Sustaining a National Program within a Federated Structure: The F/P/T Environment

1. Sustaining a National Program within a Federated Structure: The F/P/T Environment 14th John K. Friesen Conference Gerontology Research Centre Simon Fraser University at Harbour Centre, Vancouver Gregory P. Marchildon, Ph.D. Canada Research Chair and Professor, University of Regina May 20, 2004

2. The Canadian Health Care Pie Source:CIHI, NHEX 2003 Canadian Health Care: Expenditure Perspective, 2003 Note: Excluded from the calculation are expenditures by municipal governments, workers compensation and by social security funds. Figures for 2003 are forecasts. Gregory P. Marchildon, University of Regina

3. Ranking by Health Status Indicators, Selected Countries Source: OECD 2003 Gregory P. Marchildon, University of Regina

4. Ranking by Disease Indicators, Selected Countries (1997)Source OECD: 2003 Gregory P. Marchildon, University of Regina

5. The Canadian Medicare Model: Components • CHA insured services: hospitalization + medical care + • Narrow but deep coverage • Parallel private tier prohibited or discouraged in provincial legislation • Provincial + Federal revenue sources Gregory P. Marchildon, University of Regina

6. First Phase of Changes, 1988-1996 • Provincial studies and reports, 1988-91: QC, NS, AB, ON, SK, BC • Regionalization reforms • Integration • Rationalization (cost cutting) • Local decision-making re: allocation of resources • Continuity and coordination of care Gregory P. Marchildon, University of Regina

7. Second Phase, 1997-Present • Rapid growth in expenditures (and solid growth in revenues) • Growing concerns re: sustainability • Provincial and national studies • More focus on federalism aspect and the federal role Gregory P. Marchildon, University of Regina

8. Federal Role: Three Major Choices for Future of Canadian Medicare Model • #1 - Status quo • “death by stealth” • #2 - Tax transfer • “death by execution” • #3 - Constructive federal engagement Gregory P. Marchildon, University of Regina

9. #1 - Status Quo • Not sustainable in long run • Dysfunctional nature of intergovernmental relations • Too much focus on $ and turf • Too little focus on health policy and programs • Why bother with health ministers? Gregory P. Marchildon, University of Regina

10. F/P/T Relations and the Damage Done: Part I • CHST: cash drop + no escalator • SUFA, 1999 • FM “agreement” of Sept. 2000 • Foot dragging on aspects of “agreement” • But “we’ll be back for more” Gregory P. Marchildon, University of Regina

11. F/P/T Relations and the Damage Done: Part II • Romanow Commission: 2001-02 • Feb. 2003 Health Accord • Funding mechanism? • CHA? • Home care? • Fragmentation: Aboriginal health care? • Drug regulation, prescription and utilization? Gregory P. Marchildon, University of Regina

12. #2 - Tax Transfer: Why? • Ottawa: influence too minimal given $ and political headache • Provinces: clearer accountability and total flexibility in design, administration and delivery • Others: medicare now an established program and provinces will adhere to CHA because of electorates Gregory P. Marchildon, University of Regina

13. Tax Transfer: Why Not? • No guarantee that national dimensions would be upheld • Provincial benefit v. citizenship right • Lose equalization effect of accessing national revenue base • No future opportunity to improve upon the national dimensions Gregory P. Marchildon, University of Regina

14. #3 – Ottawa as a Real Partner • Public support for Canadian medicare model remains high • See both orders of government as responsible in respective spheres • Federal government: $ plus catalyst for change re: national dimensions • Provinces: administration and delivery within principles of CHA Gregory P. Marchildon, University of Regina

15. What is Needed? • Stable, predictable and transparent cash transfers • FM agreement on principles and future direction • Modernized CHA • Respect for provincial capacity and role within principles of CHA Gregory P. Marchildon, University of Regina

16. Next First Ministers’ Meeting • Will be decisive • Can’t afford to lose another opportunity • Public patience wearing thin • Televise proceedings • No further federal funding without agreement (opt out without cash) Gregory P. Marchildon, University of Regina

17. Conclusion • Federal role has been essential in establishing our model of medicare • SK could not have gone it alone • Federal spending power and right structural incentives important • But federal and provincial leadership (even if minority) essential Gregory P. Marchildon, University of Regina