uniform in the absence of provincial experimentation, may be less developed in the absence of provincial experimentation, may be less developed ‘watertight’ provincial jurisdiction ‘watertight’ provincial jurisdiction citizen access to public health care less uniform citizen access to public health care less uniform esp. if dependent on fiscal capacity of the provinces (e.g. no federal transfers/equalization) esp. if dependent on fiscal capacity of the provinces (e.g. no federal transfers/equalization) more experimentation more experimentation likely would be more highly varied range of models of public/private interaction likely would be more highly varied range of models of public/private interaction

34. Federalism and Health Care– Main Messages constitutional division of powers provides different orders of government with different policy tools constitutional division of powers provides different orders of government with different policy tools the operational division of powers in health care is determined politically the operational division of powers in health care is determined politically the politics of federal-provincial interaction in health care occur in a broader political context the politics of federal-provincial interaction in health care occur in a broader political context federal-provincial interaction in health has important impacts on the dynamics driving the politics of health care federal-provincial interaction in health has important impacts on the dynamics driving the politics of health care

37. Source: Canada Institutes for Health Information, Statistics Canada

44. Pollara, Health Care in Canada Survey, 2005.

45. Ipsos-Reid, CFNU, January 2006.

47. Ipsos-Reid, CMA, June 2006.

49. Support for Chaoulli Decision Source: IPSOS- Reid, August XX, 2005