Michael J. Prince

Lansdowne Professor of Social Policy

Remarks to the Social Dimensions of Health Program Colloquium

University of Victoria

February 3, 2012

POLITICAL DETERMINANTS OF HEALTH CARE POLICY IN CANADA

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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

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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

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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)

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Political actors in health policy

• 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

State structures Societal structures

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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

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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

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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

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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

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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

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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

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Interpretations of Harper’s Health Transfer1. 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?

2. Reflects Mr. Harper’s view of respecting classical federalism 3. Unilateral and non-negotiable decision by federal government: a

lost opportunity for cooperative dialogue and shared action among governments

4. 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

5. 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”

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Further Interpretations6. Favours some provinces and disadvantages others with older

populations, for which the per capita formula does not take into account

7. Offers scope for (if not fiscal pressure on) provinces for policy experimentation, sharing and innovation as well as further budgetary discipline

8. 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

9. Allows more time and space for the Conservatives to concentrate on their priority areas, such as the economy, defence, law and order

10. Is a political plan which can be altered by Harper or a future prime minister or federal government

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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

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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

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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?