federalism and the politics of health care policy in canada

FEDERALISM AND THE FEDERALISM AND THE POLITICSPOLITICS OF HEALTH CARE OF HEALTH CARE POLICY IN CANADAPOLICY IN CANADA

Gerard W. BoychukGerard W. BoychukDepartment of Political ScienceDepartment of Political Science

University of WaterlooUniversity of Waterloo

Political Science 321Political Science 321

March 6March 6thth, 2007, 2007

Federalism and Health Federalism and Health CareCare

constitutional division of powers constitutional division of powers provides different orders of provides different orders of government with different policy toolsgovernment with different policy tools

Health Care and the Health Care and the Constitutional Division of Constitutional Division of

PowersPowers provincial jurisdictionprovincial jurisdiction

S.92 (7) “The Establishment, S.92 (7) “The Establishment, Maintenance, and Management of Maintenance, and Management of Hospitals…in and for the Hospitals…in and for the Province…”Province…”

exceptionsexceptions gives provinces the power to gives provinces the power to

legislatelegislate in regard to health care in regard to health care

Health Care and the Health Care and the Constitutional Division of Constitutional Division of

PowersPowers federal policy toolsfederal policy tools

the federal spending powerthe federal spending power “…“…the power of [the federal] the power of [the federal]

Parliament to make payments to Parliament to make payments to people or institutions or governments people or institutions or governments for purposes on which it [Parliament] for purposes on which it [Parliament] does not necessarily have the power to does not necessarily have the power to legislate.”legislate.”

not explicit in the not explicit in the Constitution Act, Constitution Act, 18671867

formally recognized (and limited) in the formally recognized (and limited) in the Social Union Framework Agreement, 1999Social Union Framework Agreement, 1999

The Federal Role – The The Federal Role – The Canada Canada Health TransferHealth Transfer

Canada Health Transfer (CHT)Canada Health Transfer (CHT) block-funding transfer from the federal block-funding transfer from the federal

government to the provincesgovernment to the provinces the conditions for funding are set out in the conditions for funding are set out in

the Canada Health Actthe Canada Health Act notnot directly legislating – simply sets the terms directly legislating – simply sets the terms

for federal transfersfor federal transfers

The Federal Role – The The Federal Role – The Canada Canada Health ActHealth Act

Canada Health Act (CHA)Canada Health Act (CHA) the five principlesthe five principles

universality, comprehensiveness, universality, comprehensiveness, accessibility, portability, public administrationaccessibility, portability, public administration

universal availability of public health universal availability of public health insurance (on uniform terms and insurance (on uniform terms and conditions) for all medically necessary conditions) for all medically necessary hospital and physician serviceshospital and physician services without financial barriers to accesswithout financial barriers to access

no extra-billing on insured servicesno extra-billing on insured services no user/facility fees on insured servicesno user/facility fees on insured services


Canada Health Act (CHA)Canada Health Act (CHA) penaltiespenalties

non-discretionary penalties for non-discretionary penalties for extra-billing/user feesextra-billing/user fees

discretionary penalties for other violations of discretionary penalties for other violations of five principlesfive principles

nono province has province has everever been penalized for violation of been penalized for violation of the five principlesthe five principles


Canada Health Act (CHA)Canada Health Act (CHA) non-requirementsnon-requirements

no legal prohibitions on private provision of no legal prohibitions on private provision of servicesservices

no legal prohibitions on private insuranceno legal prohibitions on private insurance



the operational division of powers in the operational division of powers in health care is determined health care is determined politicallypolitically

The Politics of the The Politics of the CHACHA

““There’s nothing that says you There’s nothing that says you have to stay in the Canada Health have to stay in the Canada Health Act.”Act.” Premier Ralph Klein, June Premier Ralph Klein, June 20042004 ……so…why do provinces abide by the so…why do provinces abide by the

CHA?CHA? provinces need the money?provinces need the money?

CHT (cash) equals roughly…CHT (cash) equals roughly… 36% of total federal transfers to provinces36% of total federal transfers to provinces 19% of provincial health expenditures19% of provincial health expenditures 6.5% of total provincial revenue6.5% of total provincial revenue

Ipsos-Reid, CFNU, January 2006.

