Tuesday's first ministers meeting on health care ended in a disagreement over money. Because of course it did.
"One of the things we did see today was that there wasn't a lot in the way of new funding," Manitoba Premier Heather Stephanson said when the premiers emerged from their meeting with the prime minister.
An hour later, Justin Trudeau appeared before reporters and described what his government was offering as "a major federal investment in health care."
The premiers had been demanding that Trudeau's government immediately increase annual transfers to the provinces by $28 billion — an enormous sum that almost certainly would require the federal government to either raise taxes or make significant cuts to spending in other areas.
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Asked if this offer would be the government's final one to premiers, Prime Minister Justin Trudeau said that while negotiations with provinces will continue, the federal government's offer represents its 'fiscal frame.'
The federal offer is much less than that. But the provinces couldn't reasonably have imagined they would get what they asked for.
And the question of which level of government covers what share of the cost of public health care may not be the most important issue facing health care in Canada right now. (Not that knowing that would ever keep prime ministers and premiers from haggling when things get tough — as things obviously are now.)
"We all know that money alone is not the answer," Trudeau said Tuesday.
Granted, that's exactly the sort of thing a prime minister might say when he's only prepared to offer so much. But he's not wrong.
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Manitoba premier says 'we're a little disappointed' after meeting with PM on health funding
Trudeau picks up where Martin and Harper left off
When Paul Martin set out to "fix" health care for a "generation" in 2004, he convened a first ministers conference to strike a grand bargain. After three days of tense and dramatic negotiation, Martin had a much-ballyhooed accord.
Seven years later, as the end of Martin's deal approached, Stephen Harper dispatched his finance minister, Jim Flaherty, to surprise the provinces with an announcement that federal transfers for health care would soon stop increasing at the rate agreed to by Martin. The premiers didn't have to like it, but there would be no negotiation.
Trudeau's approach splits the difference between Harper and Martin. The premiers demanded a meeting, so Trudeau gave them two hours. But he used that time only to lay out his terms. For each province, there will now be bilateral negotiations between health and finance ministers aimed at filling in the details.
In terms of dollars and cents, Trudeau's offer actually exceeded Martin's "fix." Martin's accord amounted to $41 billion over ten years. Trudeau is offering $46 billion in new money over the next ten years.
Flaherty reduced the annual "escalator" for the Canada Health Transfer to three per cent. Trudeau is offering to raise it to five per cent for the next five years. That would amount to an additional $17 billion for provincial governments. Another $25 billion is being set aside for separate deals with each province, aimed at directing funds toward a set of specific priorities, including primary care, mental health and hiring more doctors and nurses.
Notwithstanding the unhappy noises coming from the premiers on Tuesday, Trudeau's hand is strengthened by the absence of an alternative proposal at the federal level.
Pierre Poilievre's Conservatives have had almost nothing to say about these negotiations with the provinces. During the last federal election, the Conservative Party was prepared to offer an unconditional $60 billion boost to federal transfers over the next 10 years. But the Conservatives don't seem interested in repeating that commitment now.
In response to recent developments in Ontario, Jagmeet Singn's NDP has raised concerns about the use of privately owned clinics within the public system. The Trudeau government has been willing to interject when provinces allow private payment for necessary services – as in the case of Saskatchewan – but private delivery is not a new phenomenon and is not in clear contravention of the Canada Health Act.
Moving beyond dollars and cents
When Martin struck his deal in 2004, the federal government also created the Health Council of Canada, a panel of experts charged with monitoring performance and innovation across the health-care system. The Harper government eventually cut funding for the council in 2013. But in one of its final reports, the council noted that while more money had been invested over the previous decade, tangible improvements were few.
"Although the resources to improve our health system and the health of Canadians were made available, the success of the health accords in stimulating health system reform was limited," the council reported.
Trudeau is not proposing to revive the health council. But the federal terms include new requests for data and information from the provinces and a commitment to producing annual reports on progress and "common indicators" — such as the percentage of Canadians who have access to primary care, wait times for mental health services and the number of new physicians, nurses and nurse practitioners.
"What gets measured gets done," Trudeau said on Tuesday, perhaps hopefully.
Making good use of that data will require real and sustained follow-through — and data shouldn't stop flowing with a change of government. (The Trudeau government's own "mandate tracker" is little more than a distant memory.) But it shouldn't cost much to do. And if anything is going to drive change, it's going to be efforts to hold the system accountable to Canadians' demands for better.
There will be some days or weeks now of arguing over those billions. But it would be a mistake to imagine that a fight over big numbers is the only thing that matters here.