In the Canadian federation, healthcare is considered to be an area of provincial jurisdiction. Section 92 of the Canadian Constitution specifically states that hospitals and psychiatric institutions are within the purview of the provinces; the federal government retained control over marine hospitals and quarantine laws. So why should the federal government increase its role in healthcare – or play a role at all?
In 1867, healthcare was not nearly as complex a system as it is now. As in the case of the environment, the Fathers of Confederation could not anticipate the way healthcare would evolve, in terms of delivery, cost or issues. Consequently, according to the Supreme Court, “Health is not a single matter assigned by the Canadian constitution exclusively to one level of government. Like inflation and the environment, health is an ‘amorphous topic’ which is distributed to the federal parliament or the provincial legislatures depending on the purpose and effect of the particular health measure at issue.”
This is because firstly, health issues do not neatly confine themselves to provincial boundaries. Pandemics can impact the whole country; the opioid crisis has become a nationwide scourge; drug approvals are done at the national level; food guides and safety regulations are set in Ottawa; research is conducted at universities that can benefit the entire country. The federal government has a role in all of these, in the national interest.
Second, Canada was founded on a basis of equality of provinces. At the federal level, many programs exist to create a level playing field between provinces in matters of services. Equalization is one such program; the Canada Health Transfer is another. The goal of such programs is not merely financial, it is based on what defines Canada as a federation, one where Canadians can expect a similar level of quality in the services governments provide from coast to coast, regardless of where they live.
While provinces are constitutionally mandated to deliver healthcare, the reality is they do not all have a sufficient tax base to fund it on their own. Healthcare already consumes over 40% of most provincial budgets, and will only increase as the population ages. This is why Ottawa has always funded health care and does so now through the Canada Health Transfer. From a high of 50% at Medicare’s inception, Ottawa now covers barely 15% of the provinces’ health care bills, despite the fact that they consume an ever-larger portion of provincial funds.
Third, the federal government enacted the Canada Health Act. The Act precludes provinces from alternate forms of funding such as allowing for-profit provision of services that are covered by Medicare. This restriction is often seen as the “quid pro quo” for federal funding, but the reality is, it could be changed if there was a public and political consensus. To date, such a consensus has not been found, and healthcare remains a single-payer universal system. Until and unless that changes, it is hypocritical of Ottawa to limit provinces’ ability to finance services and yet constantly give them less money.
In other words, Ottawa has a serious and important role to play in healthcare. Our leaders have to account for this – and give Canadians the answers the deserve.