Would O'Toole's health transfers 'without conditions' conflict with universal health care?

Conservative Leader Erin O’Toole’s position on Canadian health care has been a point of debate throughout this election.

He has consistently expressed support for “public/private synergies,” praising programs like the private MRI clinics offered in Saskatchewan. He has made increasing the Canada Health Transfer amount a key part of the Conservative platform, promising no-strings-attached funding to provinces. But he has also expressed unequivocal support for Canada’s public and universal health-care system.

THE CLAIM

In last week’s English language debate, CTV News’ Evan Solomon asked O'Toole what kind of private health-care innovations he would like to see more of, and whether he would enforce the Canada Health Act by holding back funding if a province introduced more private health care.

"I 100-per-cent support our public and universal system. I've said it's paramount. And after COVID-19 we need to rebuild it. So we have the most substantive plan to do that. Six per cent increase per year, stable, predictable, without conditions, funding to partner with our provinces. We will respect them running and putting priorities to get wait times down, to give more choice for universal public access, that's what we need," O'Toole responded during the debate, but did not directly address Solomon’s questions.

Is it a contradiction to support universal health care while also pledging unconditional funding to provinces?

BACKGROUND AND ANALYSIS

The Canada Health Act was enacted by Parliament in April 1984 under Pierre Trudeau’s Liberal government. It outlines five criteria, two conditions, and two provisions provinces and territories should meet in order to receive money from Ottawa under the Canada Health Transfer.

Specifically, it says the primary objective of the Canadian health-care policy is to “protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers.”

In the fiscal year 2019-2020, provinces and territories received $40.37 billion under the health transfer. Based on 2021-2022 estimates, health care is the second largest expenditure by the government after Old Age Security payments.

Among the criteria stipulated in the act, the province’s health-care insurance plan must be comprehensive, universal, portable and accessible. “The aim of the Act is to ensure that all eligible residents of Canadian provinces and territories have reasonable access to medically necessary hospital, physician, and surgical-dental services that require a hospital setting on a prepaid basis,” the 2019-2020 Canada Health Act annual report explains.

The act grew out of a review of Canada’s health-care services and the debate that followed, which warned that extra-billing and user charges levied by doctors and hospitals were creating a two-tiered system that "threatened the universal accessibility of care."

Since the act was passed, some $10.5 million have been deducted from provinces, according to the annual report. This excludes the initial three-year transition period and other deductions that were later reimbursed.

"The Canada Health Act, what it stands for is that, in exchange for the money that the federal government gives the provinces, the provinces will comply with certain conditions. For example, no two-tiered health care," Colleen Flood, University Research Chair in Health Law & Policy with the University of Ottawa, told CTVNews.ca in a phone interview.

Flood says the Conservatives cannot support universal health care without enforcing those conditions, but noted that during the debate, O’Toole said immediately after expressing support that he would not put any conditions on the money he would give provinces.

"So there’s a contradiction between these two things. They can’t go together."

By putting money through the health transfer, you are implicitly still supposed to be protecting and enforcing the act, says Gregory Marchildon, a professor and Ontario Research Chair in Health Policy and System Design with the University of Toronto.

There are penalties associated with extra billing and user fees that are automatically triggered and non-discretionary, Marchildon said in a phone interview. These fall under the two provisions outlined in the act.

The five principles, however, are more discretionary by the federal government, he said. In the past, the federal government has asked certain practices to stop and provinces have complied, but in other cases, such as the portability criteria, Marchildon says it is questionable whether Ottawa has really enforced it. Portability allows, among other things, for emergency coverage when residents are transitioning to another jurisdiction or temporarily away from their home province or territory, but it is one that Quebec does not recognize in the same way, he explained.

Quebec has been outspoken about demanding unconditional health transfers, arguing that health-care is a provincial jurisdiction.

"There is wiggle room and there is lots of opportunity for the federal government to simply look the other way and not do anything," he said, adding that governments in general have not been overly aggressive in tackling breaches to the act.

Even so, Liberal governments have historically been somewhat more careful and more concerned about breaches than Conservative ones, he noted, pointing to the Harper government which, in his view, treated the health transfers as essentially unconditional.

Federal governments do not want a major clash with provincial governments, Marchildon said, pointing to Quebec in particular.

"The second reason though, is that the federal government is not in a great position to monitor what is going on. The provinces are supposed to be self-reporting, but it’s not really in the interest of any province to self-report any transgressions of the Canada Health Act."

All this suggests that O’Toole and the Conservatives would not enforce the act, according to both Flood and Marchildon.

"He hasn’t specified and it’s a bit perplexing what he means by this...the way I would interpret it is, he plans to send the money through the Canada Health Transfer and he has no intention of enforcing it," he said.

It also suggests that more privatization across Canada would be expected, Flood added, saying that enforcement of the act depends on the willingness of a government in power.

"They don’t have to do anything. It’s easy for them. By doing nothing, they sort of undermine or hollow out the Canada Health Act. He can say he supports it, because he’s not going to actively dismantle it," she said.

"It’s a piece of legislation that doesn’t give Canadians any rights to anything. All it is, is that in exchange for federal dollars, the provinces will do these things."

Erin Strumpf, an associate professor in the Department of Epidemiology, Biostatistics and Occupational Health at McGill University says the Conservatives are also likely pandering somewhat to Quebec.

"You can’t say, I believe in the Canada Health Act and put no string attached because the Canada Health Act is a lot about strings," Strumpf said in a phone interview. At the same time, she says O’Toole does not want to tell provinces how to spend the money or direct them to certain sectors like mental health or long-term care, explaining that this kind of restriction or direction is different from the "strings" associated with the act.

"So it’s not a contradiction I don’t think to say that I believe in the Canada Health Act, and I believe there’s scope for private provision in the Canada health-care system, because we absolutely have that for the services that aren't covered."

She points to services like psychotherapy that are not publicly covered, but adds that a private surgical clinic or specialty hospital would be different as they overlap with treatments already publicly available.

"It’s two sides of a coin, right? People recognize that the provinces and territories have jurisdiction over their health-care systems, a lot of control over how they spend money and the policies they put in place … and [their] ability to respond to the needs of their particular population."

This flexibility in local decision-making and setting priorities can help spur innovation, Strumpf said. At the same time, not all Canadians have equal access to the same medications, for example, which speaks to Canadians wanting more equitable medicare.

"There’s also some perceived benefits to having some consistency and some baseline across the country and those things are inherently in tension with each other," Strumpf said.

Marchildon also noted that even if conditions are attached to the transfers, it is in reality difficult to determine what happens to the money once it flows into the general revenue fund of a provincial government.

"They don't have to use it for health care … there's no guarantee that money transferred will be used for the purpose that the federal government wants," he said.

"So it's questionable whether this is a very effective vehicle in the first place."

CONCLUSION

Our experts agree in principle that O’Toole’s position is a contradiction. He has not made it clear how he would support universal health care while also giving provinces money with "no conditions." This leaves some of our experts to interpret his claim as suggesting he would not enforce the Canada Health Act, which is built on the precept that provinces and territories must fulfill nine requirements in order to qualify for the health care funding provided by Ottawa. There is some room for interpretation, however, on what he means with respect to unconditional transfers and whether certain types of restrictions or demands would be considered an overreach by the federal government.

Edited by Michael Stittle