Quick: define medicare.
How did it develop?
What makes it unique?
Like love and brain freeze, everyone knows what you mean when you say medicare.
Shared understanding works for honeymoons and slushies, but not for a $254 billion industry.
We need a common language to fix medicare.
Most people find policy rather boring. So here is a super short history of medicare.
“Canadian” Medicare
Europeans set fashion trends. Canadians copy them a year later. By then, Europeans have moved on to a new fad. This happened with healthcare.
Sir William Beveridge wrote the blueprint for British healthcare in 1942. Canada hired Leonard Marsh, a Beveridge team member, to create a blueprint for Canada.
Marsh produced a report in 1943 that looked much like the Beveridge report of ’42.
Medicare is European, despite the fact many Canadians consider it part of our national identity. More precisely, medicare is an out-of-date European fashion.
By the time we built what we had copied, Europe had moved on to something better.
Just the Acts, Please
The Constitution Act gave healthcare to the provinces (formerly the British North America Act 1867).
But the Act also gave the federal government the power to tax and spend.
So the feds have used their spending power to bribe the provinces to do things provinces might not have otherwise.
The history of medicare is all about money:
Money for hospitals:
Feds funded provinces for healthcare services with the 1948 National health grants program. It created a hospital building boom well into the 1970s.
Money for hospital services:
Feds promised to pay 50% of all hospital and diagnostic services. (Hospital and Diagnostic Services Act, HIDSA 1957)
Money for medical care:
Feds promised to pay 50% of all necessary medical care (Medical Care Act, MCA 1966).
Money without strings:
Feds grew tired of paying 50% of everything; created block grants instead (Established Programs Financing Act, EPFA 1977).
Money for good behaviour:
Feds promise claw backs from provinces that allow user fees or extra-billing (Canada Health Act, CHA 1984).
Who’s in Charge?
The feds give money with strings.
Federal healthcare laws put conditions on how the feds are allowed to spend money. If provinces meet the conditions, then the feds can release the money.
Provinces do not have to participate in medicare. Everything is voluntary, just like doctors voluntarily renew their medical licences. Click To TweetSo provinces take the money and complain about the conditions.
Quebec Premier Francois Legault told reporters recently, “We will not be dictated to by the federal government [on healthcare].”
But do provinces have any right to complain? He who pays the piper calls the tune.
To finance WW II, the provinces gave up corporate and personal tax room to the federal government, in a temporary tax-rental agreement, 1942. In return, the feds gave provinces a per capita rental payment.
Thirty years later, the Carter commission brought peace but still never returned taxation to pre-war arrangements.
Management Won’t Save Medicare
Medicare has floundered for decades. 2008 sped up the process.
I used to think we could manage medicare to improve performance. We could lead better. Management and leadership will not fix medicare. We need to change the rules.
Most people point to the Canada Health Act as the heart of medicare.
But four of the core principles came from 1957: public administration, portability, universality, and comprehensiveness.
The CHA added ‘accessibility’. Other than outlawing user fees and balanced/extra billing, the CHA offered nothing new.
Romanow called for an update to the CHA in 2002. Naylor said the same in 2015.
Maybe it is time to re-evaluate the CHA?
Would We Do It Again?
Medicare is European. Medicare is old. And medicare is about money.
Medicare is a giant federal experiment that the provinces support because the feds help fund it.
If we were doing it again, would we build it this way?
