Promises, promises
Charlotte Gray
CMAJ 1997;156:1433-5
[ en bref ]
Charlotte Gray is a contributing editor to CMAJ.
© 1997 Charlotte Gray
In brief
As the federal election nears, Charlotte Gray looks at the role health care will play during the brief campaign. Reading through the campaign literature, she found that all parties are making similar statements. However, there are striking differences in the way they intend to preserve the health care system.
En bref
À l'occasion des prochaines élections fédérales, Charlotte Gray a voulu examiner le rôle de la santé dans cette courte campagne électorale. Elle a pu constater que la documentation de tous les partis contient des énoncés généraux semblables, mais que la façon dont on envisage de préserver le système de santé varie énormément.
There's nothing like an election call to galvanize the passionately deep commitment Canadian politicians feel toward our health care system. In between elections they might slash budgets, make throwaway remarks about privatization and bad-mouth doctors, but when the day of reckoning with voters looms they all sing the same hymn of praise.
Take this sentence from one party's election manifesto: "Our health care system is viewed by many as the best in the world. It is one of the most important achievements in our history and a cornerstone of Canadian society. Preserving and improving health care is a top priority for Canadians, and must be just as important to every government."
Stirring stuff -- but is it a Liberal, Tory, Reform or New Democrat declaration? Does it come from the right, left or middle of the political spectrum?
In fact, it pops up on page 23 of Let the future begin: Jean Charest's plan for Canada's next century, already known as the Tory Blue Book. But any political party could lay claim to it -- even the Bloc Québécois, if "Québec" and "Québecers" were substituted for "Canadian" and "Canadians" throughout.
The Liberals' Red Book from the 1993 election trumpeted the same sentiment: "As one of our greatest national projects, our health care system is a defining element of Canadian society. . . . A Liberal government will not withdraw from or abandon the health care field." Four years later, however, many Canadians think that the Liberals have started to withdraw from the field, and they are very worried about it. All federal parties have heard from their pollsters that concern about medi-care is higher than ever. Canadians want to retain it, and they will vote accordingly.
Still, there are striking differences in the way each party intends to preserve and improve the medicare system. The Liberals have the trickiest challenge, since as the incumbent government they must defend their record as well as find some goodies to put in the shop window. The cuts to provincial transfers in successive federal budgets have taken a whopping $4 billion out of provincial budgets, and citizens of every province have felt the consequences. The squeals of dismay from Ontario, as the Health Services Restructuring Commission closes hospitals, are only the latest and loudest protests because this process had started years ago everywhere else.
However, the Liberals have reinforced their credibility as the defenders of national standards with their victory in the user-fee dispute with Alberta in 1996. They have also made some important announcements related to medical research and technology. In last February's budget, Finance Minister Paul Martin allocated $150 million for pilot projects in drug payments and home care, initiatives that Health Minister David Dingwall billed as "the building blocks that will lead us to the inevitable extension of what we now know as medicare."
And in April, Manitoba MP Jon Gerrard, a physician who serves as secretary of state for science, research and development, announced in Winnipeg the creation of the Western Medical Technology Strategy (WMTS), a partnership among the federal government, the National Research Council (NRC) and Manitoba. The WMTS is designed to fund the development of new health services and medical technologies while helping to establish new businesses in these sectors. The minister hopes that these budding businesses will cluster together in a new medical technology innovations centre close to the NRC's Institute for Biodiagnostics in Winnipeg. Ottawa will put $70 million into the WMTS pot, which will be pooled with $32 million from Manitoba and $10 million from the private sector and other provinces.
The government knows that these initiatives get a good response from academics and researchers. However, the money involved is chicken feed in the context of Canada's $72-billion health care budget. Moreover, they have no popular appeal. Liberal MPs need something catchier for the campaign trail, and the National Forum on Health gave them a good idea when it released its report in February.
The forum recommended "full public funding for medically necessary drugs." From then on, the caucus lobbied the prime minister to put a national pharmacare plank in the campaign platform. The program would be an important financial boost for many Canadians, including families and the working poor, who do not have either public or private coverage. (Most provinces pick up the tab for prescription drugs for welfare recipients and the elderly, and many middle-class Canadians have private insurance to cover drugs.) A national pharmacare program would allow Liberal candidates to show that they are just as concerned as their opponents about the continued strength of medicare.
