Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 9 - Evidence, March 23, 2000
OTTAWA, Thursday, March 23, 2000
The Standing Senate Committee on Social Affairs, Science and Technology met
this day at 11:03 a.m. to examine the state of the health care system in Canada.
Senator Marjory LeBreton (Deputy Chairman) in the Chair.
The Deputy Chairman: Honourable senators, this is the third meeting with
witnesses on our health care study. Our first witnesses this morning are from
Health Canada. The committee has asked Health Canada to provide us with a
general briefing on the population and health in Canada, including a current
status report on the health of Canadians, long-term and recent trends and
comparisons with other countries.
With us today are Dr. Wendy Watson-Wright, Mr. Sylvain Paradis, Ms Liz Kusey
and Ms Monique Charron.
Honourable senators, the witnesses will show a short video before they make
their presentation. You will hear the audio in English and French through your
earpieces. Since this is relatively new technology, I ask for your patience.
Dr. Wendy Watson-Wright, Director General, Policy and Major Projects
Directorate, Health Promotion and Programs Branch, Health Canada: Honourable
senators, we are pleased to be with you today to speak about the health of
Canadians and the underlying conditions which influence health.
We are tabling "Toward a Healthy Future: Second Report on the Health of
Canadians." This report, as I believe most of you know, was produced by the
Federal, Provincial and Territorial Advisory Committee on Population Health and
certainly provides the most comprehensive information we have to date on the
health of Canadians.
My colleagues have been introduced. I would like to say that we also have
with us in the audience two other people from our Childhood and Youth Division,
Julie MacKenzie and Mary Johnston, who can respond to any questions on our
children and youth programs.
As you mentioned, Madam Chair, we will be showing a short video. We had not
planned to give a presentation, but we can do so if you wish that in addition to
the video. I will leave that up to you once you have seen the video.
Coming out of the report, the priority areas for action have been agreed to
by all FPT Ministers of Health. The role of staff is to work with the other
jurisdictions in promoting the messages which come from the report.
We are also distributing a presentation deck which more or less organizes the
information you will be seeing on the video and reinforces the main points.
Again, we would be happy to answer your questions following the video.
The Deputy Chairman: Dr. Watson-Wright, before we open the floor to
questions, would you care to make any more statements in addition to the video?
Ms Watson-Wright: At this point, perhaps we could bring out more highlights
from the report. I will ask Ms Kusey to do that. This information is contained
in the deck that has been handed out to you.
Ms Liz Kusey, Policy Analyst, Policy and Major Projects Directorate, Health
Promotion and Programs Branch, Health Canada: Honourable senators, the video
gives a good indication of some of the status measures of the health of
Canadians. The report answers three questions: How health healthy are we, what
makes us healthy, and what can we do to improve our health? With your
permission, I should like to talk briefly about those questions.
As mentioned, "Toward a Healthy Future: Second Report on the Health of
Canadians" was developed by the Federal, Provincial and Territorial
Advisory Committee on Population Health in collaboration with Health Canada,
Statistics Canada and the Canadian Institute for Health Information.
The report provides a comprehensive picture on the health of Canadians and
what makes us healthy. It does this by taking a population health approach in
its organization and analysis. This means that it integrates traditional health
status measures with data on the interrelated factors and conditions that make
Canadians healthy. These factors or determinants include the socio-economic
environment, physical environment, healthy child development, gender and
culture, personal health practices, biology and genetic endowment and health
The goal of the population health approach is to maintain and improve the
health status of the entire population as a whole and to reduce inequities in
health status between groups.
When we look at the health of Canadians, you will see in the first slide of
your briefing deck some key population health measures that have been used, one
of which is life expectancy, where we have reached new highs. Another is the
infant mortality rate, where we have reached new lows. As well, the United
Nations continues to rank Canada as number one on its human development index,
which takes into account life expectancy, educational attainment and adjusted
Canada continues to have an enviable health care system, despite continuing
pressures in a period of reform. Access to insured health services has been
safe-guarded for all Canadians, regardless of their income level.
More positive results include factors such as most older Canadians are
independent and healthy, recent immigrants are in good health, and Canadians are
taking action to improve their health and their declining death rates and
potential years of life lost.
The graph on the fourth page relates to potential years of life lost. What
you will see is heart disease and unintentional injuries, two of the major
causes of death before age 70, continue to decline. Over the past 20 years, we
have seen particularly impressive declines in childhood deaths. However,
unintentional injuries that are virtually all preventable still remain the
number one cause of death among children and youth.
Cancer, which is the principal cause of potential years of life lost, has
declined somewhat in men but has only stabilized in women, largely due to
increases in lung cancer deaths among women.
Unless there is a decrease in current smoking rates among women, we will see
large increases in female deaths attributable to tobacco in coming years.