0

5

10

15

20

25

30

35

40

45

50

Pe

rce

nt

(%)

BC/Terri. Alberta MB/SK Ontario Quebec Atlantic Canada

SUPPORT FOR CONDITIONS ON ALL FEDERAL HEALTH TRANSFERS, 2006

Strongly Agree Somewhat Agree Somewhat Disagree Strongly Disagree


-30

-20

-10

0

10

20

30

40

50

60

70

Pe

rce

nt

(%)

BC Alberta SK/MB Ontario Quebec Atlantic Canada

PREFERENCES FOR STRONG CHA ENFORCEMENT VS. GREATER PROVINCIAL LATITTUDE, 2006

Strong CHA EnforcementGreater Provincial LatitudeNet CHA Support


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

the CHA?the CHA?



the CHA?the CHA? the CHA is politically popularthe CHA is politically popular



the CHA?the CHA? the CHA is politically popularthe CHA is politically popular the CHA is enforced the CHA is enforced politicallypolitically



the CHA?the CHA? the CHA is politically popularthe CHA is politically popular the CHA is enforced the CHA is enforced politicallypolitically

provincial violations of the CHA tend to be provincial violations of the CHA tend to be politically unpopularpolitically unpopular




the the politicspolitics of federal-provincial of federal-provincial interaction in health care occur in a interaction in health care occur in a broader political contextbroader political context

Federal Involvement in Health Federal Involvement in Health CareCare

nation-buildingnation-building origins of the origins of the CHACHA

Quebec referendum, 1980Quebec referendum, 1980 Canada-US free trade debate, 1988Canada-US free trade debate, 1988

continuing contextcontinuing context 1995 Quebec referendum1995 Quebec referendum


globalizationglobalization globalization has constrained national gov’ts globalization has constrained national gov’ts

more than sub-national govt’smore than sub-national govt’s what does the federal government do in a what does the federal government do in a

globalized world?globalized world? trade policy, industrial policy and regional trade policy, industrial policy and regional

development policy, monetary policy, fiscal policydevelopment policy, monetary policy, fiscal policy what do the provincial governments do in a what do the provincial governments do in a

globalized world?globalized world? education education post-secondary educationpost-secondary education health carehealth care


vertical fiscal (im)balancevertical fiscal (im)balance definitiondefinition

federal government has excess revenues federal government has excess revenues (relative to its responsibilities) and provincial (relative to its responsibilities) and provincial governments have insufficient revenues governments have insufficient revenues (relative to their responsibilities)(relative to their responsibilities)

Source: Canada Institutes for Health Information, Statistics Canada

PUBLIC HEALTH CARE EXPENDITURESAlberta and Canada, 1990-2005

0

500

1000

1500

2000

2500

3000

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Co

ns

tan

t (1

99

2)

$ p

er

ca

pit

a

Alberta

Canada


vertical fiscal (im)balancevertical fiscal (im)balance effectseffects

e.g. federal government is strongly positioned e.g. federal government is strongly positioned to powerfully exercise the federal spending to powerfully exercise the federal spending powerpower

excess federal revenuesexcess federal revenues provincial demands for federal government provincial demands for federal government

to share excess revenuesto share excess revenues


constitutional politicsconstitutional politics formerly the preoccupation of federal-formerly the preoccupation of federal-

provincial relationsprovincial relations shift in 1993shift in 1993

demise of Meech Lake Accord (1988) and demise of Meech Lake Accord (1988) and Charlottetown Accord (1992)Charlottetown Accord (1992)

shift to emphasis on ‘functional’ shift to emphasis on ‘functional’ federalism (and away from constitutional federalism (and away from constitutional discussions)discussions)

result – health care replaced constitutional result – health care replaced constitutional discussions as the central focus of federal-discussions as the central focus of federal-provincial relationsprovincial relations

less evident since 2004less evident since 2004


context for a renewed federal role context for a renewed federal role in health carein health care health care policy has become a health care policy has become a

defining characteristic of Canadian defining characteristic of Canadian identityidentity

globalization has weakened federal globalization has weakened federal raison d’etreraison d’etre

federal gov’t has more financial federal gov’t has more financial resources than it knows what to do resources than it knows what to do withwith

continuing vacuum in federal-continuing vacuum in federal-provincial relationsprovincial relations


federal proposals for federal proposals for reinvigorated federal role (1995-reinvigorated federal role (1995-20??)20??)

