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The health care system was in crisis. It took nearly 15 years of incremental increases to bring the federal portion of health funding back to the level is was at before Paul Martin took his axe to it. Going through an exercise like that again would be devastating for the health services that Canadians depend on each and every day.

Adding fuel to the speculation that the Liberals are planning massive cuts to health funding is Trudeau’s September 2nd letter to the Council of the Federation that makes no firm commitments to health care or federal transfers. The only firm commitment was to improve the federal-provincial relationship. That’s pretty thin gruel considering the state of that relationship after 10 years of Stephen Harper!

All Canadians who are concerned with the future of health care in this country need to scratch below Trudeau’s soothing words and take a look at his hard numbers. When you break down their plan, 77 per cent of the value of their “new investments” are tax shifts and benefits (including others not listed under that category), 12 per cent is the catch-all of ‘infrastructure’ spending (though most Canadians don’t think of early learning and cultural facilities as ‘infrastructure’), and five per cent is EI (paid for through EI premiums).

That leaves only six per cent, or a little over two billion a year for everything else. How much of that available funding will go to public home care and long-term care? How much will go to the provinces for new hospital beds after years of cuts? On reading the Liberal plan, we have to conclude: not a penny.

Their plan also targets $6.5 billion in spending reductions from an expenditure review. Will health care be on the table for cuts, if they can’t meet that ambitious target? John McCallum said on Saturday that in the effort to balance their books before the next election, ‘everything was on the table.’ Contrast this with Tom Mulcair’s plan for health care under a federal NDP government, and the stark choice is brought in to focus. 

Mulcair has committed to reversing Harper’s $36 billion in health care transfer cuts to the provinces.  He has committed to investing $5.4 billion into new public health care programs, including a prescription drugs, a plan for 41,000 home care and 5,000 long-term care spots. Over five million more Canadians will have access to primary health care through his plan to build 200 Community Health Clinics. And there are practical policy initiatives on mental health for youth, Alzheimer’s and dementia care.

Canadians cherish their universal Medicare system as one of the things that makes Canada great. They want a federal government that will commit the necessary funding and leadership to build the public health care system of our collective futures, to meet the challenges of an aging population and increasing drug costs. The next party to lead the federal government should be judged by the real dollars and focused policy it has committed to meet Canadians’ health care needs.

On that measure, the Liberal plan is dead on arrival. Paul Moist is national president of the Canadian Union of Public Employees. Representing over 633,000 members, including over 153,000 working in the health care sector, it is Canada’s largest union.

This federal budget also cut Health Canada funding by 6.4 percent

The immediate federal cuts are already taking a toll on women’s and Aboriginal health groups.

One week after the Senate committee reviewing the health accord called for stronger federal leadership and new pan-Canadian programs (pharmacare and continuing care), the budget shows a federal government in retreat.

We need the federal government to negotiate with the provinces a new ten year health accord that will protect, strengthen and expand Medicare.

For more details on these recommendations and why they’re needed, see CUPE’s report on the health accord.

Support public health care: sign the Call to Care!

in 1999-00

If tax points are not included as part of the federal contribution, then the proportion of health care spending by provincial governments totals some 82%, while the federal share is 18%.

the federal share for that year is approximately 35%

Health Canada’s data also indicate that the provincial governments’ share of public health care expenditures has been increasing steadily since the late 1970s, irrespective of the method of calculation used. Concurrently, the estimated federal share has been declining since then. The value of tax transfers and federal direct funds(24) are increasing slightly, but the cash transfer share is largely decreasing. This downward trend could be reversed, however, with the additional federal investment in health care provided in Bill C-45 (2000).

However, until now no federal government has had the nerve to take on serial offender Quebec. Quebec has been allowing its doctors and clinics to charge extra user fees since 1979. The province's current health minister, Gaetan Barrette, freely acknowledges this. In some cases, these fees were truly exorbitant. The Montreal Gazette reported last year that some colonoscopy clinics were charging patients an extra $600 for medications - on top of the publicly paid medicare fee. Many Quebecers were outraged. The provincial Liberal government's somewhat peculiar response was to pass a bill codifying the practice of extra-billing but giving itself the authority to regulate it. In March 2015, the then-Conservative government in Ottawa formally notified Quebec that it would be looking into the issue. This March, Liberal Philpott sat down with Barrette to discuss the practice. On Sept. 6, she sent her provincial counterpart a letter threatening cutbacks to Quebec's health transfer. A few days later, Barrette announced that extra billing will end as of next January.

It is hard to gauge the importance of Philpott's threat. User fees have become widely unpopular in Quebec. That alone may have been enough to drive the provincial government to disavow them. Still, it was bracing to see a federal health minister publicly standing up for the principles of medicare. It is not an everyday occurrence. It is particularly interesting that she targeted a province that is notoriously touchy about what it sees as federal interference. Perhaps she will do more. Certainly, more needs to be done. The latest annual report on the Canada Health Act filed with Parliament notes that private MRI clinics in British Columbia, Alberta, Quebec, New Brunswick and Nova Scotia are charging user fees to patients. It says some hospitals are avoiding the ban on charging for drugs by routing the sick through outpatient clinics - which do charge. It also notes that the portability requirement of medicare, which allows Canadians to receive care outside their home provinces, is routinely ignored.