The video was very good in showing that high standards of health are not
shared by all and disparities relate to age.
In 1990, one-in-five children were living in low-income families and this has
changed to one-in-four children living in low-income families by 1995. It is a
significant problem. That puts them at greater risk for infant death, for low
birth weight, developmental delays and exposure to environmental contaminants.
The psychosocial health of our young people is of concern, as are high levels
of stress, depression and suicide, and multiple risk-taking behaviours.
While women live longer than men, many are more likely to suffer from stress,
depression, chronic conditions and injuries, and death related to family
Aboriginal Canadians have made impressive improvements in educational levels,
infant mortality rates and substance abuse; however, their life expectancy is
still a full seven years less than other Canadians. They also suffer more
chronic diseases than the general population, and there is evidence that some
conditions are still on the rise.
Children and youth in aboriginal families have high rates of respiratory
infections and unintentional injuries and early deaths from drowning, suicide
and other causes. Many of the health concerns are linked to problems with
housing and food affordability, unemployment and low incomes.
The UN, which rated Canada number one on the human development index, rated
Canada tenth on the human poverty index for developed countries in 1998 and
ninth in 1999. In explaining this, the U.S. suggests that Canada is not doing as
well as we could on literacy, unemployment and income distribution.
I draw your attention to the graph on page 6, which shows self-rated health
by income level. Only 47 per cent of Canadians in the lowest income group rate
their health as excellent or very good, compared to 73 per cent in the highest
group. You can see from this graph the persistent socio-economic gradient that
affects health at every rung up the ladder. This holds true regardless of the
cause of death and how much we spend on the health care system. These
perceptions are backed up by hard data. Canadians with incomes below Statistics
Canada's low-income rate suffer more illnesses and die earlier than Canadians
with higher incomes.
The priority areas for action have been agreed on by all Ministers of Health
at the federal, provincial and territorial levels. They include investing in the
health of three key population groups -- children, youth and aboriginals --
improving health by reducing disparities in literacy, education and income, and
renewing and reorienting health services.
Efforts to invest in health during early childhood are partially related to
research which shows that experiences from conception to age six have the most
important influence on brain development and, therefore, that all children and
families can benefit from an integrated early child development strategy.
The second priority group is young people. Despite concerns raised about
youth health, youth volunteerism is on the rise. As you see, the number of young
women completing post-secondary levels of education is at its highest point
ever. However, the report suggests the need to involve young people themselves
in addressing challenges to their health and well-being. It also notes that
personal lifestyle choices are linked to the capacities of homes, schools,
communities, workplaces and governments to create environments for young people
that make the healthy choices the easier choices for them to make.
The third priority group, aboriginal people, have the lead role in finding
culturally appropriate ways to enable their people to improve their health, but
in doing so they need the support of all Canadians.
Taking action to provide all Canadians with the opportunities they need to
obtain a solid education, adequate literacy skills and a sufficient income to
support themselves and their families would help foster healthy citizens and a
prosperous, competitive nation. When we talk about renewing and reorienting
health services, this is what we mean. Evidence shows that health promotion and
injury and disease prevention activities have been working. In areas such as
immunization, mammography and seat belt use, we have seen dramatic improvements,
and prevention and promotion activities must be continued and broadened.
A number of concerns are noted in the report, including access to uninsured
services, such as eye and dental care, prescription drugs, home care, and mental
health counselling. Since many of the determinants of health that I am speaking
of are outside the traditional health services system, building alliances with
other sectors is a primary strategy for improving the health of the population.
The ideal outcome of these collaborations would be healthy public policies in a
variety of sectors, as well as the health sector. The health sector cannot do it
all, and it cannot impose its agenda on others, but it can initiate dialogue and
partnerships with others and act as a collaborator for change.
We need to increase our understanding about how the determinants of health
influence well-being, and the report also points to the need for better data on
effectiveness, accountability and quality of care. "Toward a Healthy
Future" suggests a paradigm shift in the way we think about health, and it
suggests that actions in the broad determinants of health are as important as
efforts within the traditional health services system. It is clear that
improving health must be a shared responsibility -- shared across organizations,
disciplines and sectors. Honourable senators, we can give no greater gift to the
next generation than a healthy future.
Senator Carstairs: I wish to deal with the youth issue and, in particular,
the statements about the stress levels of those in the 18- and 19-year-old
category. I think your data was that 37 per cent of them indicated they were
suffering from some kind of stress.
My experience in working with kids that age is that "stress" has
become a buzzword with them. If they are the least bit upset, they say, "I
am stressed." I have heard that from both of my daughters at various times.
Usually I suggest that they take a run, which might make them feel a little less
stressed. I also recognize that with the increasingly high suicide rate,
particularly among young men, stress is leading to clearly unhealthy behaviours.
