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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
The Federal Role – The The Federal Role – The Canada Canada Health ActHealth Act
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
The Federal Role – The The Federal Role – The Canada Canada Health ActHealth Act
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
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
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
Ipsos-Reid, CFNU, January 2006.
-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
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 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 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 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 is politically popularthe CHA is politically popular
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 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 is politically popularthe CHA is politically popular the CHA is enforced the CHA is enforced 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 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 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
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
the operational division of powers in the operational division of powers in health care is determined health care is determined politicallypolitically
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
Federal Involvement in Health Federal Involvement in Health CareCare
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
Federal Involvement in Health Federal Involvement in Health CareCare
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
Federal Involvement in Health Federal Involvement in Health CareCare
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
Federal Involvement in Health Federal Involvement in Health CareCare
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
Federal Involvement in Health Federal Involvement in Health CareCare
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 Involvement in Health Federal Involvement in Health CareCare
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
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
the operational division of powers in the operational division of powers in health care is determined health care is determined politicallypolitically
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-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
the operational division of powers in the operational division of powers in health care is determined health care is determined politicallypolitically
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-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
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
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 (%
)
BC/Terri. Alberta MB/SK Ontario Quebec Atlantic Canada
SUPPORT FOR PRIVATE INSURANCE FOR NON-EMERGENCY SERVICES, 2005
Total Agree-Total DisagreeStrongly Agree minus Strongly Disagree
Ipsos-Reid, CFNU, January 2006.
0
5
10
15
20
25
30
35
Per
cen
t (%
)
BC/Terri. Alberta MB/SK Ontario Quebec Atlantic Canada
PATIENT ALLOWED TO PAY/INSURE, 2005(When Timely Access Not Provided in Public System)
Disagree-AgreeDisagree Strongly-Agree Strongly
Ipsos-Reid, CFNU, January 2006.
-20
-10
0
10
20
30
40
50
Per
cen
t (%
)
BC/Terri. Alberta MB/SK Ontario Quebec Atlantic Canada
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 (%
)
BC/Terri. Alberta MB/SK Ontario Quebec Atlantic Canada
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