To stop creeping corporatization of Canada’s health care system, Justin Trudeau’s Liberals need to put robust restrictions on how provinces use the health care funding they receive from the federal government. The Liberals aren’t doing that.

Justin Trudeau’s stipulations about how provinces use federal health care funding are nothing near what’s needed to preserve the universal and public element of the system against a rising tide of for-profit care. (R. J. Johnston / Toronto Star via Getty Images)

Health care in Canada is in a perpetual state of crisis. As surgical wait lists grow, family doctor scarcity abounds, nurses quit the profession, and costs rise, the federal and provincial governments are under pressure to secure a deal to ensure that people who need it can get care that is timely, safe, and publicly insured.

In an effort to stanch the crisis, the federal government is putting new money on the table — to the tune of CAD $46 billion over the next decade. That money will be geared toward a wholesale fix of the system, with some of the cash allocated toward four spending focuses: primary care, health care human resources, mental health, and modernization. The federal government is also asking the provinces to chip in some cash of their own for those areas of focus. The deal includes annual increases of 5 percent each year for five years to the Canada Health Transfer, which hands over resources from the federal government to the provinces. This 5 percent increase will drop to 3 percent in year six of the deal.

The provinces are on board — they’ve accepted the deal. But they wanted more money and fewer conditions — much more money and many fewer stipulations. For months, Prime Minister Trudeau and his ministers have been saying that future money for provincial care ought to come with strings attached. In the past, money hasn’t solved the health care crisis. Indeed, in many areas it’s gotten worse, with longer wait times to get surgeries and to see specialists alongside fewer doctors and nurses. These shortfalls are not just because of the pandemic.

Meanwhile provinces — Ontario, Alberta, Quebec, British Columbia, and Saskatchewan — have been opening the healthcare system up to more for-profit entities from general practitioners to surgeries. Indeed, in Ontario, Premier Doug Ford is in the midst of a massive giveaway to for-profit surgery clinics despite evidence suggesting that there are better public and not-for-profit ways to improve care.

The Feds vs. Provincial Governments

The federal government can’t make health care policy decisions for the provinces. The Constitution grants provinces the right and responsibility over health care in their jurisdictions. But the government can decide under what conditions it grants funding and require that funds are contingent on spending being compliant with the Canada Health Act, which requires provinces to meet certain general health service delivery criteria — first and foremost, publicly insured care — in order to receive health transfers from the feds.

But the federal government can and ought to have gone further. They should require that health care dollars are fully spent, and fully spent on health care that is publicly funded and delivered wherever possible by public or not-for-profit institutions. And these outlays should be carefully monitored. In the absence of these measures, the federal government would be complicit in opening the system to more for-profit entities.

The health care crisis is also a labor crisis. There simply aren’t enough staff — certain types of doctors, nurses, technicians — to deliver care. This is a direct result of wage suppression. Few of the ideas on offer now will solve that labor crisis. Before now provinces have been dealing with the problem by unclothing Peter to clothe Paul. A good example of this is Ontario premier Ford’s plans to poach staff from other provinces to cover for their human resource shortages. Further exacerbating the crisis, Ford has also been fighting to preserve a law struck down by the courts that limits wage increases for public employees, including many nurses, and exacerbates the crisis.

Stipulate or Fail

Canada’s immigration policies and programs make recognizing foreign-credentialed health care professionals cumbersome, onerous, and slow. And more for-profit care centers will risk draining public and not-for-profit clinics and hospitals of the staff they so desperately need. If these problems do not receive the attention they need, the health care deal will fail to improve the ailing system. The federal deal does include nearly $2 billion for personal-support worker wages. But again, at best, reforms on offer will tend to move the crisis around or slow the bleeding. They won’t solve it.

To attain the improvements to which the deal aspires, the federal injection of cash would require robust stipulations. The deal should have demanded conditions around the issues of credential recognition, fair recruitment, long-term training programs, and wages. Of course, in the event that such stipulations were implemented, constitutional purists and provincial autonomists would cry interference. But the federal government has every right to place conditions on how the money it transfers to provinces is spent.

Obviously, the status quo isn’t working, and indeed, the growth of for-profit care is a threat to a universal public system that treats everyone equally. So not only can the federal government put further conditions on dollar transfers to provinces — it should. It is squarely on the shoulders of the one government that is meant to govern for all Canadians to protect national health care goals — not systems, which are provincial — as public and universal.

There are barriers to stipulations, of course. First and foremost is politics. And Quebec. The federal Liberals will always be hesitant, to the say the least, to be seen dictating terms to a popular Quebec premier and a province that prefers the national government to mind its own business. Moreover, when the federal government negotiates, it tends to run up against provinces working in concord. These provincial blocs, fickle and wobbly though they may be, can be formidable opponents. In this case, all the premiers have been demanding more money for health care. Trudeau has demonstrated a willingness to cough up money, but he needs to be willing to step on provincial toes to ensure the money does much good.

There’s also the battle of public pressure and blame. Canadians want good, public, timely care, and they aren’t so interested in hearing about jurisdictional squabbles. But there is always a battle of blame — the struggle over who is responsible for failing to deliver what people want and literally need to survive – when jurisdictions disagree.

The Fix Must Be More Than Money

Trudeau’s approach to the health care deal aimed to manage some of these challenges by focusing on making bilateral deals tailored to each province alongside a standard deal for all provinces. Rather than deal with the provinces as a gang, the feds divide and conquer. It’s a good approach; it’s what they did with the childcare deal. That approach could have gone further by separating out the particular needs (and demands) of each entity. Perhaps it still can — as the government now moves on to a second-stage round of negotiations, this time bilaterally, over targeted funding.

Trudeau attached some conditions to the money, but they seem to be, at best, tailored to futzing around the margins — health care data collection, for instance, and better data sharing across the industry. Trudeau’s stipulations, such as they are, are nothing near what’s needed to preserve the universal and public element of the system against a rising tide of for-profit care that is, no doubt, the tip of the financialized health care spear.

In the end, Trudeau didn’t really stand up to Ontario and Quebec. Instead, we heard about “concern” and “monitoring” and “metrics” from the federal government and ensuring that money spent is compliant with the Canada Health Act. The federal government says it expects the money to go to public care — but it’s not clear how serious they are about that commitment and what they’re prepared to do to enforce it. And that’s not nearly good enough.

The health care crisis in Canada requires more money, but it also requires doubling down on public and not-for-profit care. Improvements are badly needed to reform those elements of the system that will produce better outcomes, but it is crucial that these corrections are brought about without selling out the system to financial interests. This will require higher wages, faster foreign-trained credential recognition, more specialized public and not-for-profit community surgeries, centralized referral-intake systems, and more community health teams.

In the absence of these policy changes and conditions made to the deal, the federal government is throwing more good money after bad, setting themselves up for bigger fights in the future. Now, without a more robust deal, future negotiations will potentially be led by a future federal government that doesn’t wish to even pretend to protect the universal public system.

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