Daphne Bramham: Provinces, not Ottawa, need to fix health care

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Provincial and territorial leaders jealously guard their jurisdiction over health care, chafing against any perceived interference from Ottawa except when it comes to money.

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As each week seems to bring more tragic stories about unnecessary deaths resulting from inadequate health services, health ministers empathize.

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Almost every month, at least one of them announced plans to “fix” the shortages of nurses, doctors and other health-care workers. Saskatchewan’s minister emphasized his commitment by jetting off to the Philippines to recruit them.

They talk about the failures in terms of the pandemic, the opioid crisis, the aging demographic. They blame their predecessors.

But at every turn, when asked why more can’t be done more quickly, the lament is that they would, if only the federal government could give them more money.

They are demanding that Ottawa cover 35 per cent of health-care costs across the country, up from the current 22 per cent. They want the money to come untethered so that they can spend as they please.

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But health-care spending already accounts for 13 per cent of Canada’s gross domestic production. The only good thing that can be said about that is that at least it’s not as much as in the United States, where it is 18 per cent.

Canada is 10th of 11 in the Commonwealth Fund’s 2021 comparison of health system performance in Australia, Canada, France, Germany, Netherlands, New Zealand, Norway, Sweden, Switzerland, Britain and the United States.

For the last 15 years, Canada’s ranking has remained second-last. In 2021, it was well below top-ranked Norway, Netherlands and Australia — especially in equity and health-care outcomes.

Canada’s best rankings were for care process (fourth) and administrative efficiency (seventh).

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Care process includes preventive care, safe care, coordinated care, and engagement and patient preferences. It’s the only category in which the United States excels and ranks at No. 2. In every other respect, it ranks at the bottom, far below even Canada.

The unwelcome truth is that while universal medicare is a source of pride for an overwhelming majority of Canadians, it’s been decades since it was a world-class system.

Now it’s in crisis, something that was inevitable even without a pandemic because of the policy choices made primarily by premiers and health ministers.

But change how? And to what?

Peter Nicholson offers some rather surprising suggestions in a policy paper released last week by the University of Regina’s Johnson Shoyama Graduate School of Public Policy.

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He urges Ottawa to essentially walk away.

He recommends getting rid of the Canada Health Transfer (CHT) that now covers almost a quarter of provincial health spending, transferring so-called “tax points” to the provinces that exist under long-established precedent, and bolstering the equalization of payments to ensure that poorer regions aren’t disadvantaged.

“The CHT is always deemed by the provinces to be insufficient, a claim used by provincial governments to shift some of the blame for the inadequacies of the health-care system onto the federal government,” wrote Nicholson, who was deputy chief of staff for policy to former prime minister Paul Martin.

“By muddying the assignment of responsibility, the CHT has reduced the pressure on the provinces to undertake the politically difficult task of health-care reform.”

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The result would be a reduction in Canadians’ federal tax bill. Then, it would be up to the provinces to “weigh the public desire for better health care against public resistance to (provincial) tax increases.”

Some may choose to simply fill the gap left by the federal transfers. Others may choose to increase the amount or decrease it.

But with more confidence than many, Nicholson asserts: “There is essentially zero risk of back-sliding into a US-style system that is scorned around the world and increasingly within the US itself.”

Encouraged by their electors’ desire for better health services, his provinces will experiment more and look to the experiences of countries like Norway, the Netherlands and Australia for best practices.

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That includes, Nicholson suggests, having a mix of public and private health providers.

Former federal finance minister Bill Morneau is also weighing in on health reform in his book, Where To From Here, scheduled for release today.

Fixing Canada’s $300-billion system is a central theme, according to The Globe and Mail, which received an advance copy.

He wrote that the federal government “gives money while accepting a fiction: that the provinces will apply the funds to the system for which they are responsible, which is something that often fails to happen.”

Unlike Nicholson, Morneau urges Ottawa to take a firmer hand by making federal transfers conditional on provincial commitments to achieve “measurable progress” on reform.

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For decades, Canadians have been paying a high price for a system that has been delivering much less than other wealthy nations. With the collapsing system, they are fed up with finger pointing, unfulfilled promises and sub-par services.

They have had their fill of delays, and there are already decades worth of studies, royal commissions and policy papers urging reform. Nicholson and Morneau are only the latest to chime it.

The bottom line is that health care is the responsibility of the provinces. Premiers need to quit whining, step up and do what’s necessary to make the system work.

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