Quebec routinely refuses to fully reimburse other provinces that provide health services to Quebec residents. Yet it has never been penalized by Ottawa for this. Nor have an unspecified number of other provinces that, at one time or another, did the same. Except for Prince Edward Island, the report says, no province appropriately reimburses residents who obtain medical care outside Canada. Such patients aren't necessarily entitled to the full cost of their out-of-country care. But they are entitled to be reimbursed for the amount it would have cost them to be treated in their home province. To work as a national program, Canadian medicare needs two things. First, the federal government must put up enough money to give it a real financial role in the system. The 2002 Romanow royal commission suggested that Ottawa provide at least 25 per cent of medicare funding. That figure still makes sense. Second, Ottawa has to use its financial clout to enforce those few national standards that do exist. A former Liberal health minister, Diane Marleau, tried to do this back in the 1990s. She was sandbagged by Jean Chrétien, the prime minister of the day. Let's hope Philpott has better luck.

It was bracing to see a federal health minister stand up for medicare principles, writes Thomas Walkom.

Since federal transfers have been growing at more than twice the rate of health spending since 2010, some federal cash destined for health care is presumably being diverted elsewhere or replacing provincial cash. The Canadian Institute for Health Information says spending on health care in Canada grew by 2.1 per cent in 2014. But federal health transfers grew by 6 per cent. Starting in 2017, federal health transfers will grow at the same rate as the economy, with the floor for increases set at 3 per cent. The advisory panel on health innovation led by former University of Toronto president David Naylor rejected provincial calls to maintain the annual 6-per-cent escalator adopted in 2007. It also rejected a "return to earlier approaches that depended on unanimously agreed priorities and formulaic allocations of funds" between Ottawa and the provinces.

Yet, this is precisely what NDP Leader Thomas Mulcair and Liberal Leader Justin Trudeau are promising should one or the other become prime minister after Oct. 19. "If my party forms government, it will call a federalprovincial meeting to reach a long-term agreement on health care funding," Mr. Trudeau wrote last week in a letter to Quebec Premier Philippe Couillard. Mr. Mulcair promises an NDP government would "use any budget surplus" to restore the 6-per-cent escalator. "Money alone cannot solve the problems facing our health-care system. But without money, we won't solve a thing," he told the Canadian Medical Association in 2014.

The approach promised by Mr. Mulcair and Mr. Trudeau has a clear track record of failure. Despite its good intentions, the 2004 health accord negotiated by former prime minister Paul Martin reduced pressure on the provinces to overhaul the outdated architecture of their health systems. As the Naylor panel noted, most of the $41-billion transferred under the accord was used to increase doctors' fees rather than invest in innovation or more cost-effective ways to deliver health care. This is exactly what should have been expected. As William Robson and Alexandre Laurin of the C.D. Howe Institute concluded in a recent report on this history of fiscal federalism: "The more federal transfers appear to respond to provincial fiscal pressures, the weaker are the incentives for provincial governments to raise [provincial taxes] or manage expenditures efficiently."

Now, the premiers are warning that their provinces are about to be submerged by a grey tsunami. Though the proportion of healthcare spending devoted to seniors' care has not budged, remaining steady at 45 per cent since 2002, the CMA projects it will hit 62 per cent by 2036. But that's only if Canada keeps on doing what it has always done - pumping more money into a system designed in the 1960s and which has barely changed since.

It's hard to see how yet more federal cash would incentivize the provinces to innovate their way to health-care sustainability. The Naylor panel's recommendation for the creation of a $1-billion federal health-care innovation fund hits the mark. The most meaningful contribution Ottawa could make to saving Canadian health care right now is as a catalyst for change, not as an enabler of the status quo.

When the Harper government took office, federal tax revenues (2006-07 fiscal year) were 13.5 per cent of GDP, a bit shy of the 14.5per-cent peak in 2000-01. In the most recent fiscal year (2014-15), they are projected in the most recent federal budget to be just 11.4 per cent of GDP, which is lower than in the mid-1960s before the creation of much of the modern welfare state. With total GDP now just under $2-trillion, a seemingly small decline in federal tax revenues of 2.1 percentage points of GDP translates into foregone annual revenues of $41.5-billion. To put that in perspective, in 2014-15, federal transfers to the provinces for health care and social programs combined came to almost as much, $44.7-billion. If federal capacity were at the same level as in 2006, Canada could afford eight national childcare programs on the scale proposed by NDP Leader Thomas Mulcair. Or we could more than triple the current level of federal funding of transit and municipal infrastructure.

Tax cuts have clearly been a much greater priority for the Harper government than investments in programs or services, or balancing the federal budget. Revenues continued to fall after 2008-09 when the government first ran a deficit, mainly as a result of corporate tax cuts. Almost all taxes have been reduced. The general corporate income tax rate has been cut gradually but deeply from 22.1 per cent to 15 per cent, with each one percentage point reduction costing $1.85-billion in lost revenue per year according to the Parliamentary Budget Officer. The two percentage point cut to the GST introduced in the early days of the government now costs $12.8-billion per year in lost revenues.

With respect to the personal income tax, the government has brought in numerous "boutique" tax credits and deductions, a universal child tax credit, and family income splitting, which mainly benefits more affluent families with children at a cost of $2.2billion a year. While it still costs relatively little, the new system of Tax-Free Savings Accounts now allows for contributions of up to $10,000 a year with no cap on total accumulations. This will eventually all but eliminate taxation of investment income such as capital gains as the assets of the richest Canadians are gradually shifted to tax-free vehicles.

