On Tuesday in Ottawa, CanadaB次元官网网址檚 13 premiers and Prime Minister Justin Trudeau will sit around the same table in person for the first time since COVID-19 hoping to find a path toward a new long-term health-care funding deal.
Both sides are optimistic a deal will emerge but there are some big divides to overcome, including how much more money Ottawa is willing to put on the table, and how much accountability the provinces are willing to put up in return.
The premiers have been asking for a new deal for more than two years. Trudeau kept punting until the COVID-19 crisis was largely over.
That time has come.
Trudeau has been clear a deal is not going to be finished this week. But hereB次元官网网址檚 a snapshot of how we got to this point, and what theyB次元官网网址檙e going to be talking about.
Money, Money, Money, Money
This year Canada expected to transfer almost $88 billion to the provinces and territories for health, education, social supports and equalization. The Canada Health Transfer, or CHT, is $45.2 billion, or 51 per cent of that.
In their 2022-23 budgets, the provinces collectively forecast to spend $203.7 billion on health care. OttawaB次元官网网址檚 transfer accounts for 22 per cent of that. The provinces want that increased to 35 per cent, which would mean $26 billion more this year alone.
B次元官网网址淭hereB次元官网网址檚 been continual demands for an increase in the CHT although IB次元官网网址檝e never seen quite as large a demand for an increase as this one,B次元官网网址� said Gregory Marchildon, a professor emeritus at the Institute of Health Policy, Management and Evaluation at the University of Toronto.
Trudeau intends to put an offer on the table Tuesday. It will not be an immediate increase of $26 billion, but Ottawa has been silent on where it will land.
While it has existed in its current form only since 2004, some sort of federal health transfer dates from 1957, when Ottawa offered 50-50 funding for health care to provinces that agreed to provide public hospital services based on national standards.
It has evolved and changed at least five times since then, including splitting the federal share between cash and a transfer of tax points B次元官网网址� when the federal government cut its income tax rates and the provinces could raise their own in exchange.
In 1995, then-finance minister Paul Martin, desperate to turn around CanadaB次元官网网址檚 debt problems, slashed the health and social transfer by 20 per cent, followed by a 15 per cent cut in 1996. Some provinces have said their health systems have never recovered.
In 2004, a new deal was reached between the premiers and Martin, who by then was prime minister, to see the Canada Health Transfer increased six per cent a year for a decade.
The Conservatives under prime minister Stephen Harper kept that in place, but told the provinces that in 2017-18, the CHT increase would be based on a three-year average of economic growth, but with a minimum increase of at least three per cent.
Trudeau and the Liberals have maintained that.
With economic growth, the annual CHT increase has averaged five per cent since 2017-18.
Over the last 10 years, the CHT has increased 67 per cent, to $45 billion from about $27 billion in 2012-13.
An attempt in 2016 to negotiate a new CHT deal mostly failed, resulting in one-on-one agreements between Ottawa and the provinces and territories to share $11.5 billion over 10 years, beginning in 2017-18, to improve mental-health and home care.
Angling for Accountability
In the split jurisdictional world CanadaB次元官网网址檚 governments live in, provinces are the ones who control health-care delivery. So for the most part, the federal government helps fund it and the provinces get to say how itB次元官网网址檚 spent.
The Canada Health Act, passed in 1984, sets out the guiding principles for recipients of the Canada Health Transfer, including that health-care systems must be universally accessible. Failing to abide by the principles can, and has, resulted in Ottawa clawing back some transfers.
Trudeau has made clear any increase to federal health transfers must be met with provincial accountability to show results. The federal government has been frustrated at the lack of accountability from provinces over transfers for health care made during COVID-19.
It is adamant that will not be the case with a new funding deal, and is looking at a combination of an annual increase to the CHT and separate deals to target specific problem areas, like health-care worker retention and training, access to family doctors, surgical backlogs, and data collection and sharing.
The 2017 deals on mental-health and home care will be a bit of a model. Those deals saw Ottawa promise $11.5 billion over 10 years for the two areas, but in exchange provinces had to agree to a common set of principles and goals, and to report results.
The Canadian Institute for Health Information was tapped to help collect and publish data. The most recent report in December is still laden with gaps and incomplete data. The reports note it will take time for the reporting to lead to change, and that provinces need to harmonize their data collection in order to better compare statistics across provincial lines.
Marchildon said one of the biggest problems for the federal government in demanding accountability is that measuring health outcomes is difficult, and hard targets are rare.
ItB次元官网网址檚 all about the numbers
Of course, itB次元官网网址檚 difficult to measure progress if youB次元官网网址檙e not keeping track.
Data B次元官网网址� or the lack of it B次元官网网址� is a long-standing weakness of CanadaB次元官网网址檚 federalized system, with 13 separate health-care systems working alongside one another but not necessarily in tandem.
In his first public overture to open negotiations with provinces on health funding in November, Health Minister Jean-Yves Duclos told provincial health ministers the federal government would increase the Canada Health Transfer if provinces agree to work together on a B次元官网网址渨orld-class health data system for Canada.B次元官网网址�
B次元官网网址淚t is the foundation for understanding what weB次元官网网址檙e doing, whoB次元官网网址檚 receiving services, whether weB次元官网网址檙e making improvements,B次元官网网址� said Kim McGrail, a professor with the University of British Columbia School of Population and Public Health.
McGrail was one of several experts the federal government tasked with reporting on what a B次元官网网址渨orld-class health data systemB次元官网网址� would look like in Canada.
Gaps in CanadaB次元官网网址檚 data tripped up the national health responses in dozens of different ways during the pandemic, from tracking the number of COVID-19 cases to reporting adverse effects from vaccines.
