canada’s most controversial public figure? gary bettman, nhl commissioner

CANADA’S MOST CONTROVERSIAL PUBLIC FIGURE?CANADA’S MOST CONTROVERSIAL PUBLIC FIGURE?

GARY BETTMAN, NHL CommissionerGARY BETTMAN, NHL Commissioner

Health Care Health Care and and

Federal-Provincial PoliticsFederal-Provincial Politicsin Canadain Canada

Gerry Boychuk, February 4Gerry Boychuk, February 4thth, 2005, 2005

OverviewOverview

trends in Canadian federalismtrends in Canadian federalism a primer on Canadian health carea primer on Canadian health care the importance of health care in Canadian politicsthe importance of health care in Canadian politics First Ministers’ Health Summit, 2004First Ministers’ Health Summit, 2004

the negotiationsthe negotiations the health care dealthe health care deal broader implications for Canadian federalismbroader implications for Canadian federalism

conclusionsconclusions

Trends in Canadian FederalismTrends in Canadian Federalism

decentralizationdecentralizationentanglemententanglement

Explaining DecentralizationExplaining Decentralization

shifting importance of various enumerated powersshifting importance of various enumerated powers lack of representation of provincial interests lack of representation of provincial interests withinwithin the the

federal governmentfederal government representation of provincial/regional interests primarily through the representation of provincial/regional interests primarily through the

provincial governmentsprovincial governments

existence of Quebecexistence of Quebec Quiet Revolution (1960) -- “maitre chez nous”Quiet Revolution (1960) -- “maitre chez nous”

– accommodating Quebecaccommodating Quebec asymmetrical federalism vs. decentralization of power to all asymmetrical federalism vs. decentralization of power to all

provincesprovinces– generally favoured the lattergenerally favoured the latter

Federal-Provincial EntanglementFederal-Provincial Entanglement explaining entanglementexplaining entanglement

– division of powers spells out tools more than areas of division of powers spells out tools more than areas of responsibilityresponsibility

– division of powers not suited to emerging policy problemsdivision of powers not suited to emerging policy problems– vertical fiscal disequilibriumvertical fiscal disequilibrium

federal spending powerfederal spending power

prevailing views of entanglementprevailing views of entanglement– pragmaticpragmatic

federalism should be about ‘what works’ – “subsidiarity”federalism should be about ‘what works’ – “subsidiarity” entanglement is inefficient, ineffectiveentanglement is inefficient, ineffective

– principledprincipled democratic deficitdemocratic deficit entanglement undermines the constitutionentanglement undermines the constitution

– basis of our division of powers is the federal deal basis of our division of powers is the federal deal notnot simply concerns simply concerns about what works bestabout what works best

OverviewOverview




Universal Public Health Care in Universal Public Health Care in Canada – A PrimerCanada – A Primergovernment role in health care in Canadagovernment role in health care in Canada

– hospital insurancehospital insurance Saskatchewan, 1947Saskatchewan, 1947 federal hospital insurance, 1957federal hospital insurance, 1957

– medical care (e.g. physician) insurancemedical care (e.g. physician) insurance Saskatchewan, 1962Saskatchewan, 1962 federal Medicare, 1966federal Medicare, 1966

Universal Public Health Care in Universal Public Health Care in Canada – A PrimerCanada – A Primer

provincial roleprovincial role primary jurisdictionprimary jurisdiction actually provide public health insuranceactually provide public health insurance

federal rolefederal role– transfers funds to the provincestransfers funds to the provinces

federal spending powerfederal spending power

– set and enforce national principles under Canada Health set and enforce national principles under Canada Health Act (CHA)Act (CHA)

comprehensive, universal, portable, accessible, public comprehensive, universal, portable, accessible, public administrationadministration

– no province has ever been penalized under these provisions of no province has ever been penalized under these provisions of CHA (despite obvious infractions)CHA (despite obvious infractions)

banned extra-billing and user feesbanned extra-billing and user fees

Differences – Differences – Public Policy & Health Public Policy & Health Insurance in the US & CanadaInsurance in the US & Canada public health insurance for hospital care and public health insurance for hospital care and

medical care is universal in Canada (and medical care is universal in Canada (and categorical in the US)categorical in the US)

public health insurance in Canada is compulsory public health insurance in Canada is compulsory – private provision of insurance for publicly-insured private provision of insurance for publicly-insured

health services is prohibited in Canada (but not in the health services is prohibited in Canada (but not in the US)US)

important differences in funding (single-public-important differences in funding (single-public-payer in Canada, and multiple-payer in the US), payer in Canada, and multiple-payer in the US), less significant differences in modes of deliveryless significant differences in modes of delivery