Opinions obviously differ as to the wisdom of specific tax cuts and their impact on economic growth and social justice. The government argues that lower taxes and smaller government underpin a strong economy, while the critics point to the unfair distribution of winners and losers from tax cuts, weak business investment despite corporate tax cuts and the costs of foregone public investments. One thing is clear. A progressive alternative to the Harper government and ambitious investment plans will be possible only if some part of the massively eroded fiscal capacity of the federal government is restored. Andrew Jackson is adjunct research professor in the Institute of Political Economy at Carleton University, and senior policy adviser to the Broadbent Institute.

Yet a glance at the actual data shows that the unemployment rate has been steady at 6.8 per cent for several months - an enviably low rate that most countries around the world would kill for. Another bogus Unifor claim is that the federal government has cut health care transfers to the provinces by $36 billion. In fact, the feds have merely reduced the rate of growth of health care transfers from an unsustainable 6 per cent per year to a more realistic 3 per cent per year, still well in excess of inflation. Facts show that the federal government will transfer $34 billion to the provinces this year for health care, which represents 23 per cent of provincial health budgets, up from 15 per cent in the late 1990s. Over the past decade federal health transfers have increased 70 per cent - hardly a pittance. These fabrications are only two of the many whoppers in the Unifor ads.

In addition to reiterating the false claims of Unifor concerning health care spending and other issues, the unionbacked group Engage Canada, which interestingly is an alliance of Liberal and New Democratic Party interests, has made other inaccurate claims in its advertising. For instance, they say tax measures introduced by the federal government will merely benefit the rich. To choose one of these tax measures, the enhanced contribution limits for Tax Free Savings Accounts (TFSAs), the facts show quite the contrary. Currently about half of Canadians have TFSAs, and 60 per cent of those who have maxed out their TFSAs earn less than $60,000 annually - hardly the rich. Also, TFSAs are a great tool for older Canadians for whom RRSPs are no longer useful.

Another falsehood promoted by the left is that Canada has a pension crisis with a majority of Canadians not saving enough for their retirement. As noted by knowledgeable professionals such as tax expert Jack Mintz of the University of Calgary and Morneau and Shepell actuary Fred Vettese , no such crisis exists.

Facts indicate that most Canadians are well prepared for retirement and do not need another forced savings plan such as higher CPP premiums or the very flawed Ontario Retirement Pension Plan promoted by the Ontario government. The motivation behind the unions' and other left groups' advocacy for more forced savings is that it will mean more taxpayer funds in government hands to spend on even higher pay and benefits for government workers and more funds for pet government programs.

All political parties are campaigning for the middle class vote in this election, as is always the case since that is where most votes are. Recent results from a study conducted by the New York Times, as well as information from other sources, show that the Canadian middle class is currently the most prosperous in the world. In the last couple of months, an annual analysis from the international Reputation Institute concluded that in 2015 Canada is the most respected nation in the world, with the best reputation. Not too shabb

So why all of the fabrication and dishonesty from our brethren on the left? One reason is that the left always thrives on misery and, despite facts to the contrary, must constantly tell people they are doing badly, should be doing better, are ill-treated, etc. This is true no matter which political party is in government. Look no further than our very wellpaid and entitled teachers in the public school system, who constantly whine about how "disrespected" and poorly treated they are while earning very generous salaries, having lots of time off, retiring early and having one of the best pension plans around.

Another key reason is that the money behind all of these leftist groups is largely coming from unions, and most Canadian union members these days are government workers. It is hardly surprising that the ads of the Public Service Alliance of Canada are claiming that services are suffering because of cuts in the number of federal workers. Yet once again, a quick look at the facts show that there are still more federal government workers today than there were in 2006 when the current government was initially elected. It is completely understandable that government unions want more government employees and therefore more union dues in their coffers, but the 80 per cent of Canadians who do not work for government should realize that they are hurt when government unions prevail.

Interestingly enough, whenever I get into a debate with union folks about all of the horrendous things the current federal government has supposedly inflicted on the Canadian people, I always ask them one question, which is "Where in the world would you rather live?" Tellingly, I have not ever gotten an answer to that question. And perhaps that is answer enough.

Catherine Swift is Spokesperson for Working Canadians. www.workingcanadians. ca, @WorkingCdns

The penalties are assessed on a dollar-for-dollar basis, meaning they are equal to the amounts patients complained about paying for procedures. B.C. and Newfoundland were the only provinces assessed penalties for the last three years. When the 2013-14 annual report comes out soon, B.C. will once again be penalized, this time $224,000, said provincial Health Ministry spokesman Ryan Jabs.

Since 1994, the federal government has docked B.C. $3.2 million, slightly lower than the record-holder Alberta ($3.6 million). Since 1994, provinces have been assessed nearly $10 million in penalties for extra billing charges. A Health Canada spokesman could not explain why Quebec has never been penalized, even though it reportedly has a thriving private medicine sector. Ontario has also not faced any penalties.

The penalty to B.C. is paltry in relation to the province's $20-billion health budget announced Tuesday. It is also insignificant relative to the federal transfer payments B.C. will collect this year ($4.4 billion) and next ($4.7 billion). In 2006, the then-deputy health minister of B.C., Penny Ballem (now Vancouver city manager) questioned whether B.C. was really the only province where extra billing and private sector queue jumping was taking place. Jabs said Wednesday he can't comment on what happens elsewhere.

In 2005, the B.C. government did not submit a dollar value to the federal government for such extra billing, so Health Canada bureaucrats based the penalty sum on news releases from anti-privatization unions and newspaper clippings about patients who accessed the private system. The Sun learned about that through a Freedom of Information request. The story detailed how discretionary the penalties appear to be and that they are based on "guesstimates" of user fees. Provincial Health Ministry officials often base their reports submitted to the federal government on complaints from patients who go to private clinics for expedited care and then try to collect the fees paid from government. One such patient is Mariel Schoof, who had sinus surgery at a private clinic in 2003. She paid $6,150 for the "facility fee" and then tried to recover the fee from the provincial government or the clinic. She is now one of the interveners in a private versus public medicine trial starting March 2 between Dr. Brian Day and the provincial government. Timeline of Canada Health transfer compliance in B.C.

