Political Determinants of Health C are Policy in Canada

1. Political Determinants of Health Care Policy in Canada Michael J. Prince Lansdowne Professor of Social Policy Remarks to the Social Dimensions of Health Program Colloquium University of Victoria February 3, 2012

2. Outline • What it means to examine the politics of health care • What is federalism and how it matters for health policy • Jurisdictions in health • The federal spending power • Canada Health Act • The Harper Canada Health Transfer • Interpretations of Harper’s Announcement • Beyond Ottawa: deeper health politics

3. Canadian scholars on the politics of health care policy making • Duane Adams • Pat and Hugh Armstrong • Vanda Bhatia • Bernard Blishen • Gerald Boychuk • Harvey Lazar • Antonia Maioni • Tom McIntosh • Dennis Raphael • Candace Redden • Donald Swartz • Malcolm Taylor • Carolyn Tuohy

4. Taking political determinants seriously • Recognizing that power is intrinsic to, and formative of social roles, ways of knowing, and relationships • Acknowledging: • Multiplicity of values, beliefs and interests • Inequality of relations of power and legitimacy • Inequity of outcomes and statuses • Inevitability of tensions, conflict, disagreement • Knowing the specificity of the political: “the permanent circumstances of Canadian nationhood” (Smiley)

5. Political actors in health policy State structures Societal structures • Federal, indigenous, provincial/territorial, municipal governments • Legislatures, councils and parliament • Federalism: intergovernmental relations • Courts and the role of litigation • Public service bureaucracies • Professional associations • Employer groups • Unions and employee associations • Pharmaceutical industry and firms • Publics: opinions, concerns, expectations • Organized interest groups and social movements • Political parties

6. How federalism matters to health policy • Divides state powers and law making powers between two (or more) orders of sovereign governments in a given territory • Sets jurisdictional boundaries and limits for each order of government • Courts mediate disputes and interpret the legality of laws • Decentralization of powers allows for innovation and experimentation in policy, practice and governance arrangements at level of the provinces • Shapes discussions of health policy, finance and reform among political elite and influences media coverage • Creates collective political identities with different capacities and constituencies

7. Jurisdiction in health: provincial • Health-care policy and governance is a jurisdictional space shared between the federal and provincial orders of government • Provincial authority over health-care services is dominant constitutionally to the extent that provinces have explicit grants of authority for: • hospitals and related care institutions • property and civil rights, including mental health matters and the regulation of health professions and practices • local or private matters, including community health and municipal health boards

8. Jurisdiction in health: federal • generally through the federal spending power as applied to health transfers • specific groups where it has designated responsibility, including the armed forces, RCMP, First Nations and Inuit peoples, immigrants and refugees, inmates in federal penitentiaries, and veterans • for emergency or national health matters, the peace, order, and good government power may apply • for ‘patents of invention and discovery,’ Parliament has jurisdiction for food and drugs, hazardous products • for aspects of environmental and reproductive health, through the federal criminal law power

9. The federal spending power • The Government of Canada providing funds to people, civil society organizations or to provinces/territories for purposes, programs and services within provincial jurisdictions • The federal spending power is a: • set of financial mechanisms based in revenues and expenditures • constitutional practice for several decades • social policy instrument for national programs • politically charged symbol, a contested assortment of concepts and choices about the federation and citizenship • controversial issue politically and judicially

10. Canada Health Act • Federal bill by Trudeau Liberal government in 1984, passed with all party support in parliament • A product of health politics, intergovernmental politics, and party politics of early 1980s • An exercise of the federal spending power • Five principles of health care • Conditions attached to federal cash contributions toward provincial health insurance costs • A symbol of political myths and values • A source of stability and rigidity • A site of enthusiasms and antagonisms

11. The Harper Health Transfer • Minority governments of 2006-08 and 2008-11 endorsed the 2004 federal-provincial First Ministers’ Health Accord • During 2011 federal election, Conservatives said there would be no cuts to health transfers to provinces • Next Canada Health Transfer unveiled in December 2011 by Finance Minister Flaherty: • Another 10 year health transfer funding plan: 2014-2024 • Continue to increase federal health care transfer payments to provinces by 6% each year from 2014-15 to 2016-17 • From 2017-18 to 2023-24, increases tied to economic growth, including inflation rate, roughly 4% [with guaranteed floor of a 3% annual increase] • Funds not tied to any explicit federal or intergovernmental goals or targets • Allocated on a per capita basis of provincial/territorial populations

12. Interpretations of Harper’s Health Transfer • That it is a “no-strings” funding formula for health care, a “hands-off” strategy with Ottawa leaving the provinces to shape health policy as they see fit: where is federal policy leadership? • Reflects Mr. Harper’s view of respecting classical federalism • Unilateral and non-negotiable decision by federal government: a lost opportunity for cooperative dialogue and shared action among governments • Less funding than what some provinces hoped; a “slow erosion of federal health funding increases” -- though nothing like the major cutbacks and absolute declines in federal transfers in the 1990s • Downloads a large financial burden on provincial and territorial governments: an increase in differences in services and access across provinces? An example of “beggar-thy-partner federalism”

13. Further Interpretations • Favours some provinces and disadvantages others with older populations, for which the per capita formula does not take into account • Offers scope for (if not fiscal pressure on) provinces for policy experimentation, sharing and innovation as well as further budgetary discipline • Prime Minister is trying “to take health care off the federal political agenda for the next four years” and perhaps beyond the next national election • Allows more time and space for the Conservatives to concentrate on their priority areas, such as the economy, defence, law and order • Is a political plan which can be altered by Harper or a future prime minister or federal government

14. In historical and comparative policy contexts • A review of several policy case studies by Lazar (2006) found that the kind of federalism in health tends to be more hierarchical and unilateral than in other policy sectors such as disability and labour market programming • In other words, intergovernmental relations in health care is often characterized by top-down, coercive and independent action by Ottawa • Reasons Lazar suggests for this style are political: health care is commonly associated with “high politics” of first ministers and finance ministers; is about money, power and jurisdiction; is a process dominated by political elites; and, is linked to important political symbolism

15. Beyond Ottawa: deeper health politics • How important are federal principles and fiscal strings, relative to other political actors and determinants, in the health sector? • For some time, the federal framework for financing health care has been a secondary force in affecting health policy and service across the country (constitutional limits, declining share of costs, little enforcement of the Canada Health Act) • The shape of health care delivery and public financing in Canada is largely worked out between highly mobilized health care provider groups and governments at the provincial level • Health care policies, programs and practices occur through a complex series of processes and institutions, ideas and discourses, interests and relations of power

16. A few questions • How will the Harper health transfer affect the development of health care in Canada? • How and where can public health care reform be advanced in this fiscal and political context? • What political determinants do we need to better understand and more fully address? What are the main sources or drivers of health policy formation and implementation?