OverviewOverview




The Symbolism of Health Care in The Symbolism of Health Care in CanadaCanada

““We want a Canada where our universal health care We want a Canada where our universal health care system is a proud example of our national values at system is a proud example of our national values at work… Health care is the nation’s first priority. Quality work… Health care is the nation’s first priority. Quality care; timely care. Care that is accessible regardless of care; timely care. Care that is accessible regardless of income; portable right across Canada; and publicly funded. income; portable right across Canada; and publicly funded. We are committed irrevocably to the principles of the We are committed irrevocably to the principles of the Canada Health Act. Canada Health Act. They are part of who we are — a They are part of who we are — a moral statement about fundamental fairness — that all moral statement about fundamental fairness — that all Canadians should stand equal before our health care Canadians should stand equal before our health care systemsystem.”.”

Prime Minister Paul Prime Minister Paul MartinMartin Reply to the Reply to the Throne SpeechThrone Speech January January 20042004

“The patron saint of The patron saint of Canada is Tommy Canada is Tommy Douglas. Any time Douglas. Any time someone has a new someone has a new idea about the idea about the health-care system, health-care system, someone else someone else invokes the sacred invokes the sacred memory of St. memory of St. Tommy and that's Tommy and that's the end of it.”the end of it.”

Margarent Wente’s Margarent Wente’s “Guide For Expat “Guide For Expat Americans” G&M, Americans” G&M, Nov.9th 2004Nov.9th 2004

Health Care and Health Care and National IdentityNational Identity

82%

14% 3% 1% Very ImportantSomewhat importantNot very importantNot at all important

How important are the following to the Canadian identity… Canada’s health care system?

Source: Environics Focus Canada Survey, March 1996

Why is Health Care So Politically Why is Health Care So Politically Important?Important? the provision of health services touches every the provision of health services touches every

individual Canadian directlyindividual Canadian directly– ““The federal government has few direct touch points The federal government has few direct touch points

with individual Canadians. So whenever it has an with individual Canadians. So whenever it has an opportunity to deal directly with its citizens, it opportunity to deal directly with its citizens, it should do so, to increase the federal government’s should do so, to increase the federal government’s relevance to their daily lives. The more Ottawa relevance to their daily lives. The more Ottawa becomes involved with Canadians, the more becomes involved with Canadians, the more individuals are likely to see the value of the national individuals are likely to see the value of the national government, nationalism and our federation.” government, nationalism and our federation.” (Goldfarb, 2004)(Goldfarb, 2004)

Why is Health Care So Politically Why is Health Care So Politically Important?Important? the provision of health services touches every the provision of health services touches every

individual Canadian directlyindividual Canadian directlyother spheres of government competence other spheres of government competence

increasingly limitedincreasingly limited– federal governmentfederal government

– trade policy and tarriffstrade policy and tarriffs

– industrial developmentindustrial development

– monetary policymonetary policy

– fiscal policy (taxing and spending)fiscal policy (taxing and spending)

what is left for the federal government to do??what is left for the federal government to do??

OverviewOverview




Health Care in the Federal Election , Health Care in the Federal Election , 20042004Prime Minister Martin promised to...Prime Minister Martin promised to...

– ““fix health care for a generation”fix health care for a generation”– undertake negotiations with the provinces and undertake negotiations with the provinces and

not abandon talks until a deal was strucknot abandon talks until a deal was struck– to negotiate in an open, televised forumto negotiate in an open, televised forum

First Ministers’ Meeting on Health Care, September 2004First Ministers’ Meeting on Health Care, September 2004

PM MartinPM Martin

The PremiersThe Premiers

OverviewOverview




Health Summit -- The Negotiations...Health Summit -- The Negotiations...

federal-provincial diplomacy and the federal-provincial diplomacy and the ‘democratic deficit’‘democratic deficit’

federal provincial gamesmanshipfederal provincial gamesmanship democratic deficit – closed door negotiationsdemocratic deficit – closed door negotiations

Health SummitHealth Summit televised negotiationstelevised negotiations

– decrease the level of acrimony (public grandstanding)decrease the level of acrimony (public grandstanding)

– enrich the substantive debate about health careenrich the substantive debate about health care

– transparencytransparency

Media ReportsMedia Reports

““Health Care’s Gong Show,” Health Care’s Gong Show,” National PostNational Post, 14 , 14 September 2004, A18.September 2004, A18.

““Premiers Blast PM’s ‘Silly’ Offer,” Premiers Blast PM’s ‘Silly’ Offer,” Globe and Globe and MailMail, 14 September 2004, 14 September 2004

““This process has been a farce. Federal This process has been a farce. Federal negotiating tactics have been disgusting.” negotiating tactics have been disgusting.” Newfoundland Premier Danny WilliamsNewfoundland Premier Danny Williams

John Ibbotson, “Amid All the Acrimony, They John Ibbotson, “Amid All the Acrimony, They Could Still Cut a Deal,” Could Still Cut a Deal,” Globe and MailGlobe and Mail, 14 , 14 September 2004.September 2004.