Early 1990s: As a result of a dispute between the British Columbia Medical Association and the B.C. government over compensation, several doctors opt out of the provincial health insurance plan and began billing their patients directly, some at a rate greater than the amount the patients could recover from the provincial health insurance plan. May 1994: Canada Health deductions began and continue until extra-billing by physicians is banned when changes to B.C.'s Medicare Protection Act come into effect in September 1995. In total, $2,025,000 was deducted from B.C.'s cash contribution for extra billing that occurred in the province between 1992-1993 and 1995-1996. These deductions were non-refundable, as were all subsequent deductions. January 2003: B.C. provides a financial statement in accordance with the Canada Health Act Extra-billing and User Charges Information Regulations, indicating aggregate amounts charged with respect to extra billing and user charges during fiscal 2000-2001 totalling $4,610.

Accordingly, a deduction of $4,610 was made to the March 2003 federal transfer payment. 2004: A $126,775 deduction was taken from B.C.'s March 2004 Canada Health Act payment, based on the amount of extra billing estimated to have been charged during the 2001-2002 fiscal year. Since 2005: $786,940 in cash transfer deductions have been taken from B.C.'s federal health transfer payments on the basis of charges reported by the province to Health Canada. January 2011: Vancouver General Hospital begins charging patients a fee when they elect to have robot-assisted surgery versus the conventional surgical alternative for certain medically necessary procedures. 2013: Deductions in the amount of $280,019 are taken from the March 2013 federal transfer payments of B.C. in respect to extra billing and user charges for insured health services at private clinics. Source: Canada Health Act Annual Report 2012-2013

The branch investigates about 30 cases a year of extra billing, usually related to private surgical facilities or expedited visits to specialists. The government is not sure whether it will be penalized in the future for allowing Vancouver General Hospital to charge patients fees for robotic surgery. VGH spokesman Gavin Wilson says since 2012 patients choosing to have surgeons remove their prostates using the robot have been charged on a partialcost-recovery basis. The B.C. government allows the extra billing because robotic surgery is discretionary, not medically necessary, and there are higher costs associated with it. In 2012, however, Health Canada began examining the Canada Health Act implications of patient charges for robotassisted surgeries. The process convinced the health minister that VGH should stop charging for robot-assisted surgeries as of Jan. 1, 2015. Vancouver Coastal Health collected $345,000 a year for the procedures; most recently, the patient fee was $5,700. Sun health issues reporter pfayerman@vancouversun.com

It also exercises many responsibilities that affect health outcomes. Here are important examples. The federal government regulates the marketing of drugs. What could it do to contribute to cost control in that area? Are there ways the federal government could use its considerable health research dollars to support health-care reforms? As the Canadian population ages, the use of health technology will cost more. Here again, the federal government has some jurisdiction. What about health costs and health outcomes for first nations?

Process matters in federal-provincial relations. A federation is about rules and process. In this case, why does it matter? Because federal involvement in health care is necessary and can be achieved only with co-operation. Even if one rejects the use of the federal spending power to influence health-care delivery, the federal government holds many levers that affect health-care costs directly.

Co-operation in these areas might be more fruitful than in areas where the federal comparative advantage is not strong.

André Juneau, director of the Institute of Intergovernmental Relations at Queen’s University, is a former federal deputy minister

The federal government is the fifth of six of the largest health-care providers in the country," said the University of Victoria social policy professor. "It's a major health-care provider and player in its own right and bringing the government of Canada to the table is going to be very helpful." Philpott said in a statement that combining the negotiating power of federal, provincial and territorial governments achieves greater savings for all publicly funded drug programs, increases access to drug-treatment options and improves consistency of pricing across Canada.

Federal health plans provide drug benefits to First Nations and Inuit, the RCMP, the Canadian Forces, veterans, federal inmates and refugee protection claimants, totalling $630 million in drug-related spending in 2014. The pan-Canadian Pharmaceutical Alliance has completed more than 89 negotiations on brand-name drugs and price reductions on 14 generic drugs, producing a savings of more than $490 million annually. British Columbia Health Minister Terry Lake said federal government participation greatly enhances the strength and purchasing power of the alliance. "That's what we want," he said. "The more the merrier."

Polls show Canadians overwhelmingly support these conditions. Medicare's key limitation, however, is that it applies only to services offered by doctors and hospitals. It does not apply to home care. Increasingly, provincial governments are trying to save money by encouraging acute-care hospitals to discharge patients as quickly as possible. In most provinces, these patients find themselves reliant on badly underfunded home-care services. Unlike hospital care, such services are usually neither comprehensive nor universal. As an Alberta oil worker with incurable cancer found when he tried unsuccessfully to come home to Ontario to die near his family, they are not even portable. Ontario pays $3 billion on home care each year. But Queen's Park saves more than that in foregone hospital and nursing home costs. In that sense, home care is a revenue tool. It allows provincial governments to evade the spirit, if not the letter, of the Canada Health Act. In Ontario, as my Star colleague Bob Hepburn has pointed out, the results are sometimes absurd. When the provincial Liberal government boosted wages for badly paid home-care workers earlier this year, some cost-conscious agencies responded by cutting services. In the weird world of Canadian health care, it was the logical thing to do. But there is a way to fix the home-care anomaly. Roy Romanow's royal commission on health care pointed to it 14 years ago.