What proof do we have or what analysis has been done about why these young
people think they are suffering from stress? Rather than just telling us they
have stress, have they told us in any studies what it is that makes them think
they are under stress?
Ms Kusey: The report shows that the 18- and 19-year-old youth, particularly
females, report that they are under stress. From observers outside the system,
youth and particularly females between the ages of 15 and 19 are observed by
others, by health professionals, to be exhibiting signs of distress and stress.
Does that answer your question?
Senator Carstairs: Partly, although it seems to be an area in which we need
to do more specific research and study.
According to your statistics, 9 per cent of youth suffer from some sort of
depression. Are these young people getting treatment for that depression? My
experience is that most people in this country who suffer from depression do not
get adequate treatment. Is this also applicable to young people?
Ms Mary Johnston, Consultant, Childhood and Youth Division, Health Canada: In
response to the first part of the question, we have done some work and other
groups have done work and asked young people point blank what causes them
stress. School is one answer -- pressure to achieve grades, pressure to be able
to earn money so they can afford to go to school, pressure from parents to
achieve grades, and, I guess very similar to adults, balancing work, family and
Regarding treatment for depression, you are correct that the majority of
youth with subclinical depression, and even many of them with clinical
depression, are not getting the identification of the condition and the
treatment that they need.
We know from work in the province of Ontario and work in other provinces that
many of the provinces are looking for ways of integrating the services so that
when young people are identified in one venue or in one setting as having a
problem with mental health issues, they can be referred and get treatment
Senator Carstairs: Is the ongoing discussion and debate about the stigma that
is still attached to mental illness in this country, despite the fact that
probably one-in-five people in Canada will at some time in their life suffer
from some form of mental illness?
Ms Watson-Wright: Is your question in regard specifically to youth?
Senator Carstairs: Clearly for everyone, but particularly for youth, is the
stigma still there for them?
Ms Johnston: I would say from work that we have done with school-based
programs and with other youth programs that, yes, there is a stigma. There is
also a difficulty with self-identifying or getting the actual identification and
clinical assessment of clinical depression.
Senator Carstairs: My final question has to do with the reasons you have
given us, including school achievement. In my other life, I was an educator.
What I have seen in almost a perverse way is that the expectations for young
people today are so much greater than the expectations for my generation. For
example, it recently required a higher academic average coming out of high
school to get into dental hygiene than it did to get into dentistry; it required
a higher average to get into physiotherapy than it did to get into pre-medicine.
Many of these fields, coincidentally, are "female" fields.
It is not obviously in the mandate of the Department of Health, but when you
talk about school achievement levels, is any of that feedback coming back to
Ms Johnston: Yes, the feedback is coming back to us. We are looking at and
collaborating on indicators. As well, the ministries of education are looking at
indicators of school achievement and indicators that are more pan-Canadian. They
are looking at having those made broader than just academic achievement.
Senator Callbeck: My first question pertains to what a witness had to say
yesterday. That witness indicated that they felt there was a lack of national
data in the entire health care field. They spoke glowingly about the system in
the province of Manitoba. Do you agree that we have a lack of data in the health
care field? If so, what are we doing about it?
Ms Watson-Wright: I will ask Dr. Paradis to respond to that.
Dr. Sylvain Paradis, Acting Policy Group Manager, Policy and Major Projects
Directorate, Quantitative Analysis and Research Section, Health Promotion and
Programs Branch, Health Canada: Senator, there is actually a lot of data in the
system already. It is not always the best data, and there is a lack of certain
types of data to do certain types of assessment.
One of the big problems is how we attack all this data. For instance, if we
look at mortality, hospital human resources and doctors and nurses, Statistics
Canada carries a wide variety of surveys and the Laboratory Centre for Disease
Control at Health Canada looks at diseases, mortality, morbidity, and other
factors like this.
To be able to make all the assessments, we must link all this data to find
the paths within the process. Money has been invested in a project called the
Road Map Initiative, which is a link between Health Canada, the Canadian
Institute for Health Information, Statistics Canada and the provinces to better
focus on what is required, methods of data collection and stronger standards of
data collection. It is a huge initiative.
As an example, the National Population Health Survey is conducted every two
years on the same 20,000 people. We can actually track over time the same
individuals, if they get better, if they get worse, what is their health status
and if they are highly stressed.
In addition, we have just created a new survey called the Canadian Community
Health Survey, which will actually go deeper in the communities with a larger
sample of 150,000 households.
The problem is we could not do good assessments in small areas because we did
not have enough numbers. Now we are increasing the size to be able to capture
better what is taking place.
Similarly, the Advisory Committee on Population Health is looking at vital
statistics, such as cause of death and the quality of the record. Hopefully we
can improve the quality of reporting of this data. It is done systematically
with all the organizations.
