Social Policy in Ontario

Monday’s premiers’ conference marked the opening round in what promises to be intense federal-provincial negotiations over pharmacare.

In one corner are the provinces — jealous of their prerogatives and deeply suspicious of Ottawa.

In the other is the federal Liberal minority government — desperate for a political win and reliant on support from either the New Democrats or the Bloc Québécois.

At stake is the boldest health care idea since medicare was instituted in 1968 — a plan to provide all Canadians with cheap, publicly funded prescription drug coverage.

Prime Minister Justin Trudeau’s Liberals promised universal pharmacare in the last election campaign. That in itself is not new. The Liberals have been promising pharmacare since 1997.

What is different now is that Trudeau’s government holds only a minority of seats in the Commons. That makes it dependent on the good will of either the NDP or the Bloc.

The NDP has made it clear that its support is dependent on the government implementing national, universal pharmacare. The Bloc I shall get to later.

The Liberals have no good reason to delay. An advisory panel led by former Ontario health minister Eric Hoskins has provided them with a blueprint for implementing pharmacare. The government has pledged to use this blueprint as a basis for its plans.

Indeed, it has already set aside money for a new Canadian Drug Agency to lay the groundwork for pharmacare, as recommended by the Hoskins panel.

And then there are the premiers.

The premiers are not necessarily opposed to pharmacare. In fact, their Council of the Federation has been toying with aspects of the idea since 2010.

Every province operates some form of public drug plan for seniors and the poor. All premiers would be pleased to have Ottawa take on part of that financial burden.

But they don’t want to be hosed again, as many feel they were with medicare.

That worthy social program was sold to the provinces as one in which Ottawa would pick up half the costs. But by the late ’70s, the federal government had changed its mind. It began to unilaterally roll back its cash contributions, leaving the provinces to make up the difference.

That’s why the premiers insist that any national pharmacare scheme must have “adequate and sustained” federal funding.

Many would prefer to get the money with no strings attached. In some cases, as British Columbia Premier John Horgan noted Monday, it’s because they want to beef up existing provincial drug programs. In others, as Manitoba Premier Brian Pallister noted, it’s because they have different health-care priorities.

To that end, all premiers have seized on two principles of federal-provincial funding that Ottawa, unwisely, agreed to 15 years ago during another intense round of negotiations over health care.

The first was the principle of asymmetrical federalism. It stated that, because Quebec was different, it could opt out of any future federal-provincial shared-cost programs but still get Ottawa’s money.

The second was the principle of provincial equality. It stated that, because all provinces are equal, any of them could get the same deal as Quebec.

The effect of the two principles combined has been to make it near impossible for Ottawa to set national standards for new social programs.

More specifically, it makes the creation of a national, universal, public pharmacare plan — that treats all Canadians the same no matter where they live — extraordinarily difficult.

Theoretically, Ottawa could back away from the two principles. Theoretically, it could follow the advice of the Hoskins panel and fund pharmacare only in those provinces that have agreed to abide by broad national standards. Theoretically, the Liberals could take on Quebec Premier François Legault.

But in practice, the chance of such a thing happening is next to zero. First, it would make the Trudeau government’s situation in the Commons vis-à-vis the Bloc more precarious. More importantly, it would not play well among Quebec voters the Liberals hope to attract in the next election.

The question now is whether the Trudeau government can finesse all of this and manage to negotiate a meaningful pharmacare deal. The provinces have spoken. We wait now to find out what Ottawa has to say.