Romanow argued it made no sense to exclude home care from medicare. He recommended home care services for the mentally ill, for patients just released from acute care hospitals and for those needing palliative care be written into the Canada Health Act immediately. By 2020, he said, all home care services should be covered by medicare. Interestingly, federal Health Minister Jane Philpott is also focusing on home care, mental health and palliative care. How would she get the provinces onside? Many assume a final deal over medicare spending can be hammered out only by the first ministers meeting in a marathon bargaining session - as happened in 2004. In that session, the premiers ran roughshod over then Prime Minister Paul Martin. Quebec demanded and received the principle of asymmetric federalism - that it could do whatever it wished with the massive health transfers Martin was offering. Alberta then demanded and received the principle of provincial equality - which meant any province could mimic Quebec. As a result, no real conditions applied to any of the money Ottawa agreed to hand over.

This is one way of doing things. The other is for Ottawa to ignore provincial objections. That's what Lester Pearson's Liberal government did in 1966 when, in concert with the New Democrats and over the strident objections of Ontario, Quebec, Alberta and the federal Conservatives, it passed Canada's first national medicare act. The Canada Health Act is the successor to that 1966 law. It is a federal statute that can be amended unilaterally by Parliament. In 2016, it makes sense that it be amended to include home care as a core medicare service. Some provinces may disagree. If so, they won't have to take any extra money that Ottawa puts on offer. Thomas Walkom's column appears Monday, Wednesday and Friday.

The PBO report estimates that the new health formula – which accounts for economic growth and inflation – will cause transfers to grow at 3.9 per cent annually from 2017-18 to 2024-25. In contrast, the watchdog projects provincial and territorial health spending will grow at 5.1 per cent over the same period.

a spokesman for Mr. Flaherty, disputed the PBO’s claim that provincial and territorial health spending will grow faster than the growth in federal transfers.

The budget officer states provincial-territorial net debt relative to GDP “is projected to increase substantially over the long term.” While the ratio stood at 20 per cent of GDP in 2010-11, the PBO expects that will now climb to over 125 per cent in 2050-51 and to over 480 per cent by 2085-86.

Closing this gap, according to the PBO, would require provinces and territories to take a combination of actions such as higher taxes or lower spending that would amount to $49-billion in 2011-12 - an amount that will grow over time in line with nominal GDP - in order for Canada’s finances to be sustainable.

The PBO report also analyzes the impact of Ottawa’s new transfer arrangement in terms of what it will mean for Ottawa’s contribution toward overall health spending. In 2010-11, the federal share of health spending was 20.4 per cent. The PBO projects the federal share will average 18.6 per cent from 2011-12 to 2035-36, then 13.8 per cent over the following 25 years and 11.9 per cent over the next 25 years.

Historically, federal health transfers averaged about 37 per cent of health spending from 1968-69 to 1995-96. That dropped sharply during the deep budget cuts of the Liberal government in the mid-1990s, hitting 16.3 per cent in 1995-96 and reaching an all-time low of 9.8 per cent in 1998-99.

It's not hard to figure out why the Naylor report displeased the government. The panel was given a difficult, bordering on impossible, job: recommend innovations without Ottawa spending any more money. The panel's mandate read that recommendations "must not imply either an increase or a decrease in the overall level of federal funding for current initiatives supporting innovation in health care."

The Naylor panel ignored the mandate, explaining in its report that "although it was not an easy decision, we did not follow this guidance." Later, it warned that "absent federal action and investment, and absent political resolve on the part of provinces and territories, Canada's healthcare systems are headed for continued slow decline in performance relative to peers." To that end, the panel recommends creating a health innovation fund with a $1-billion yearly budget to invest in changes to the health-care system in conjunction with willing provinces and health-care institutions.

Such a fund would be just about the last thing the Harper government desires. This government is running on balancing the budget. Adding $1-billion a year in spending would not be what the government wants. Such an investment fund would have little political profile - nothing as sexy as, say, national pharmacare (which the panel cursorily debunked). It would also run the risk of provoking premiers who screamed in St. John's for more cash transferred from Ottawa to them, without strings attached.

For 2017-18, the federal government has announced it will reduce the increase in Ottawa's annual health-care transfer to the provinces from 6 per cent to something in the range of 3 per cent to 3.5 per cent, depending on economic growth. The provinces would likely not appreciate losing money from Ottawa with one hand, and then getting some, but only some, of it back through the innovation fund. The Harper government was hoping for change-on-the-cheap from the panel: innovation that would cost nothing but improve the system. It certainly has no interest in an expanded, direct federal role in health care, having made it abundantly clear that health care is for the provinces, except for Ottawa's responsibility for aboriginal and veterans' health, public health and drug approvals.

Moreover, provincial health budgets are rising on average now by only 2 per cent a year, compared with 7 per cent a decade ago, far below the 6-per-cent increases in transfers still coming from Ottawa. The premiers would love the transfer to return to 6 per cent, as would the federal New Democrats. That would be the single dumbest move any federal government could make, given the lamentable experience of the 2004-11 period, when money gushed out of Ottawa but bought little improvement in the healthcare system. The Naylor panel noted, as have many observers, that the money improved things for providers, but not for many patients.

The Naylor report covers all the ground about the manifold weaknesses and sturdy strengths of the Canadian system compared with other countries. It hails, quite rightly, some aspects of the U.S. system, especially the coordinated care of the best health organizations such as Kaiser Permanente.