Senator Callbeck: In other words, we are working to come up with a better
Mr. Paradis: If we look at international comparisons, usually we provide data
that meets international standards, compared to other countries that cannot meet
some of these standards. Canada is developing many new indicators at the same
time. We have a significant amount of information. The research shows there is
much information at this time.
Ms Watson-Wright: In answer to your question, Senator Callbeck, yes, we are
working on it.
Senator Callbeck: In 1974, a report was done by the Minister of Health at the
time, Mr. Lalonde. In 1984, the then Minister of Health, Mr. Epp, did another
report. I believe that they both dealt with a population health approach. Now we
have another report, or is what you have just completed not as in-depth as the
other two reports?
Ms Watson-Wright: No, this report is quite different from those reports. This
is really bringing statistics together and addressing policy issues. The other
two were much more intellectual pieces relating to how we can change what we
have been doing and change the world. There were thoughts about doing another
report similar to that, but the report we are speaking about today is quite
different from the previous two.
Senator Callbeck: Those previous two reports dealt with the population health
approach in Canada. Since those two reports, one in 1974 and one in 1984, what
major initiatives has the federal government taken in that field?
Mr. Paradis: In fact, the first report was a broad brush report looking at
four different sectors -- biology, personal behaviours, a health care system and
Mr. Epp's report dealt specifically with health promotion. If you remember,
Dr. Glouberman yesterday spoke about four phases of the health system.
The new wave is the population health approach dealing much more with life
conditions. The report that Mr. Epp put together related much more to people's
behaviour, health education and community support. The new report addresses
broader conditions, such as education, income, early childhood, culture and
gender-oriented factors. That is the new direction. We are doing that jointly
with the provinces. Most of the documents are coming out of the Advisory
Committee on Population and Health.
Senator Callbeck: I read the report in 1974, but it was very much along the
line of the population health approach, as was Mr. Epp's report. My question
really was the following: What major thrust has the federal government taken in
this area since that time?
Ms Watson-Wright: If I could attempt to answer that, there are some major
approaches. Certainly, promotion of population health as a business line within
Health Canada is a major factor. A number of smaller initiatives that have gone
forth, not just within government but outside government.
In order to give you a good picture of that, it would be important to put all
of this information together for you rather than my trying to pick out some of
these initiatives for you.
The important thing, as you obviously know already, is to bring sectors other
than the health sector together with health in order to address the
If you would like us to put together everything that has happened under a
population health approach, we would be happy to do so.
Senator Callbeck: I wondered if there were any major initiatives that really
Ms Watson-Wright: Perhaps Dr. Paradis would like to talk about the Canadian
Population Health Initiative.
Mr. Paradis: Under the Road Map Initiative I was talking about earlier,
although Mr. Lalonde's report talked about the four sectors of social and
environmental conditions, we did not have much evidence of that factor.
This report really shows discrepancies in the social economy. We thought it
was important to look at new research to show these factors in terms of social
A new initiative called the Canadian Population Health Initiative actually
pulls together researchers from the CIAR. Dr. Fraser Mustard is one of them.
They are looking at very specific connections between factors.
One of the areas they are addressing is the impact of a poor environment, as
well as being poor. How does the environment, itself, affect people? We do not
have a significant amount of information on this issue. That is where we are
actualizing the proposals that were in the Lalonde report, proposals that have
not been put in place over the years. That is the major initiative. We have
started to look at the conditions we knew were there but had never assessed
The Deputy Chairman: In your report you talk about asthma dramatically
increasing among young children in the last decade. Can you can shed some light
on this? The assumption or perception is that we have a more smoke-free
environment. Do you have data to illustrate why asthma is on the increase? Is it
related to the environment?
Mr. Paradis: This is not in the report, per se, but a study prepared by
Health Canada a couple of years ago showed that when the temperature would rise,
there were more hostile conditions for asthma in a geographic corridor running
from the Midwest to Quebec City, including the entire Great Lakes region. That
is certainly an important factor.
I think the potential for years of life lost is fairly flat, as all ages
average out. However, if we take an approach that is age-group specific, we see
consistent variations among these groups.
The Deputy Chairman: If there has been a dramatic increase of asthma among
young children, then obviously that line will not remain flat. If asthma is in
that particular age group, surely more data can be gathered. There must be some
reason for this increase. We all think that the air we breathe and the air in
buildings is less polluted, but obviously it is not.
Ms Watson-Wright: If I could, I would like Ms Johnston to respond to that
The Deputy Chairman: There may be other factors as well.
Ms Johnston: Health Canada is currently working on another report that looks
at children's development from the perspective of each one of the determinants
of health. The one on the physical environment collects quite a significant
amount of data on air.
We know that there are increases in hospitalization for respiratory distress.