Ralph “I’m Outta Here” Klein, Premier of AlbertaRalph “I’m Outta Here” Klein, Premier of Alberta

Alberta Premier Ralph KleinAlberta Premier Ralph Klein

Manitoba Premier Gary DoerManitoba Premier Gary Doer

““Paul, I am Paul, I am notnot your son...I your son...I am the Premier of Quebec.”am the Premier of Quebec.”

Jean Charest Jean Charest (reportedly (reportedly

to Paul to Paul Martin Martin during during closed door closed door negotiations)negotiations)

Health Summit -- The Negotiations...Health Summit -- The Negotiations...

federal-provincial diplomacy and the federal-provincial diplomacy and the ‘democratic deficit’‘democratic deficit’

federal provincial gamesmanshipfederal provincial gamesmanship democratic deficit – closed door negotiationsdemocratic deficit – closed door negotiations

Health SummitHealth Summit televised negotiationstelevised negotiations

– decrease the level of acrimony (public grandstanding)decrease the level of acrimony (public grandstanding)

– enrich the substantive debate about health careenrich the substantive debate about health care

– transparencytransparency

OverviewOverview




Health Summit, 2004 – The Health Health Summit, 2004 – The Health Care DealCare Dealfederal financial contributionfederal financial contribution

– $41 billion over 10 years$41 billion over 10 years close short-term Romanow gapclose short-term Romanow gap

– i.e. federal contribution = 25% of provincial costsi.e. federal contribution = 25% of provincial costs

6% escalator6% escalator no change in structure of fundingno change in structure of funding

Health Summit, 2004 – The Health Health Summit, 2004 – The Health Care DealCare Deal

– Wait Times Reduction FundWait Times Reduction Fund setting targetssetting targets

– comparable indicators to be established by each jurisdiction and wait comparable indicators to be established by each jurisdiction and wait times reported to citizens (Dec. 2005)times reported to citizens (Dec. 2005)

– medically-acceptable wait times established (Dec.2005)medically-acceptable wait times established (Dec.2005)

– targets established by each jurisdiction (Dec.2007)targets established by each jurisdiction (Dec.2007)

– by 2008, provinces to begin to report in progress in meeting wait by 2008, provinces to begin to report in progress in meeting wait time targets time targets

strategy to lower waiting times?strategy to lower waiting times?– to be determined by each provinceto be determined by each province


primary care reformprimary care reform duplicates commitment of HCRA, 2003duplicates commitment of HCRA, 2003 offer 24/7 access to 50% of the population by 2011offer 24/7 access to 50% of the population by 2011

home carehome care duplicates commitment of HCRA, 2003duplicates commitment of HCRA, 2003 coverage for up to 2 weeks of homecare of various typescoverage for up to 2 weeks of homecare of various types

PharmacarePharmacare commit to establishing a Ministerial Task Force (June 2006) commit to establishing a Ministerial Task Force (June 2006)

to “develop, assess and cost options for catastrophic to “develop, assess and cost options for catastrophic pharmaceutical coveragepharmaceutical coverage

HCRA, 2003: commitment to “ensure that Canadians have HCRA, 2003: commitment to “ensure that Canadians have reasonable access to catastrophic drug coverage by the end of reasonable access to catastrophic drug coverage by the end of 2005/06”2005/06”


emphasized symbolism over substanceemphasized symbolism over substancedemonstrates the degree of entanglementdemonstrates the degree of entanglement

OverviewOverview




““...the most important federal-provincial deal since ...the most important federal-provincial deal since the constitution...”the constitution...”

Globe & MailGlobe & Mail

““...a triumph for Canadian federalism” ...a triumph for Canadian federalism” Globe & MailGlobe & Mail

““...a debacle...” ...a debacle...” National PostNational Post

REACTIONS TO THE HEALTH SUMMIT REACTIONS TO THE HEALTH SUMMIT AGREEMENT...AGREEMENT...