Its broad recommendations, however, are dead on arrival in Mr. Harper's Ottawa, which is why the report slid into the public domain with such little notice.

"I don't see how we can go another four years with this government, frankly. The past nine years have been disastrous in terms of us as First Nations accomplishing what we set out to do for our peoples. A lot of that has to do with the failure of First Nations policy in this country," said Ghislain Picard, the AFN's regional chief for Quebec and Labrador. Rarely has First Nations anger translated into such pragmatic talk, but aboriginal leaders will have to change a political culture that has traditionally shied away from involvement in federal and provincial politics with just three months left between now and the Oct. 19 election. "I know these are not our governments, but this is a strategic vote," said Grand Chief Patrick Madahbee of the Union of Ontario Indians, which represents 39 First Nations in the province.

Madahbee criticized Prime Minister Stephen Harper for signing trade deals that involve resources pulled from the land without the consultation or agreement of First Nations. But such complaints will receive little traction with federal parties if aboriginal people maintain their low-rates of election participation, he said. "The Indo-Canadians, the Chinese Canadians ... There's a whole number of groups that have learned that already. They have mobilized and they have influence. Right now we're being ignored." Bellegarde said the AFN is looking for politicians to implement the recommendations of the Truth and Reconciliation Commission, call an inquiry into the large numbers of missing and murdered aboriginal women and end a 20-year funding freeze for aboriginals that has contributed to problems with aboriginal health, housing and education that other Canadians never have to experience. "Invest in the fastest-growing segment of Canada's population, our young men and women. Invest now and there will be huge rates of return on investment in the future," Bellegarde said.

Both New Democratic Party Leader Tom Mulcair and Liberal Leader Justin Trudeau spoke at the AFN meeting Monday and committed to improving the relationship between the federal government and aboriginal people. Both noted the fact that they had prominent and numerous aboriginal candidates who will be running for their parties in the next election. "Aboriginal Canadians have understood for 10 years now what happens when their voices are not heard by the political process, when they are written off as they are by this Harper government," said Trudeau.

It's a hopeful sign for Tyrone Souliere, of the Garden River First Nation in Sault Ste. Marie, Ont., who has taken it upon himself to lobby chiefs and band councils to get their people registered to vote in the October election. Founded in frustration with the federal Conservative government, Souliere estimates there are some 30,000 eligible aboriginal voters in Ontario alone who could be harnessed to advance the cause of indigenous people in the coming election campaign. His efforts are focused on educating eligible voters about the issues and on what they steps they need to take to ensure they can cast a ballot in the election, following changed to the Elections Act that place higher standards on what can be used to confirm one's identity. "The only way to change how the government treats us is to change the government and to get that message to the politicians that there's a block of votes in Indian country and it will be available to the one party that will best represent treaty, charter and indigenous rights in Parliament," Souliere said.

"That's the goal." What the leaders say Tom Mulcair promises: Every government decision will be reviewed by a cabinet committee to ensure they respect federal responsibilities toward aboriginal people. Increasing federal funding for aboriginal education so that it rivals that spent on non-aboriginal children in Canada. Federal environmental assessments for resource development projects will become more rigorous. Justin Trudeau promises

There will be a legislative review that scraps or amends laws dealing with aboriginals that are deemed to be a violation of a section of the Constitution that affirms aboriginal rights. A guaranteed annual meeting between the prime minister and First Nations leaders. The 2-per-cent freeze on aboriginal funding will be lifted to make more money available of the likes of education, health and housing.

St. Albert physician Dr. Darryl LaBuick said while a bit more money for home care will help the situation, it barely scratches the surface in addressing the biggest issues facing healthcare in Canada. "We've got a huge increasing requirement for seniors care. We look at home care, we look at long-term care, we look at assisted living care, palliative care," he said. "We look at all those areas nobody has looked at closely from a political point of view to address some of the issues." The importance of home care is something stressed by Dr. Kim Fraser, a nursing professor at the University of Alberta and expert on the topic.

She said while seeing the commitment to improve home care in the province is a step in the right direction, simply throwing more money at the problem won't be enough. Instead, we've got to rethink how home care in Canada is provided. "Co-ordinated home care programs first came into effect in the late '70s and 1980s in Canada, and our approach to home care has not changed since that time," she said. "It's really kind of episodic, targeted, taskspecific care rather than a more comprehensive integrated care approach." So rather than simply having more home-care aides providing this kind of task-oriented service to patients in their home, we should look at providing a higher level of care to patients with more complex needs.

"We have got just so many more patients going into that system," she said. "I think funding will help the growing home care problem, and will help provide, perhaps, more professional nursing services from RNs and LPNs in the community." Alberta Health Minister Sarah Hoffman said she was pleased to see the commitment to home care on the federal agenda, noting it was one of the main pieces of the NDP platform with respect to the healthcare system. "Home care is certainly one of the pieces we're focusing our effort on as a government, and I look forward to working with the new federal government to make that a reality," she said. When pressed for specific details about what form home care may take, she said she couldn't talk about specifics until they're released as part of the provincial budget next week.

"The pillars of the platform should be reflected in the work we're doing," Hoffman said. LaBuick also identified the importance of a national drug strategy that would cover the cost of prescriptions for all Canadians. Seniors still must pay a portion of prescription drug costs, and many young adults without health benefit plans are left in a position where they must pay the full cost or simply go without; it's something he's seen in his own practice. "We see young folks that don't have a good prescription plan, or any prescription plan," he said, "And the Blue Cross plan doesn't cover everything either, so there's gaps within that system, too."