The asthma rate in young children usually goes up when ground-level ozone rises
in the Windsor-Quebec corridor. Ground-level ozone is a matter of air pollution.
As Dr. Paradis was saying, we need to work on many fronts simultaneously. We
can work toward more smoke-free environments, but we need clean exterior air as
a starting point. We need to reduce our pollution levels and our ground-level
ozone in the exterior environment. Exterior and interior environments are
Senator Cohen: Yesterday, Dr. Mustard explained to us the diseases of the
elderly. Research has found that some diseases can be traced to the first five
years of a child's life, even right back to conception. We know that children
from low-income families are at a much higher risk when it comes to health. If
the mother carrying the child does not get proper nutrition, the child does not.
This impacts on the whole health picture.
Would the health of Canadians improve with early childhood intervention
programs such as parenting centres or child care centres? I am not talking about
daycare. I am talking about centres that could support low-income people and
even some middle-class families, where both parents are working and there are no
grandparents or extended family to offer the support that I knew growing up in
Canada after the Second World War. I would like to hear some comments about how
dollars spent on early childhood intervention can help the delivery of the
Ms Watson-Wright: I will ask Julie MacKenzie, who works specifically on
childhood issues within Health Canada, to respond to that question.
Ms Julie MacKenzie, Senior Research Analyst, Childhood and Youth Division,
Health Canada: Honourable senators, that is a very good question and certainly
one that officials are working on right now.
In terms of the cost benefit or dollars spent in early or intervention
programs, several studies have been done, particularly in the United States
where their expenditures on so-called head-start programs go back to the 1960s.
They have been able to trace children up into adulthood. Right now, that is the
richest overall source of data.
The programs that were started in the United States in the 1960s focus on
high-risk, low-income children who obviously have a different cultural
background than children in Canada. Many of the base-line indicators are quite
comparable to children in Canada.
The Rand Corporation has found that for every $1 spent on early child
intervention, $7 is saved down the road. That ratio relates to eventual costs in
terms of crime prevented, welfare costs not incurred, et cetera.
Going back to what Dr. Mustard said yesterday, one of our concerns in Health
Canada and in the provinces is trying to raise the low birth weight, which is a
key expense to the system. Low birth weight is responsible for about 75 per cent
of neonatal deaths. The children who do survive are quite expensive to the
health care and social service system. The current figure is that approximately
$200,000 is expended in the first year of life on a child who does survive. We
hope to lower that rate by putting a relatively modest amount of money into
prenatal care and nutrition and even pre-conception health. The video indicated
that this rate has gone down, but it is certainly not as low as the rate in
other OECD countries, particularly Japan and the northern countries. It is
possible to further lower the rate, and the health care system and social
services would save enormously.
Senator Cohen: I am more interested in the early intervention after birth.
Are there any statistics on how effective this program could be, or is this a
new phenomenon that is just being looked at now? Has it been proven in other
Ms MacKenzie: In terms of early intervention, particularly in North America,
the bulk of the activity has been on targeting high risk. Usually that means
low-income children. The evaluation data and cost-saving studies are slightly
skewed in that they are looking at this particular set of children. Your
question was in terms of the broad level. You wanted to broaden that to
We have to look to evaluations and surveys that have been done in European
countries because they have had broader systems of social support, child-care
programs and parenting centres for a fair amount of time. I would not say it is
universal, but it is broader than what exists here. They are finding positive
outcomes across all socio-economic groups.
Senator Cohen: Does Health Canada have any of those studies available that we
could look at?
Ms MacKenzie: We could probably access them for you. I believe Dr. Mustard
has circulated his report on the early years, and he has mentioned the studies.
He referenced them in quite extensive detail. We could try to get hold of them
Senator Cohen: In travelling the country on behalf of poverty last spring and
summer, many people complained that we have lowered our national standards in
health care. I know that "national standards" is not a popular phrase
in the provinces today. Do we need national standards in our health care system,
or do we leave it to each province to develop their own? If so, what do you feel
the role of the federal government should be vis-à-vis this area?
Ms Watson-Wright: There is actually a group in Health Canada working on the
overall federal role in health, and they are scheduled to appear before this
committee on April 5. With your permission, I would defer that question until
that group appears.
Senator Keon: It is very encouraging to see the information that is being
gathered on population health and the way the methodologies for data collection
are being refined and the evolution of the Canadian Institute for Health
Information. Hopefully the Canadian health information system will contribute a
great deal to this.
I am concerned that we do not have any way of closing the loop. It is part of
our Canadian mosaic that we have this federal-provincial grey zone in
jurisdiction and communication. I compliment the current federal and provincial
ministers and deputy ministers for the efforts they are making to get together
regularly to work this out. Still, there is no feedback in the system.