““Health is Not the Issue” Health is Not the Issue” National Post Editorial National Post Editorial Headline, Sept.13 2004Headline, Sept.13 2004

““Ask your new Canadian friends to explain the ins Ask your new Canadian friends to explain the ins and outs of asymmetrical federalism to you. They and outs of asymmetrical federalism to you. They will be delighted at your interest. But don't ask them will be delighted at your interest. But don't ask them the words to the national anthem. They'll only be the words to the national anthem. They'll only be embarrassed.” embarrassed.” Margarent Wente’s “Guide For Margarent Wente’s “Guide For Expat Americans” G&M, Nov.9th 2004Expat Americans” G&M, Nov.9th 2004

““Ask your new Canadian friends to explain the ins Ask your new Canadian friends to explain the ins and outs of and outs of asymmetrical federalismasymmetrical federalism to you. They to you. They will be delighted at your interest. But don't ask them will be delighted at your interest. But don't ask them the words to the national anthem. They'll only be the words to the national anthem. They'll only be embarrassed.” embarrassed.” Margarent Wente’s “Guide For Margarent Wente’s “Guide For Expat Americans” G&M, Nov.9th 2004Expat Americans” G&M, Nov.9th 2004

Health Summit, 2004 – Federalism Health Summit, 2004 – Federalism AspectsAspectsspecial side-agreement with Quebecspecial side-agreement with Quebec

– formal recognition of the principle of asymetrical formal recognition of the principle of asymetrical federalism federalism

“…“…flexible federalism that notably allows for the existence flexible federalism that notably allows for the existence of specific agreements and arrangements adapted to of specific agreements and arrangements adapted to Québec’s specificity…” Québec’s specificity…”

– criticismscriticisms may have implications for the application of the CHA may have implications for the application of the CHA

principles in Quebecprinciples in Quebec

Health Summit, 2004 – Federalim Health Summit, 2004 – Federalim AspectsAspectsassymetrical federalism and the context of the assymetrical federalism and the context of the

health care deal, 2004health care deal, 2004 ““A Second Quiet Revolution?”A Second Quiet Revolution?”

National Post Editorial Headline, National Post Editorial Headline, Sept.16 2004Sept.16 2004

““A Province of Private Clinics”A Province of Private Clinics”National Post, Sept.9 2004National Post, Sept.9 2004

““Don’t Push Quebec, PM Warned: Forced Deal Would Backfire, Don’t Push Quebec, PM Warned: Forced Deal Would Backfire, Report”Report” National Post, Sept.9 2004National Post, Sept.9 2004

– Andre Senikas, President Quebec Medical Association:Andre Senikas, President Quebec Medical Association: ““If other provinces tried to set up what we have, they’d have a revolt on If other provinces tried to set up what we have, they’d have a revolt on

their hands. But in Quebec, it’s accepted.”their hands. But in Quebec, it’s accepted.” ““Universal health coverage is still important to Quebecers, but it’s Universal health coverage is still important to Quebecers, but it’s

certainly not a defining characteristic of their national identity. In certainly not a defining characteristic of their national identity. In places like Ontario, people talk about the health care system being places like Ontario, people talk about the health care system being public like its a religion. In Quebec, people think differently.”public like its a religion. In Quebec, people think differently.”

““Mr. Klein has not suggested anything Quebec governments have not Mr. Klein has not suggested anything Quebec governments have not been doing for years. [...] When you hear Mr. Charest and Mr. Klein been doing for years. [...] When you hear Mr. Charest and Mr. Klein talk, they are totally on the same wavelength...”talk, they are totally on the same wavelength...”

Health Summit, 2004 – Federalism Health Summit, 2004 – Federalism AspectsAspectsspecial side-agreement with Quebecspecial side-agreement with Quebec

– formal recognition of the principle of asymetrical formal recognition of the principle of asymetrical federalism federalism

“…“…flexible federalism that notably allows for the existence flexible federalism that notably allows for the existence of specific agreements and arrangements adapted to of specific agreements and arrangements adapted to Québec’s specificity…” Québec’s specificity…”

– criticismscriticisms may have implications for the application of the CHA may have implications for the application of the CHA

principles in Quebecprinciples in Quebec may have implications for the application of the CHA in may have implications for the application of the CHA in

other provincesother provinces

OverviewOverview




Health Care and Federal-Provincial Health Care and Federal-Provincial Relations -- ConclusionsRelations -- Conclusions

illustrates two central trends of Canadian federalismillustrates two central trends of Canadian federalism decentralizationdecentralization entanglemententanglement

illustrates the central problem of executive federalism illustrates the central problem of executive federalism (federal-provincial diplomacy)(federal-provincial diplomacy)

transparency and the democratic deficittransparency and the democratic deficit

illustrates the centrality of the politics of territorial integration illustrates the centrality of the politics of territorial integration in federal-provincial relations and public policy (esp.health in federal-provincial relations and public policy (esp.health care)care)

competitive state buildingcompetitive state building– nation-building vs. province-buildingnation-building vs. province-building

illustrates the central tension of Canadian federalismillustrates the central tension of Canadian federalism accommodating provincial distinctiveness (esp. Quebec) while accommodating provincial distinctiveness (esp. Quebec) while

maintaining national unitymaintaining national unity

canada’s most controversial public figure? gary bettman, nhl commissioner

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