It's a concern echoed by Friends of Medicare director Sandra Azocar, who spoke with the Gazette prior to the election and said a national drug plan was high on her organization's agenda. She expressed concern that the Trans-Pacific Partnership, a trade deal negotiated by the previous government behind closed doors that has yet to be approved by Parliament, could make it more difficult to get cheaper generic drugs. "We see that as having a negative impact for generics to be available in the market, and people will pay significantly more for drugs," she said. "I don't think medicine should be a luxury, it should be available for all people who need it. These are huge concerns we have." Hoffman said bringing down the cost of prescription drugs is something she's heard is important to Albertans, but is also significant within her own ministry when it comes to budgeting. She said a provincial prescription drug plan is something worth considering, but it's not going to happen in the near future.

"I think it's a great long-term objective, but in the short-term I need to address the immediate pressures of drug costs," she said. "I think we can find ways to do bulk buying and find other efficiencies in a pan-Canadian strategy, and look at other partnerships in taking it further so we can maximize those savings and pass those savings on for an increased benefit to all Albertans." Health Accord Azocar identified the need to renew the Canada Health Accord as an important component of what the federal government must do to support healthcare in the country.

"We need to go back to the level of leadership in our healthcare system for it to be functional all across the country," she said. "That's not something we've seen coming from some of the parties." The Liberal platform includes a commitment to renew the waccord, and to include a long-term funding agreement. This is a crucial element, Azocar noted, because in tough economic times federal funding in health care tends to decrease to the detriment of Canadians. "People don't stop needing health care when the economy is down, in fact it's the reverse," she said. "Studies have shown people need more services when the economy is down, so it's a situation that doesn't play well for the sustainability and the long-term planning that health care needs across the country."

Hoffman said she's unsure what negotiating a new accord might look like, as she hasn't been through the process before, but said it's something she looks forward to working on with the federal government. "We were elected not too long ago and they were elected more recently, and I think Albertans deserve to have the very best public health-care system," she said. "I look forward to working with the federal government to make that a reality." Elephant in the room One element of the discussion around health care that is absent and has been for quite some time, LaBuick suggested, is the "elephant in the room" of increasing private delivery as a way to reduce the budget impact of health care. "The minute we start to talk about it, they catastrophize the whole conversation," he said. "The reality is we need to talk about it because we simply can't afford it."

He noted roughly 30 per cent of health care in Canada is already provided privately - things like dental, vision, psychology, and private insurance plans. Furthermore European countries that blend public and private have better outcomes. LaBuick suggested the way forward is to look to European models that provide universal health care with a blend of public and private delivery - many of which have better outcomes at a lower cost than the Canadian model. He's not optimistic, however, that a federal Liberal government or provincial NDP government will engage in that discussion.

We have all of these areas that are private, but nobody talks about it," he said. "Nobody talks about a strategy around how it can benefit all citizens, for the betterment of everybody."

Health Canada’s annual reports show that Quebec has sometimes complied with its concerns. But in its 2003-2004 report, the agency observed that the Quebec government was “not at liberty to reveal the status of the province’s investigation” into user charges imposed by a private surgical clinic. A year earlier, Health Canada expressed concern “about private surgical clinics that allow individuals to privately pay for medically insured services and thus jump the queue. … Health Canada asked Quebec to confirm that the matter had been resolved.” A long-standing complaint of Quebec by Health Canada is that it allows patients to be charged for MRIs and CT scans if they are done in private clinics. In its 2004-2005 report, Health Canada held discussions with British Columbia, Alberta and Nova Scotia about charging for medical imaging in private clinics, but Quebec refused to participate. 

Health Canada officials did not respond to requests for an interview since last Thursday. Reacting to the Quebec lawsuit last week, federal Health Minister Jane Philpott said she’s a strong supporter of the CHA, and did not rule out reducing transfer payments to provinces that flout the law.

Equally concerning, wait times are defined here as the interval between seeing a specialist and receiving treatment. But that doesn't count the growing delay most patients face before they meet a specialist. Ottawa isn't impressed. Second, there are indications the federal government wants to strike out on its own. Prime Minister Justin Trudeau's health minister, Jane Philpott, has said she's "not convinced" that putting more cash into the accord is the right way to go.

She believes federal funds should be used instead to boost home care, mental-health services and palliative care. And that has infuriated the premiers. Constitutionally speaking, they are responsible for health-care delivery. Yet here we have a federal minister suggesting she wants to steer the ship.

The provinces have already signalled this means war. Quebec Premier Philippe Couillard and B.C. Health Minister Terry Lake, will lead a spirited defence against further intrusions into provincial jurisdiction. And they have a case to make. When universal health care was first introduced in Parliament, the provinces feared that any such commitment would ruin them. The federal government met that concern by pledging to fund half the costs.

But that isn't what happened. Today, Ottawa pays only a quarter of the bill, and that bill is rapidly rising. In 1975, health expenditures, countrywide, were less than $50 billion. Today, they've reached $230 billion, and these are constant dollars, adjusted for inflation. The result is that, as federal cost-sharing declines, the provinces are struggling to make up the shortfall.

In 2013, more than 12,000 jobs in health care and social assistance were eliminated in B.C. That is one symptom of the emerging crisis. There are many more: Too few GPs, unacceptable wait times to see a specialist, crowded hospital emergency departments. If Philpott chooses to redirect the remaining federal cash to new priorities that will create additional strains on the system, fur will fly.