We are getting a lot of information now on population health, but by the time
that information is carried to the populations that are most adversely affected,
a great deal of time will have transpired. There must be a better way of doing
How do you see that system unfolding? You have your information. It comes
into the loop for intervention or feedback. You close the circle with the
provinces and territories who are delivering health care and who are, to a large
degree, responsible for environmental factors and some of the other determinants
Ms Watson-Wright: That is quite a question. I am not sure if I fully
understand exactly what you are asking for at this point. Obviously the ideal
would be to have real-time data collection and real-time action on that data.
Could I ask you to rephrase your question somewhat?
Senator Keon: I think one of the major problems we have in health research
and in health care delivery, and indeed in public health, is fragmentation and
gaps in communication. We have not been able to integrate these various services
the way that they could be integrated to our tremendous advantage. I am not
suggesting it would be easy, but I would like to hear your thoughts on that.
Mr. Paradis: You have captured the difficulty that we have. The fact that the
Road Map Initiative and the CIHI project and the CPHI project is now reporting
to the Advisory Committee on Population Health certainly creates a larger
dynamic between the federal government and the provinces. StatsCan is coming out
with a new report, as is the CIHI. The reporting capacity will be speeded up
One difficulty we have in collecting all these data files is personal
confidentiality. Many Canadians fear having government organizations and
non-government organizations connecting the number of visits they make to their
doctors and the number of drugs they take. They feel it is like Big Brother
coming into their backyard. The Road Map Initiative is looking into the legal
dimensions of individual rights and collective rights, and that certainly
increases much of the difficulty you mention.
On the CPHI, there is a huge provincial representation. The growth of the
health research institute is also a very good way to improve, smoothen and speed
up the delivery. One of the ways we have tried to do that is through the
Canadian Health Network. I do not know if you have had a chance to visit this
Web site, but it pulls together about 400 high-quality Web sites on health
information that will speed up this process.
I agree that some provinces are more advanced, such as Manitoba, in
connecting the database. British Columbia has done that. In the last StatsCan
survey, they increased their share of respondents on the surveys in an effort to
gather better information. However, it is still quite difficult to connect these
data files because of the confidentiality implications associated with it.
Senator Keon: It is something with which we have tried to grapple.
The Deputy Chairman: You may not have this at hand, but in the database, what
percentage of health care costs are taken up by treating those individuals who
fall into the unintentional injuries category? Do you know?
Mr. Paradis: I do not have it with me, but there is a report called the
"Economic Burden of Illness in Canada." I think it is now the third or
fourth report. We can provide that to you. It is unfortunate that I did not
bring it with me today.
The Deputy Chairman: It seems to me that if people are more educated in that
respect, it would free up more dollars to look after people who are ill because
of a sickness and not because of unintentional injuries. It is something I would
like to have at some point.
Mr. Paradis: Unintentional injury is an interesting phenomenon. It has
decreased considerably in Canada, but it is still one of the highest causes of
death for most of the younger age groups.
The Deputy Chairman: On television this morning, there was a report on young
people driving and how the chances of them being seriously injured or killed
goes up with the number of people in the car. It was an interesting report.
Mr. Paradis: The World Health Organization, with the World Bank and the
Harvard Center for Population and Development Studies, has put together a book
called The Global Burden of Disease. They are reporting that car accidents are a
growing problem in industrialized countries and established market societies.
The Deputy Chairman: Thank you all very much for your presentations.
Senators, our second witness today is Dr. Keith Banting.
Please proceed, Dr. Banting.
Dr. Keith Banting, Director, School of Policy Studies, Queen's University:
Honourable senators, I want to begin by commending this Senate committee for
undertaking the review that it has launched. It is clearly an ambitious review
and it will require stamina by the members of this committee to engage in such a
sweeping and long-term review. It is highly appropriate. The Senate has often
played an important role in setting the climate for debate on critical issues in
this country. I wish you well.
When I was first approached about appearing before you, I demurred in the
first instance because, although I have done work on Canadian social policy and
federalism, I am not an expert in the particular area of health care, so I said
that perhaps you should turn to others. However, it was agreed that in the
context of your general discussion a retrospective view of some of the broad
approaches to social policy in this country, and in particular
federal-provincial relations and the role of different levels of government, may
be helpful. It is there that I may have some limited contribution to make to
I shall speak in my opening remarks to the issue of the social union debate
in Canada; that is to say, the debate about the relationship between our federal
system and our approaches to social policy, the ways in which we have organized
our relations in the past, why those relationships broke down in recent decades,
and the kind of directions we seem to be setting with the Social Union Framework
Agreement, and what the implications for the health care debate might be over
the next few years. That is a big mandate and I have been asked to restrict my
introductory comments to 10 minutes. When I mentioned that to my family, they
laughed uproariously, thinking that I am programmed to speak in 50-minute
Given the breadth of the topic, I have circulated a handout with figures to
highlight some of the points to which I will allude. We can revert to any of the
specific points or other issues you would like to raise in the discussion
because I will not have time to develop all of these points.
