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FEDERALISM AND THE POLITICS OF HEALTH CARE POLICY IN CANADA

FEDERALISM AND THE POLITICS OF HEALTH CARE POLICY IN CANADA. Gerard W. Boychuk Department of Political Science University of Waterloo Political Science 321 March 6 th , 2007. Federalism and Health Care.

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FEDERALISM AND THE POLITICS OF HEALTH CARE POLICY IN CANADA

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  1. FEDERALISM 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

  2. Federalism and Health Care • constitutional division of powers provides different orders of government with different policy tools

  3. Health Care and the Constitutional Division of Powers • provincial jurisdiction • S.92 (7) “The Establishment, Maintenance, and Management of Hospitals…in and for the Province…” • exceptions • gives provinces the power to legislate in regard to health care

  4. Health 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

  5. The Federal Role – The Canada Health Transfer • Canada Health Transfer (CHT) • block-funding transfer from the federal government to the provinces • the conditions for funding are set out in the Canada Health Act • not directly legislating – simply sets the terms for federal transfers

  6. The Federal Role – The Canada Health Act • 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

  7. The Federal Role – The Canada Health Act • Canada Health Act (CHA) • 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

  8. The Federal Role – The Canada Health Act • Canada Health Act (CHA) • non-requirements • no legal prohibitions on private provision of services • no legal prohibitions on private insurance

  9. Federalism 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

  10. The Politics of the CHA • “There’s nothing that says you have to stay in the Canada Health Act.” Premier Ralph Klein, June 2004 • …so…why do provinces abide by the CHA? • provinces need the money? • CHT (cash) equals roughly… • 36% of total federal transfers to provinces • 19% of provincial health expenditures • 6.5% of total provincial revenue

  11. Ipsos-Reid, CFNU, January 2006.

  12. Ipsos-Reid, CFNU, January 2006.

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

  14. The Politics of the CHA • “There’s nothing that says you have to stay in the Canada Health Act.” Premier Ralph Klein, June 2004 • …so…why do provinces abide by the CHA? • the CHA is politically popular

  15. The Politics of the CHA • “There’s nothing that says you have to stay in the Canada Health Act.” Premier Ralph Klein, June 2004 • …so…why do provinces abide by the CHA? • the CHA is politically popular • the CHA is enforced politically

  16. The Politics of the CHA • “There’s nothing that says you have to stay in the Canada Health Act.” Premier Ralph Klein, June 2004 • …so…why 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

  17. Federalism 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

  18. Federal Involvement in Health Care • nation-building • origins of the CHA • Quebec referendum, 1980 • Canada-US free trade debate, 1988 • continuing context • 1995 Quebec referendum

  19. Federal Involvement in Health Care • globalization • globalization has constrained national gov’ts more than sub-national govt’s • 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

  20. Federal 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)

  21. Source: Canada Institutes for Health Information, Statistics Canada

  22. Federal Involvement in Health Care • vertical fiscal (im)balance • 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

  23. Federal 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

  24. Federal 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 d’etre • federal gov’t has more financial resources than it knows what to do with • continuing vacuum in federal-provincial relations

  25. Federal 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

  26. Support for 5 Harper Priorities Source: IPSOS-Reid, November 26, 2006

  27. Federalism 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

  28. Effects 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

  29. Effects 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 access 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

  30. Federalism 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

  31. Source: Canada Institutes for Health Information, Statistics Canada

  32. Source: Canada Institutes for Health Information, Statistics Canada

  33. Source: Canada Institutes for Health Information, Statistics Canada

  34. Pollara, Health Care in Canada Survey, 2005.

  35. Ipsos-Reid, CFNU, January 2006.

  36. Ipsos-Reid, CFNU, January 2006.

  37. Ipsos-Reid, CMA, June 2006.

  38. Support for Chaoulli Decision Source: IPSOS-Reid, August XX, 2005

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