Reforming health care: national or provincial leadership?

Which level of government should take the lead in reforming Canada’s ailing health care system? This question is fundamental. Either Ottawa or the provinces must take the initiative, or it’s hard to imagine much progress being made.

Dr. Jeffrey Turnbull, president of the Canadian Medical Association, delivered a major speech today in Toronto in which he gives his answer: the federal government.

This is not, of course, a self-evident conclusion. It flows from the history of Ottawa setting the basic rules for universal care under the Canada Health Act, and enforcing those principles by threatening to reduce transfer payments to any province that doesn’t live up to them. The opposing perspective emphasizes the constitutional responsibility for health care that rests primarily with the provinces, which tends to lead to the notion that provincial governments should drive any reform.

Turnbull doesn’t make a public-policy case for federal leadership so much as invite us to conceive of the health care in terms of a corporate analogy. He imagines the system as a sprawling company—it would be the third largest in North America, he observes, after Walmart and Exxon Mobil—with each of the federal, provincial and territorial health departments functioning as an autonomous operating unit.

“Its 14 divisions each carry out the same function,” Turnbull says, “but with 14 different IT systems and purchasing departments, no clear system for sharing best practices, and no evaluation of outcomes, either separately or as a whole.”

Viewed this way, it’s natural for Turnbull to posit a head office for this inefficient corporation that should be demanding greater unity of purpose and less duplication. “We ask the federal government to demonstrate courage and leadership,” he says. The challenge is to “harness the national will to reshape [health care] for the future.”

But it’s not all that easy to make the leap from local problems to national solutions.

For instance, Turnbull is at his most compelling when he tells a story from Ottawa Hospital, where he practices. An 80-year-old woman went through all the taxing preparations necessary for surgery to fix an aneurism—only to have the operation cancelled because the hospital lacked a bed for her. “Sobbing,” Turnbull says, “she told me she just couldn’t go through the process again.”

A whole lot of Canadians have a sorry tale or two like that to tell. In the annecdote Turnbull relates, the solution would clearly be to invest in new long-term care facilities in and around Ottawa. He explains how his hospital is now stuck, at any given time, with 150 or so patients filling its acute care beds while they wait for space to open up elsewhere for appropriate long-term care.

Does fixing myriad problems of that sort cry out for a national strategy? Turnbull suggests another parallel, this time to a recent public-sector initiative—the Harper government’s heavily promoted Canadian Economic Action Plan. Launched in the 2009 budget, its aim was to inject stimulus into the badly slumping economy, largely through short-term infrastructure spending.

“A Health Care Action Plan, like its economic counterpart, would call on the participation of the provinces and the municipalities to leverage transformative change,” Turnbull says. “It would address not only health infrastructure needs, but transform the system to ensure more effective use of HR, to better incorporate health IT, and to introduce new accountability mechanisms.”

The type of leverage he refers to is not a complicated matter when it comes building, say, roads or arenas. That’s not transformational stuff: Ottawa typically puts up money for a project only if a province and municipality match those funds. The notion of using federal money in the same way as the incentive for a shared-cost reform of health care is an intriguing one.

When it comes to the economy, though, there’s not much debate about Ottawa’s right to take the lead. A federally directed revamp of health care—modeled on the 2009 economic action plan and inspired by a vision of the system as something like a coast-to-coast corporation that needs a more visionary head office—would be far more contentious.

For one thing, it would be difficult to reconcile this model with the Prime Minister’s “Open Federalism” philosophy, under which Ottawa is meant to defer to the provinces in their areas of jurisdiction. For another, Turnbull would have to show how a much more national system could be designed without building in the inefficiencies that often come with centralization.

These are not insurmountable hurdles. A creative federal government might find a way to inspire provincial buy-in for reform without coercing anyone to play along. Reforms might be national in scope without succumbing to rigid centralization.

Still, when you think about it, running a company or ramping up an infrastructure program look easy by comparison.

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