Whenever one raises the question of federalism and the relations between
levels of government in a debate about social policy, eyes quickly glaze over.
People would much rather focus on the real issues, such as health care and the
types of intervention that will improve people's lives -- the sorts of things
you were discussing most recently with a group of people from Health Canada.
The typical debate seemed to be about money and power, which appear to be
perennials of our political life, but for many citizens they seem to get in the
way of the real issues. At that level, I think that those citizens are right.
However, I do think that there are key issues underlying the debate about our
federal system and social policy. In many ways, we work out our views on some of
the fundamentals about life in Canada in a federal-provincial or an
intergovernmental context. In the current context, we will be working out our
social policy values -- to a large extent, although not exclusively -- through
the mechanism of intergovernmental debates. It will be an important venue for
the debate in the health care sector about the role of the public and private
sector in the delivery of health care. Clearly, one of the ways we will work
that out is debating it in federal-provincial terms and working through
agreements such as the SUFA.
Many of our attitudes on the kind of democracy we have in this country are
also worked out in the context of debates about federal-provincial relations:
issues of accountability between citizens and their governments; issues of
transparency and the openness of policy-making in this country; and issues of
divisibility and the contribution different governments make to major programs
that matter in the lives of individuals. These issues are often worked out, or
at least set or constrained, by the intergovernmental relations we build in this
The extent to which the wider public and interested social groups can
participate in the policy process is often shaped by the way we structure our
federal-provincial agreements, or the process by which we work out
intergovernmental relations. There is often a tension between our
intergovernmental processes and our participation processes.
When we talk about our federal-provincial relations, we are talking most
fundamentally about what kind of country we are. Is this a country in which
there is a common community -- a community of Canadian citizens sufficiently
strong enough to have a common approach to social policy and something as
fundamental as health policy? Or are we, to use another phrase, a community of
communities where what is really important is to be able to build a system that
reflects the regional, linguistic and other differences of this country?
What is the balance between these two concepts of Canada? In many ways, the
debate about these issues does produce a glazing over of the eyes and it is
often difficult to keep people excited. When I talk to students at Queen's
University, their hearts sink when I turn to this phase of debate. I actually
think this is the way Canadians debate big issues. This is how we work out our
attitudes towards the role of government. This is the way we work out our
concept of democracy and the type of country we are. Therefore, I make no
apology for being a bit of a federalism junky. I just hope I can convince people
that it is an important way in which Canadians debate who they are.
What I thought I would do in that context today is talk about the mechanisms
we have used historically to structure our relations in social policy and health
policy. I want to talk about what I will call the post-war social union, the
processes we put in place and why they broke down. I want to talk about the new
agreement that has been put in place -- the Social Union Framework Agreement. As
well, I want to talk about the implications for health care in that context.
Perhaps a better way to put it is what are the implications of health care for
the fate of the SUFA? I think that is probably more important than the reverse.
I will move on to the choices or the models of federalism.
The point I wish to make here is quite simple. A tidy mind is really a
drawback when it comes to discussing Canadian federalism because we have always
had a mix of models and a mix of ways of organizing our relationships. We have a
menu of choices. There are basically four ways of dividing up relations between
federal and provincial governments, and we have tended to use them all. The
issue we face today is how are we rebalancing this menu? What is happening is
that some mechanisms are fading and some are growing, and they have very
The classic model of federalism says that the federal government has its
areas of jurisdiction here and the provincial governments have their areas of
jurisdiction over there. The two levels of government make separate decisions in
their own areas of responsibility. They are accountable directly to their
citizens. They raise their own taxes. They deliver their own programs. They are
accountable to their own electorate, and no priority is given to trying to
integrate or coordinate the activities of the two levels of government.
Historically, we have used the phrase "watertight compartments" to
describe this concept of federalism. If you believe in this concept, the
important thing is to reduce overlap and duplication, get the two governments
out of each other's hair, and let them be directly accountable to their
citizens. It is a model which stresses flexibility of the system and the ability
of different governments to respond to the diversity of the country. It says we
are not looking in many areas for common Canadian approaches. What is important
in a federal state is that we have diverse approaches.
The next three models actually say that interdependence is inevitable in a
modern society, in a modern federal state. They relate to different ways of
managing that interdependence between the levels of government.
The second model is what I call cooperative federalism. We relied heavily on
this model in the post-war period. It said essentially that the federal
government would establish cost-shared programs. The federal government would
provide funding for programs operated within areas of provincial jurisdiction,
by provincial governments, as long as those programs met conditions, principles
or objectives established by the federal Parliament.