However, Liberal strategists know that while there are strong arguments for such a program, implementation is a different matter. The forum spoke vaguely about "transitional issues" and acknowledged that nationalizing private drug plans is going to be difficult -- not to mention the challenge of absorbing 10 separate provincial plans into a federal program. Ottawa will have to offer a substantial carrot to overcome resistance from everyone who now operates a drug plan, including the Alberta government and private corporations.
And how can Ottawa justify putting money into drugs when it has just put the squeeze on provincial budgets? A major conundrum for the Liberals during this election will be the degree of detail they can provide on their promise of a brave new drug plan. But the pledge will at least demonstrate that they are not backing away from universal, accessible health care. It also indicates that the Liberals still believe that Canada needs a strong central government to coordinate reform of the health care system and maintain national standards.
Opposition parties have an easier challenge in this election. All can accuse the Chrétien government of eroding the health care system in its zeal to cut the deficit. The Conservatives, for instance, argue that Liberal cuts have put "extra pressure on provincial governments, health care institutions, health care providers and -- most of all -- on patients and their families. . . . Meanwhile, the federal government can use the savings to reduce its deficit and pretend that it is being fiscally responsible. In fact, it is an ugly political game -- a game that uses our health care system as the pawn."
Both parties on the right, Reform and Conservative, twist themselves into ideologic knots in their eagerness to slash public spending and simultaneously protect a national health care system. Both have promised to balance the budget, the Conservatives by the year 2000, Reform by Mar. 31, 1999. Both want to cut income taxes, the Tories by 10% during their first budget, Reform by $2000 per family by the year 2000. Yet both are determined to pump public money back into health care. The Tories say they will restore $1.4 billion annually to the provincial transfers cut by Paul Martin, and ensure future funding growth. Reform would restore the full $4 billion that Martin cut.
What is most significant about both Reform and Tory statements, however, is not the dollar amounts but the approach of both parties to health care jurisdiction that puts a distance between them and the Chrétien Liberals. Both parties argue that the provinces should have more flexibility to tailor health care to their own needs, and that Ottawa's authority to police the system should be curtailed.
So far, Reform has spoken only about maintaining national standards while loosening the straitjacket in which Ottawa holds the provinces. The Conservatives have fleshed out their proposals more precisely, proposing a risky trade. A Charest government would convert the federal cash transfers of $12.5 billion into tax points, which it would transfer to the provinces in a one-time deal. The provinces would then be entirely responsible for designing and financing their own health care systems. However, this would not happen until all the provinces had agreed on a "Canadian Health Care Guarantee" that outlines common standards and a binding enforcement mechanism. The federal government would no longer be able to withhold dollars from a province -- but a province would be breaking a contract if it abandoned any of the 5 principles of medicare enshrined in the 1984 Canada Health Act.
This "guarantee" would be part of a larger "Canadian Covenant" that would also cover postsecondary education and interprovincial trade. Could it work? It represents some interesting new thinking on how to avoid conflict between Ottawa and the provinces. It would establish a permanent commitment to a more binding social union. Many observers argue that Ottawa has already lost its clout to enforce national standards, since the cash transfers have fallen so low. However, the Charest platform requires consensus between 10 provinces and 2 territories -- a phenomenon not seen on any issue of significance for several years.
A wealthy province interested in privatizing some of its health care services and a poor province anxious to secure equalization payments in order to maintain quality health care would come to the negotiating table with very different priorities.
On the left of the political spectrum, the New Democrats catalogue with glee the effect of Liberal budget cuts. Party leader Alexa McDonough cites the health care workers who have lost their jobs, the waiting lists for elective surgery, the fear of ordinary Canadians that our system is being Americanized. The NDP's election manifesto, Framework for Canada's future, calls for the cancellation of proposed cuts to health care funding, increased future federal financing and an extension of medicare to cover home care and prescription drugs. McDonough calls this "universal health care for the 21st century -- that's the vision of Tommy Douglas." However, the NDP has not explained how it would pay for these initiatives, other than through higher personal and corporate taxes. The NDP also wants to see Ottawa play a larger regulatory role in the economy.
Do the election promises of any party other than the Liberals matter? At time of writing, a Liberal victory appears so inevitable that the platforms of the opposition parties will likely end up in garbage bags the day after the election.
However, the election has produced a Liberal commitment to a national pharmacare program. And the traditional Liberal skill in governing from the middle means that the party's strategists are reading their opponents' platforms carefully. With the right-wing parties promising to loosen Ottawa's controls on health care, and the left-wing party demanding a stronger central government, Liberal backroomers are probably congratulating themselves that they are exactly where they want to be.
In their next mandate they can safely stay the course they set in the past 4 years.
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