Canadian federal–provincial/territorial funding of universal health care: fraught history, uncertain future (original) (raw)
2020, Canadian Medical Association Journal
A s the coronavirus disease 2019 (COVID-19) epidemic continues in Canada and financial pressures mount on all levels of government, the federal-provincial/territorial cost-sharing framework for universal publicly financed coverage of physician and hospital services-commonly referred to as Medicare-has once again become a point of contention. In September 2020, just days before a federal Speech from the Throne, Canada's provincial and territorial premiers called for the federal government to become "a full funding partner" in health care spending, raising its contribution to provincial and territorial health spending from 22% to 35%, an increase of $28 billion per annum. 1 Yet, to the expressed disappointment of the premiers, 2 the Throne Speech offered no increases in federal funding for health. Instead it reiterated the Government of Canada's previous commitment to "a national, universal pharmacare program" and set out some steps toward that goal. Although Medicare remains one of the social programs that Canadians value most highly, its stability, and any potential expansion of Medicare services, such as pharmacare, depends on a robust federal-provincial/territorial cost-sharing framework. Yet, the conflicting perspectives of different levels of government pose major challenges to any expansion of public coverage or pursuit of national health care reforms. We review the history of federal-provincial/territorial bargaining that led to the current Medicare system and consider what constitutes a fair deal in the current climate, drawing on a variety of print and online sources (Appendix 1, available at www.cmaj.ca/lookup/ doi/10.1503/cmaj.200143/tab-related-content) as well as the firsthand observations of 2 of the authors starting in the 1980s. What is the history of Medicare bargaining in Canada? Nothing in the 1867 Canadian constitution anticipated national health insurance programs. The constitution instead assigns authority for oversight and delivery of health care services to provinces and territories. Hence, provinces moved at different speeds to implement public coverage of health care, with Saskatchewan pioneering universal hospital insurance in 1947 and universal medical services insurance in 1962. This constitutional reality means that Canada has 13 somewhat distinctive provincial or territorial health care systems. Those systems have much in common, however, given shared fiscal and legislative DNA arising from a series of agreements that, since the late 1950s, have set out terms and conditions for sharing of specified costs between the Government of Canada and provinces and territories.