1. 1 Sustaining a National Program within a Federated Structure: The F/P/T Environment 14 th John K. Friesen Conference Gerontology Research Centre Simon Fraser University at Harbour Centre, Vancouver Gregory P. Marchildon, Ph.D. Canada Research Chair and Professor, University of Regina May 20, 2004

2. Gregory P. Marchildon, University of Regina 2 The Canadian Health Care Pie Source:CIHI, NHEX 2003 Canadian Health Care: Expenditure Perspective, 2003 Note: Excluded from the calculation are expenditures by municipal governments, workers compensation and by social security funds. Figures for 2003 are forecasts.

3. Gregory P. Marchildon, University of Regina 3 Ranking by Health Status Indicators, Selected Countries Source: OECD 2003 Life Expectancy at Birth (1999) Potential Years of LL per 100,000 (1997) Perinatal Mortality per 100,000 (1999) DPT Immunization % of Children (1997) Measles Immunization % of Children (1998) SWEDEN 1 (4) 1 (1) 2 (7) 1 (2) 1 (6) CANADA 2 (5) 2 (8) 3 (13) 4 (22) 2 (7) AUSTRALIA 3 (7) 3 (9) 1 (3) 6 (25) 5 (18) FRANCE 4 (8) 5 (15) 4 (17) 2 (8) 6 (19) UK 5 (18) 4 (10) 5 (18) 3 (18) 4 (15) USA 6 (20) 6 (22) 6 (20) 5 (23) 3 (13)

4. Gregory P. Marchildon, University of Regina 4 Ranking by Disease Indicators, Selected Countries (1997) Source OECD: 2003 Malignant Neoplasms Cerebrovascular Diseases Respiratory System Diseases Ischaemic Heart Diseases SWEDEN 1 (3) 5 (9) 1 (7) 4 (16) CANADA 4 (14) 2 (3) 3 (14) 2 (11) AUSTRALIA 2 (9) 4 (5) 4 (17) 3 (14) FRANCE 3 (13) 1 (1) 2 (8) 1 (3) UK 6 (19) 6 (16) 6 (25) 6 (21) USA 5 (15) 3 (4) 5 (20) 5 (17)

5. Gregory P. Marchildon, University of Regina 5 The Canadian Medicare Model: Components CHA insured services: hospitalization + medical care + Narrow but deep coverage Parallel private tier prohibited or discouraged in provincial legislation Provincial + Federal revenue sources

6. Gregory P. Marchildon, University of Regina 6 First Phase of Changes, 1988-1996 Provincial studies and reports, 1988-91: QC, NS, AB, ON, SK, BC Regionalization reforms Integration Rationalization (cost cutting) Local decision-making re: allocation of resources Continuity and coordination of care

7. Gregory P. Marchildon, University of Regina 7 Second Phase, 1997-Present Rapid growth in expenditures (and solid growth in revenues) Growing concerns re: sustainability Provincial and national studies More focus on federalism aspect and the federal role

8. Gregory P. Marchildon, University of Regina 8 Federal Role: Three Major Choices for Future of Canadian Medicare Model #1 - Status quo “ death by stealth ” #2 - Tax transfer “ death by execution ” #3 - Constructive federal engagement

9. Gregory P. Marchildon, University of Regina 9 #1 - Status Quo Not sustainable in long run Dysfunctional nature of intergovernmental relations Too much focus on $ and turf Too little focus on health policy and programs Why bother with health ministers?

10. Gregory P. Marchildon, University of Regina 10 F/P/T Relations and the Damage Done: Part I CHST: cash drop + no escalator SUFA, 1999 FM “ agreement ” of Sept. 2000 Foot dragging on aspects of “ agreement ” But “ we ’ ll be back for more ”

11. Gregory P. Marchildon, University of Regina 11 F/P/T Relations and the Damage Done: Part II Romanow Commission: 2001-02 Feb. 2003 Health Accord Funding mechanism? CHA? Home care? Fragmentation: Aboriginal health care? Drug regulation, prescription and utilization ?

12. Gregory P. Marchildon, University of Regina 12 #2 - Tax Transfer: Why? Ottawa: influence too minimal given $ and political headache Provinces: clearer accountability and total flexibility in design, administration and delivery Others: medicare now an established program and provinces will adhere to CHA because of electorates

13. Gregory P. Marchildon, University of Regina 13 Tax Transfer: Why Not? No guarantee that national dimensions would be upheld Provincial benefit v. citizenship right Lose equalization effect of accessing national revenue base No future opportunity to improve upon the national dimensions

14. Gregory P. Marchildon, University of Regina 14 #3 – Ottawa as a Real Partner Public support for Canadian medicare model remains high See both orders of government as responsible in respective spheres Federal government: $ plus catalyst for change re: national dimensions Provinces: administration and delivery within principles of CHA

15. Gregory P. Marchildon, University of Regina 15 What is Needed? Stable, predictable and transparent cash transfers FM agreement on principles and future direction Modernized CHA Respect for provincial capacity and role within principles of CHA

16. Gregory P. Marchildon, University of Regina 16 Next First Ministers ’ Meeting Will be decisive Can ’ t afford to lose another opportunity Public patience wearing thin Televise proceedings No further federal funding without agreement (opt out without cash)

17. Gregory P. Marchildon, University of Regina 17 Conclusion Federal role has been essential in establishing our model of medicare SK could not have gone it alone Federal spending power and right structural incentives important But federal and provincial leadership (even if minority) essential