federal elections – 1997, 2000, 2004federal elections – 1997, 2000, 2004 federal proposalsfederal proposals

national pharmacare programnational pharmacare program national homecare programnational homecare program national wait times guaranteenational wait times guarantee

Support for 5 Harper PrioritiesSupport for 5 Harper Priorities

05

1015202530354045

Source: IPSOS-Reid, November 26, 2006





federal-provincial interaction has federal-provincial interaction has important impacts on the dynamics important impacts on the dynamics driving the politics of health caredriving the politics of health care

Effects of Federalism on Health Effects of Federalism on Health CareCare

health as a ‘watertight’ health as a ‘watertight’ jurisdictional compartment vs. jurisdictional compartment vs. federal-provincial federal-provincial interpenetration?interpenetration?

dynamics resulting from dynamics resulting from interpenetrationinterpenetration

intergovernmental competition has driven intergovernmental competition has driven expansion of public health insuranceexpansion of public health insurance

interpenetration has undermined interpenetration has undermined transparency and accountabilitytransparency and accountability

blame avoidanceblame avoidance

Effects of Federalism on Health Effects of Federalism on Health CareCare

different jurisdictional arrangementsdifferent jurisdictional arrangements ‘‘watertight’ federal jurisdictionwatertight’ federal jurisdiction

access to public health care would be more access to public health care would be more nationally uniformnationally uniform

in the absence of provincial experimentation, in the absence of provincial experimentation, may be less developedmay be less developed

‘‘watertight’ provincial jurisdictionwatertight’ provincial jurisdiction citizen access to public health care less citizen access to public health care less

uniformuniform esp. if dependent on fiscal capacity of the esp. if dependent on fiscal capacity of the

provinces (e.g. no federal provinces (e.g. no federal transfers/equalization)transfers/equalization)

more experimentationmore experimentation likely would be more highly varied range of likely would be more highly varied range of

models of public/private interactionmodels of public/private interaction

Federalism and Health Federalism and Health Care– Main MessagesCare– Main Messages

constitutional division of powers provides constitutional division of powers provides different orders of government with different orders of government with different policy toolsdifferent policy tools



federal-provincial interaction in health federal-provincial interaction in health has important impacts on the has important impacts on the dynamics driving the politics of health dynamics driving the politics of health carecare

Source: Canada Institutes for Health Information, Statistics Canada

ALBERTA PROVINCIAL EXPENDITURESTotal Expenditures and Total Health Expenditures

0

5

10

15

20

25

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

% o

f G

DP

Health Expenditures

Total Expenditures

Total Revenue

PUBLIC HEALTH CARE EXPENDITURESAlberta,1990-2005

0

5

10

15

20

25

30

35

40

45

50

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

% o

f T

ota

l P

rov

inc

ial

Ex

pe

nd

itu

res

Pollara, Health Care in Canada Survey, 2005.

-20%

-10%

0%

10%

20%

30%

40%

Per

cen

t (%

)


SUPPORT FOR PRIVATE INSURANCE FOR NON-EMERGENCY SERVICES, 2005

Total Agree-Total DisagreeStrongly Agree minus Strongly Disagree


0

5

10

15

20

25

30

35

Per

cen

t (%

)


PATIENT ALLOWED TO PAY/INSURE, 2005(When Timely Access Not Provided in Public System)

Disagree-AgreeDisagree Strongly-Agree Strongly


-20

-10

0

10

20

30

40

50

Per

cen

t (%

)


IMPACT OF 'GREATER PRIVATE INVOLVEMENT', 2006 Would Improve Quality of Health Care Services

Net Improve Net Definitely Improve

Ipsos-Reid, CMA, June 2006.

-20

-15

-10

-5

0

5

10

15

20

25

Per

cen

t (%

)


IMPACT ON OVERALL HEALTH CARE, 2005Medicare + Parallel Private System

Net Positive Net Very Positive

Support for Chaoulli Support for Chaoulli DecisionDecision

-20

-15

-10

-5

0

5

10

15

20

25

30

BC AB SK/ MB ON QB Atlantic CDA

Net FavourablyNet Very Favourably

Source: IPSOS-Reid, August XX, 2005

federalism and the politics of health care policy in canada

Documents

canada health actnot

politics of health care

health carehealth care

federal government

federal parliament

principlesthe federal

constitution act

popularthe cha