Title: FEDERALISM AND THE POLITICS OF HEALTH CARE POLICY IN CANADA
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5FEDERALISM AND THE POLITICS OF HEALTH CARE POLICY
IN CANADA
- Gerard W. Boychuk
- Department of Political Science
- University of Waterloo
- Political Science 321
- March 6th, 2007
6Federalism and Health Care
- constitutional division of powers provides
different orders of government with different
policy tools
7Health Care and the Constitutional Division of
Powers
- provincial jurisdiction
- S.92 (7) The Establishment, Maintenance, and
Management of Hospitalsin and for the Province - exceptions
- gives provinces the power to legislate in regard
to health care
8Health Care and the Constitutional Division of
Powers
- federal policy tools
- 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. - not explicit in the Constitution Act, 1867
- formally recognized (and limited) in the Social
Union Framework Agreement, 1999
9The Federal Role The Canada Health Act, 1984
(CHA)
- Canada Health Transfer (CHT)
- block-funding transfer from the federal
government to the provinces - Canada Health Act (CHA)
- the five principles
- 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 - without financial barriers to access
- no extra-billing on insured services
- no user/facility fees on insured services
- penalties
- non-discretionary penalties for
extra-billing/user fees - discretionary penalties for other violations of
five principles - no province has ever been penalized for violation
of the five principles - non-requirements
- no legal prohibitions on private provision of
services - no legal prohibitions on private insurance
10Federalism and Health Care
- constitutional division of powers provides
different orders of government with different
policy tools - the operational division of powers in health care
is determined politically
11The Politics of the CHA
- Theres nothing that says you have to stay in
the Canada Health Act. Premier Ralph Klein, June
2004 - sowhy do provinces abide by the CHA?
- provinces need the money?
- CHT (cash) equals roughly
- 6.5 of total provincial revenue
- 36 of total federal transfers to provinces
12Ipsos-Reid, CFNU, January 2006.
13Ipsos-Reid, CFNU, January 2006.
14The Politics of the CHA
- Theres nothing that says you have to stay in
the Canada Health Act. Premier Ralph Klein, June
2004 - sowhy do provinces abide by the CHA?
15The Politics of the CHA
- Theres nothing that says you have to stay in
the Canada Health Act. Premier Ralph Klein, June
2004 - sowhy do provinces abide by the CHA?
- the CHA is politically popular
16The Politics of the CHA
- Theres nothing that says you have to stay in
the Canada Health Act. Premier Ralph Klein, June
2004 - sowhy do provinces abide by the CHA?
- the CHA is politically popular
- the CHA is enforced politically
17The Politics of the CHA
- Theres nothing that says you have to stay in
the Canada Health Act. Premier Ralph Klein, June
2004 - sowhy do provinces abide by the CHA?
- the CHA is politically popular
- the CHA is enforced politically
- provincial violations of the CHA tend to be
politically unpopular
18Federalism and Health Care
- 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 politics of federal-provincial interaction in
health care occur in a broader political context
19Federal Involvement in Health Care
- nation-building
- origins of the CHA
- Quebec referendum, 1980
- Canada-US free trade debate, 1988
- continuing context
- 1995 Quebec referendum
20Federal Involvement in Health Care
- globalization has constrained national govts
more than sub-national govts - what does the federal government do in a
globalized world? - trade policy, industrial policy and regional
development policy, monetary policy, fiscal
policy - what do the provincial governments do in a
globalized world? - education
- post-secondary education
- health care
21Federal Involvement in Health Care
- vertical fiscal (im)balance
- definition
- federal government has excess revenues (relative
to its responsibilities) and provincial
governments have insufficient revenues (relative
to their responsibilities)
22Source Canada Institutes for Health Information,
Statistics Canada
23Federal Involvement in Health Care
- vertical fiscal (im)balance
- definition
- federal government has excess revenues (relative
to its responsibilities) and provincial
governments have insufficient revenues (relative
to their responsibilities) - effects
- e.g. federal government is strongly positioned to
powerfully exercise the federal spending power - excess federal revenues
- provincial demands for federal government to
share excess revenues
24Federal Involvement in Health Care
- constitutional politics
- formerly the preoccupation of federal-provincial
relations - shift in 1993
- demise of Meech Lake Accord (1988) and
Charlottetown Accord (1992) - 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 - less evident since 2004
25Federal Involvement in Health Care
- context for a renewed federal role in health care
- health care policy has become a defining
characteristic of Canadian identity - globalization has weakened federal raison detre
- federal govt has more financial resources than
it knows what to do with - continuing vacuum in federal-provincial relations
26Federal Involvement in Health Care
- federal proposals for reinvigorated federal role
(1995-20??) - federal elections 1997, 2000, 2004
- federal proposals
- national pharmacare program
- national homecare program
- national wait times guarantee
27Support for 5 Harper Priorities
Source IPSOS-Reid, November 26, 2006
28Federalism and Health Care
- 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 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
29Effects of Federalism on Health Care
- health as a watertight jurisdictional
compartment vs. federal-provincial
interpenetration? - dynamics resulting from interpenetration
- intergovernmental competition has driven
expansion of public health insurance - interpenetration has undermined transparency and
accountability - blame avoidance
30Effects of Federalism on Health Care
- different jurisdictional arrangements
- watertight federal jurisdiction
- access to public health care would be more
nationally uniform - in the absence of provincial experimentation, may
be less developed - watertight provincial jurisdiction
- citizen rights to public health care less uniform
- esp. if dependent on fiscal capacity of the
provinces (e.g. no federal transfers/equalization)
- more experimentation
- likely would be more highly varied range of
models of public/private interaction
31Federalism and Health Care Main Messages
- 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 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
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34Source Canada Institutes for Health Information,
Statistics Canada
35Source Canada Institutes for Health Information,
Statistics Canada
36Source Canada Institutes for Health Information,
Statistics Canada
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41Pollara, Health Care in Canada Survey, 2005.
42Ipsos-Reid, CFNU, January 2006.
43Ipsos-Reid, CFNU, January 2006.
44Ipsos-Reid, CMA, June 2006.
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46Support for Chaoulli Decision
Source IPSOS-Reid, August XX, 2005