Canada could offer $50-million funding bonuses to a province like Saskatchewan for achieving reductions in the number of people without a family doctor.
The Constitution Act assigns responsibility for most health care to the provinces. To influence provincial systems, Ottawa must negotiate its role, where “negotiate” means “fork over the cash.”
In 2023, Ottawa sent $47 billion to the provinces and territories for health care, which covers about 21 per cent of their health budgets.
The game is pay to play, and for decades Ottawa has tried to master it. It’s a tough challenge. The provinces want unconditional transfers. Ottawa wants the money to make health care better and a share of the political credit.
Beginning in 2003, Ottawa started pouring a lot of new money into health care. Billions were ostensibly earmarked to shorten wait times, buy new technology, strengthen primary care, beef up mental health services, and modernize the health information system.
Provinces were to report on how they spent the money and what they achieved.
It turned out to be a Potemkin village of pseudo accountability. Ottawa’s health-care money doesn’t get shipped with a different coloured dye. It is cash deposited into the provincial consolidated fund, which gets spent however the province decides.
Both governments might claim, for example, that new federal money bought more MRIs, but the province might well have bought them anyway. If new federal money was really tied to fixing primary care, it would surely have got a little better instead of catastrophically worse.
The only solutions that haven’t been tried are the ones that might work.
This is arguably as it should be: the provinces run their health-care systems and are politically accountable for how well they do it. The federal cash is really a remedy to the imbalances of fiscal federalism. Without it health-care spending would consume over half of some provincial budgets, like having a mortgage in Vancouver.
Pretending that federal dollars are conditional on concrete health-care achievements is good theatre. But it’s still play acting, and there are no refunds if the show’s no good.
These arrangements secure peace but not improvement. Health care is an under-performing, cash-sucking monster that defies all attempts to tame it, and federal cash is part of the problem. Ottawa typically agrees to multi-year increases in funding — the Harper government committed to six per cent annually.
This is an open invitation to providers to bargain higher pay, and to prop up the status quo rather than do the difficult work of real reform.
Ottawa could offer, say, a $50-million bonus for getting the number down to 150,000, another $50 million when it hits 100,000, and a perpetual $50 million a year for keeping the number below 50,000. The faster the problem is solved, the faster the cheques arrive. Fail to sustain the improvement and the bonus disappears.
Repeat for wait times, and any number of quality improvement targets. One might expect provinces to set such goals on their own and build them into program funding decisions and negotiations with providers.
But they don’t; neither level of government defines success because that would also define failure, which can never be acknowledged.
Health-care federalism, currently a performative irritant and fiscal sleight-of-hand, might just become a catalyst for real change. It would give provinces a strong incentive to take on the inertia and fiefdoms that stand in the way of game-changing reform.
Bilateral agreements give them the flexibility to negotiate targets that reflect provincial priorities. Where there is no stick, the solution is to design a better carrot.
Steven Lewis spent 45 years as a health policy analyst and health researcher in Saskatchewan. He can be reached at [email protected].
Our websites are your destination for up-to-the-minute Saskatchewan news, so make sure to bookmark thestarphoenix.com and leaderpost.com. For Regina Leader-Post newsletters click here; for Saskatoon StarPhoenix newsletters click here