Everyone claims victory in health care deal, but who really won?

CMAJ 2000;163(8):1029

[News & analysis in PDF]

On Sept. 12, the day after the First Ministers Conference ended, the words "health deal" dominated the headlines. Despite predictions from all sides that the talks were doomed, the prime minister and provincial and territorial leaders all signed on the dotted line and agreed to increased federal transfers in a deal worth $23.4 billion over 5 years.

Why is this man smiling? (Canapress)

Each side immediately proclaimed victory at the expense of the other, but this was as predictable as snow in January: elections loom both federally and provincially, and everyone wants to wear the cloak of "protector of medicare." And as Saskatchewan Premier Roy Romanow put it ever so succinctly, any premier who went to the polls after spiking a health care deal would be "dead meat."

So what does the deal mean? First, more money. Not as much money as the premiers wanted, of course, and money that is not coming as quickly as necessary. Nevertheless, the premiers got what they have been clamouring for ever since Ottawa began to report surpluses. The agreement to put back into provincial transfers the billions carved out of the system in the 1995 budget will boost Ottawa's spending on health and social programs by about 35% over the next 5 years, from $15.5 billion this year to $21 billion in 2005.

The deal hinged on Quebec and Ontario, the 2 most populous provinces and the only 2 to arrive at the meeting in a pugnacious mood. For different reasons, Premiers Lucien Bouchard and Mike Harris want to eliminate the federal role in health care. They presented a solid front. Harris announced that he would not agree to any deal that Bouchard would not sign, and this enraged the other premiers. Why would Ontario's premier give a veto to someone outside his own province? they asked. The Atlantic premiers, in particular, were eager for a deal, because they desperately need the money. And unlike Quebec and Ontario, they actually want Ottawa to play a stronger role in health care.

Friction among the premiers was clear in many of the nasty comments made during the talks, but in the end federal bureaucrats amended the final communiqué to assuage Harris and Bouchard, who were concerned that it gave Ottawa and the provinces equal roles in health care, even though health is a provincial responsibility. This allowed the 2 renegade premiers to claim they had stopped Ottawa from encroaching on provincial turf. The Bouchard–Harris "victory" did not sit well with the other premiers; Alberta's Ralph Klein suggested that they had endangered consensus in order to play word games.

The deal that was signed is a lot less ambitious than the one the federal government had hoped to secure. While campaigning for re-election 3 years ago, the federal Liberals promised that they would introduce home care and pharmacare programs. These, of course, never saw the light of day because of provincial hostility over having such programs introduced under the federal banner.

Ottawa has also had to back off from its plans for a federal reporting mechanism that would tabulate health care statistics across the country and allow the federal government to establish national standards. The deal signed by the premiers makes only a vague mention of a "third party" that will collect and compare statistics from each province; provinces don't have to produce "report cards" for at least 2 years. In other words, the provinces got their money with few strings attached, and it is not yet evident if and when Canadians will see any real reforms in the health care system. The new dollars from Ottawa could be siphoned off to welfare or postsecondary education programs.

So did the deal represent a defeat for the federal government? Absolutely not, the feds say. The agreement relegitimized Ottawa's role as guardian of the Canada Health Act, since the premiers all committed themselves to the CHA's principles of universality, accessibility, comprehensiveness, portability and public administration.

The deal also represents real progress in some directions that will improve the delivery of care and ensure a national rather than a patchwork system. The initial $500 million for health data technology is only the first step in a potential $2.8 billion program. The federal government also put $1 billion in the pot for medical equipment, an investment that allows Ottawa to claim a leadership role in modernizing health care.

Politically, this conference allowed Jean Chrétien to emerge with more moral authority than most of his provincial counterparts. The unholy alliance between Harris and Bouchard, the exasperation that Harris triggered in Ralph Klein, the unseemly spitting match between the have and have-not provinces — all this revealed that Ottawa bashing is the only activity that unites premiers.

Bouchard's signature on the final deal must have been particularly gratifying for Chrétien. Only 3 days earlier, Bouchard had expressed outrage that Ottawa was trying to bring the provinces "to their knees." However, Chrétien also knew that Bouchard could not afford to walk away from the deal: his voters would never forgive him. He simply told the Quebec premier that if he didn't sign, he wouldn't get the money. And billions of dollars will lubricate any negotiations.

In the end, Chrétien managed to smooth over voters' fears about health care, reveal the rifts between the premiers and reinforce his vision of health care as a national program, rather than a crazy quilt of different provincial services. All in all, not bad for a day's work. — Charlotte Gray, Ottawa

Copyright 2000 Canadian Medical Association or its licensors