Ottawa and provinces should be thinking big – health
December 14, 2011.   By Hugh Segal, The Ottawa Citizen

News that federal and provincial health ministers began discussions in Charlottetown on the new health care accord recently is very welcome. This linkage between the provinces and Ottawa is a vital foundation upon which the architecture of civility around universal health insurance is built. The coming discussions should not be about a quick and simple patch or financial roll over. They should be about a unique, non-partisan and collaborative opportunity for governments to work together to strengthen both the public and private infrastructure that sustains Canadian health care. Creative public policy as part of federal-provincial relations is not a sin.

The new agreement need not only be about who pays more or how to continue the existing system unchanged. An unchanged continuance of the present health system would be to raise complacency and naive insouciance to new levels. Canadian health care has serious strengths and some compelling weaknesses. This should be the time to lever those serious strengths to address the compelling weaknesses.

Poverty and its pathologies often force decent people into difficult lives. The 10 per cent of Canadians who live beneath the low-income-cut-off often get sick sooner, stay sick longer, eat the wrong foods, exercise less, smoke more and have less educational success (students from poor homes drop out sooner). These social determinants of health, predictors of the outcomes around illness and the related stresses, help fill our hospitals and increase the strains on health care. A majority of those who live beneath the poverty line do have jobs, often more than one, but still do not earn enough to make ends meet.

If our health-care system is to be one where flexibility, access, appropriate care and financial sustainability are real assets in the service of Canadians, it is vital that any new formula for health-care financing take the social determinants of health into account.

Those provinces that embark on programs to discourage obesity, encourage exercise and seriously reduce poverty should have incentives built into the transfer system negotiated between Ottawa and the provinces. A solid health care delivery system is a proxy for what works well in society.

Greater longevity for Canadians is the joint result of better education outcomes, less smoking, more exercise, superb pharmaceutical research and vital new realities such as universal access, better public health standards and improvements in medical practice like the stroke protocol, preventive family health groups and enhanced cancer diagnosis and treatment. But if these benefits are only there for those already better off, the low-income drivers of increased health operating costs will squeeze out the resources necessary for innovation and coping with the new pressures brought on by aging and new technologies.

And if we are not careful, a single-payer system that is unable to create room for private sector innovation and more effective service under the umbrella of universal public insurance will continue a trend of sucking money out of education, infrastructure, safe communities and new technologies vital to happy and productive lives for millions of Canadians.

Equality of opportunity is structured in Canada on a mix of education, universal health insurance, solid infrastructure, fair and reasonable taxes and vibrant private and public sectors.

Health insurance and health care are essential cornerstones of the equality of opportunity Canadians enjoy and wish to pass on to their children. The opportunity to lever the financial nexus that is the federal/provincial health finance framework has never been greater. Health care financing is only modestly about Ottawa’s fiscal capacity. It is largely about provincial expenditures, as provinces have the lead responsibility under Section 92 of the Constitution.

It is also about the role of group insurance for extra medical coverage, drug plans and the way doctors and other health professionals finance their own activities. It has always been a mix of public and private resources clustered around the principle of universal health insurance run by each province. Doctors, pharmacists and other providers are private professionals whose clients have public insurance — the single-payer model that reduces administrative and undue receivables overheads better invested in health care itself. Poverty is a deep and compelling driver of costs in this system. Using the leverage of the transfer agreement to be negotiated over the next few months, the reduction of poverty could be genuinely facilitated.

Bureaucrats in all governments will urge elected leaders of all stripes to think small; do not over reach and keep things simple. If that defeatist counsel of little expectations prevailed when Tommy Douglas, John Diefenbaker and Lester Pearson worked, each in their own way, to make the Saskatchewan experiment a national reality in the 1960s, we would not have universal health insurance today.

Taking the bureaucrats’ advice this round would be one of the most serious mistakes our elected leadership, of all political affiliations, could make.

Senator Hugh Segal (C-Ontario), is a former associate cabinet secretary for federal/provincial relations in Ontario

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