The minister's desire to steer funding into neglected areas of care is admirable. But first, she needs to get the ship off the rocks. Adding more ballast to a foundering vessel is no solution. Certainly Philpott is in a stronger position than Paul Martin, whose minority government hung by a thread when the first accord was negotiated. But the need for federal assistance is growing clearer, and more urgent. Our health-care program was a uniquely Canadian creation. The government of Canada has an obligation to step up and save it.

To download all those tasks to the provinces would risk turning many Canadians into second-class citizens.

"The big, rich provinces can do it, [but] with what consequences? The small, poor ones cannot; at any rate without massive help from that central government which [further decentralization] would enfeeble."

As my father regularly pointed out, the BNA Act (now the Constitution Act, 1867), gave the Dominion government broad powers "to make laws for the Peace, Order and Good Government of Canada," embracing all matters – foreseeable or otherwise – that were not "assigned exclusively to the legislatures of the provinces."

     Federal jurisdiction has been chipped away since then

despite those rulings, the federal government retains its powers in many fields, and shares jurisdiction with the provinces in a number of others

  To further limit or eliminate the federal spending power would severely disrupt the practical balancing mechanisms that characterize Canadian federalism. It would also go against the principles of fairness and welfare (or well-being), which are inherent in the Canadian tradition.

Section 36 of our repatriated Constitution Act, 1982, which explicitly states a shared commitment to:

"(a) promoting equal opportunities for the well-being of Canadians; (b) furthering economic development to reduce disparity in opportunities; and (c) providing essential public services of reasonable quality to all Canadians.”

radically decentralist goal

"instead of sending money to the provinces, Ottawa would cut its taxes and let them use the fiscal room that has been vacated.”

this is the position of “two of the greatest conservative statesmen of our generation, Preston Manning and Mike Harris,” as well as of the Fraser Institute

     Bernier's portrayal of Macdonald, Cartier, and the rest as avid provincialists is thoroughly debunked in Dad's popular and authoritative handbook How Canadians Govern Themselves

cite the historical record to show that our country was intended from the start to be "a real federation, a real 'union,' "une grande et puissante nation," not a league of states or of sovereign or semi-independent provinces."

"Only a real country," he said, "with a powerful national Government and Parliament, can have any hope of controlling inflation and restoring full employment. Only a real country can maintain the unemployment insurance, the family allowances and child tax credits, the Medicare, which we now enjoy. Only a real country can give the people of the poorer provinces anything like modern educational and social services."

deteriorating patchwork of policies and programs that weaken the system and aggravate disparities between provinces

we have three recommendations

Patient-centred care, inter-professional care and comprehensive care are all things that deserve and require additional investment and attention.

We need a pan-Canadian human resources for health observatory function to provide evidence and data on which to plan. Our workforce science in Canada is at a very primitive stage, and we are lurching from one crisis in one locality or one specialty to another.

The second recommendation

Our third recommendation

Canada needs an injury prevention strategy to elevate in the public's attention and bring resources to bear to reduce needless injuries in our life. The reason for this is that injuries cause a lot of loss of life, disability, long-lasting disability and painful disability, and they cost a lot of money.

Jean-François LaRue, Director General, Labour Market Integration, Human Resources and Skills Development Canada

foreign credential recognition

Marc LeBrun, Director General, Canada Student Loans, Human Resources and Skills Development Canada

Canada student loan forgiveness for family physicians, nurses and nurse practitioners, as introduced in Budget 2011

Robert Shearer, Acting Director General, Health Care Programs and Policy Directorate, Strategic Policy Branch, Health Canada

in 2004 the federal government committed to the following: accelerating and expanding the assessment and integration of internationally trained health care graduates across the country; targeting efforts in support of Aboriginal communities and official language minority communities to increase the supply of health care professionals in these communities; implementing measures to reduce the financial burden on students in specific health education programs, in collaboration with our colleagues in other federal departments; and participating in HHR planning with interested jurisdictions

Canada does not have a single national health human resources plan

Health Canada plays a leadership role in HHR by supporting a range of targeted projects and initiatives of national significance.

Pan-Canadian Health Human Resource Strategy

Internationally Educated Health Professionals Initiative

Health Canada supports collaborative efforts as co-chairs of the federal-provincial-territorial Advisory Committee on Health Delivery and Human Resources known as ACHDHR. This committee was created by the conference of deputy ministers of health back in 2002, to link issues of primary health care, service delivery and HHR.

ACHDHR will be providing a written brief

The federal government also participates on ACHDHR as a jurisdiction that directly employs health care providers and has responsibility for the funding and delivery of certain health care services for populations under federal responsibility, such as First Nations and Inuit, eligible veterans, refugee protection claimants, inmates of federal penitentiaries, and serving members of the Canadian Forces and the Royal Canadian Mounted Police.

Shelagh Jane Woods, Director General, Primary Health Care and Public Health Directorate, First Nations and Inuit Health Branch, Health Canada

Dr. Brian Conway, President, Société Santé en français

account for over a million Canadians who need access to quality health services in their own language.

Acadian and francophone communities outside Quebec

Senator Eggleton

I am interested in the injury prevention idea. We hear of it from time to time. Do you have some specific thoughts on what an injury prevention program or strategy might look like and how it might fit in with the health accord? One of the things the Health Accord brought about in 2004 was the federal government saying to the provinces, “If you do this and you do that we will give you money here and there.” Maybe we should be doing that here. Maybe we should ask the federal government to provide an incentive for the provinces to be able to do something. It would be interesting if you could come up with a vision of what that strategy might look like.