The same is true of tracking surgical backlogs and other information about how well, or not, the health system is working.
B次元官网网址淒ata informs every part of the way we think about health,B次元官网网址� McGrail said, which includes the health of individual patients.
Canadians who move from one province to another canB次元官网网址檛 easily access their records because the technology isnB次元官网网址檛 compatible.
ItB次元官网网址檚 a problem that exists even within provinces, as incompatible technology makes records inaccessible between hospitals and clinics.
B次元官网网址淲e need those technology systems to be able to talk to one another, to be able to to move data back and forth or to send messages back and forth in some way,B次元官网网址� she said.
ItB次元官网网址檚 an expensive problem to fix. Just last week, Nova Scotia government signed a $365-million contract to bring new electronic health-care records to the province, which may or may not be compatible with other provincial systems.
McGrail said investments will pay off if important information about the health of Canadians stops falling through the cracks.
The expert panel delivered a report last year that will likely serve as a road map for improving data sharing in Canada. It includes 31 recommendations, starting with provinces, territories and the federal government agreeing on a shared national vision for health data.
Ontario and Quebec have indicated a willingness to work with Ottawa on data, though other provinces have been less firm about it.
Aging gracefully
Provincial leaders have been able to agree with Ottawa on the need to reform CanadaB次元官网网址檚 long-term care homes, though exactly how to accomplish that is still up for debate.
Duclos has said helping Canadians B次元官网网址渁ge with dignityB次元官网网址� is one of OttawaB次元官网网址檚 priorities for a new health-care deal, and long-term care plays a major role in that.
So does home care, and the 2017 bilateral deals already began to advance improvements on that front.
Long-term care is an entirely different story.
The pandemic cast a glaring light on the dismal conditions in care homes across the country, when COVID-19 outbreaks led to thousands of deaths and inhumane living conditions for seniors. The military and the Red Cross were summoned to help.
In the early months of the pandemic, Canada had the worst record for COVID-19-related deaths in long-term care of the worldB次元官网网址檚 wealthy countries.
Meanwhile, residents were isolated from the outside world and workers struggled to provide basic care and ensure dignity.
Experts and advocates say the problems long predate the pandemic, and have gone largely ignored until now.
B次元官网网址淕iven the devastation that weB次元官网网址檝e seen in the COVID-19 pandemic and the impacts on our health-care system B次元官网网址� weB次元官网网址檙e seeing this unprecedented moment where finally thereB次元官网网址檚 some hope of collaboration,B次元官网网址� said Dr. Amit Arya, a palliative care physician and founder of Doctors for Justice in Long-Term Care, which advocates for an overhaul of OntarioB次元官网网址檚 long-term care system.
Governments are now scrambling to improve the conditions, as the number of people who need specialized care grows every year and the number of workers willing to provide that care dwindles.
Several provinces have already announced plans to increase the number of hours of care residents receive per day and build new spaces for the growing number of seniors who are living longer with more serious cognitive and physical impairments.
The federal government created a $1 billion B次元官网网址渟afe long-term care fundB次元官网网址� during the pandemic to help pay for immediate infection prevention and control measures to stop the spread of the virus.
The government also set aside $3 billion to help provinces bring homes in line with national standards for the design and operation of long-term care, though specific agreements with provinces havenB次元官网网址檛 yet been signed to deliver that money.
Those standards were publicly released last week but are unlikely to factor into the health-care talks.
Still, there is plenty of work that needs to be done if provinces have a hope of meeting the standards, especially when it comes to the workforce.
B次元官网网址淚 think weB次元官网网址檙e stepping into a crisis,B次元官网网址� said Dr. Joseph Wong, the founder of Yee Hong Centre for Geriatric Care, the largest non-profit nursing home in the country.
He said Canada will need upwards of 100,000 new personal support workers to provide care over the next 10 to 15 years in order to provide adequate care to residents.
B次元官网网址淚t is a time bomb,B次元官网网址� he said.
Essential Workers
The same could be said of the health system at large.
None of the lofty goals of the federal or provincial politicians will be possible if they donB次元官网网址檛 find a way to persuade workers to stay in hospitals, clinics and long-term care centres across Canada, said Linda Silas, president of the Canadian Federation of Nurses Unions.
B次元官网网址淭hey donB次元官网网址檛 have the staff to do the job,B次元官网网址� she said.
Staff shortages have been the common theme among some of the most serious issues underlying the public-health crisis in Canada.
Dozens of emergency rooms have been forced to close temporarily or reduce hours because there werenB次元官网网址檛 enough staff to treat urgent injuries and illnesses. The Canadian Medical Association estimates nearly five million Canadians donB次元官网网址檛 have a family doctor. And hundreds of thousands of Canadians are sitting on wait-lists for backlogged surgeries and diagnostic tests.
Health unions and professional associations want a national strategy to keep doctors, nurses and personal support workers in their jobs as well as train new staff to bolster their ranks.
Silas said after years of burnout and moral distress over not being able to care for their patients properly, nurses in particular have said, B次元官网网址淚B次元官网网址檝e had enough.B次元官网网址�
Nurses in Ontario have also balked at a law limiting pay increases to one per cent a year.
Data from the Canadian Institute for Health Information shows that because of new graduates, the supply of nurses is still growing. However, many have chosen not to take full-time positions, and existing staff are increasingly eyeing early retirement, Silas said.
The heavier demands of the job since the pandemic, combined with fewer and fewer people to do the work, has created what even the federal health minister calls a crisis.
B次元官网网址淲e need to stop the bleed,B次元官网网址� Silas said.
Mia Rabson and Laura Osman, The Canadian Press
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