As I said, this mechanism was relied upon heavily. The important point for my
purposes this morning is to underscore the fact that although there was an
attempt to integrate the two levels of government, legally both levels of
government remained free agents and could change their position, their level of
participation and their commitment in a given area. Certainly the federal
government, under the cooperative model, is capable of independent or, as
critics would call it, unilateral action. The federal government is capable of
changing the terms under which it provides funding and is capable of changing
the level of funding provided, without legal constraint. It is free to make
It is important to note that under this model provincial governments can also
take independent action. They can choose whether to opt into a program.
Historically, many provinces took some time to opt into some of our programs. It
took seven years for the provinces to opt into the Old Age Pension Program that
existed in the 1920s and 1930s. Provinces could decide to make a change and
accept federal penalties. For example, for a period, the Government of British
Columbia chose to impose a residency requirement on people coming from other
provinces who then sought social assistance or welfare from the Province of
British Columbia. This was clearly an infringement of the terms of the Canada
Assistance Plan at that time, but it was legally possible for the province to do
this as long as it was prepared to accept the provincial penalty.
Politically, it was always hard for provinces to take independent action, but
legally -- and this is the point I want to underline -- they could.
The third model is co-determination. The important thing about this model is
that, legally, unilateralism is stripped out of the system. Legally, the federal
government cannot move without the agreement of the provinces, and the provinces
cannot move without the agreement of the federal government.
The only example we have in our system is the Canada Pension Plan. Under the
terms of the plan, the plan cannot be changed without the approval of the
federal Parliament and a majority of the provincial Parliaments. The CPP terms
are very demanding. You need two-thirds of the provinces representing two-thirds
of the provincial population. It is more demanding than the formula to change
most parts of the Canadian Constitution.
This model is a way of managing interdependence. There are two levels of
government with a stake in this area, but this model is different from
cooperative federalism in that the federal government legally cannot act without
the provincial governments' consent, and provinces cannot choose to deviate at
the margin. I am setting aside the Quebec Pension Plan. We can discuss that if
you are interested, but what I am interested in here is the idea of
The final model is the interprovincial model. I will not linger on it because
it is not a model that we rely upon heavily, except in the area of education
The important point, for my purposes, is that the balance between these three
models is shifting from the post-war period. The cooperative model has been
fading and the real issue has been which way we are going to jump. Are we going
to jump toward the classic model or toward the co-determination model as a way
of managing our federal-provincial relations?
Let me say a word or two about how we have evolved between these models in
the post-war experience. For brevity, I will underscore that both the federal
and provincial governments had important jurisdiction in social policy in the
post-war period. Provincial governments were generally deemed to have the
predominant responsibility in a wide range of social policy areas, but the
federal government also had independent jurisdiction, often as a result of
constitutional changes, as in Unemployment Insurance or pensions. It also had,
most importantly, the spending power, and this lies at the heart of our debate.
Perhaps it is worth taking a moment to underscore its importance.
The spending power in our Constitution is assumed to lie with the federal
government -- to make payments to individuals, to institutions, or to provincial
governments, and to make payments even in areas of policy that it does not have
the constitutional authority to legislate on or regulate. The federal government
is assumed to have the constitutional power to make payments to individuals,
such as family allowances or child benefits, or to make payments to
institutions, such as research grants to universities, or payments to the
provinces. This authority is not written formally into the Constitution but has
been inferred constitutionally from a number of other jurisdictions. This power
was core to the development of the welfare state in this country and core to the
development of health policy. It is this power which has been most
Such a power exists in virtually every constitution of every federal state,
but in the Canadian case, it has never been made explicit and it has never been
made subject to any explicit controls. Much of the debate and struggle in this
country has been around the question: Should there be an approval process for
the exercise of the federal spending power other than decisions of the federal
government and the federal Parliament alone?
In the post-war period, we had this mix of jurisdiction and mix of powers. We
relied on a mix of those models I referred to a moment ago. We relied to some
extent on the classic model of federalism, with governments doing their own
thing in their own area of jurisdiction. For example, the federal government was
making Old Age Security payments to citizens and direct transfers to persons,
and the provincial governments were running their own programs without any
relationship to the federal government. These were programs such as workers'
compensation or primary and secondary education. As I say, certain aspects of
our system were classical in nature.
There was also cooperative federalism -- that is, the shared-cost program
mechanism to which I referred, which was critical to the big social services in
this country: health care -- health insurance, certainly -- post-secondary
education, social assistance and social services.
We also had a level of co-determination. I mentioned already the model of the
Canada Pension Plan. The only area where we use interprovincialism is in health
care, where provinces come together to help establish common standards and
testing. The move toward common testing at the primary and secondary level and
having tests that model international tests has primarily been an initiative of
provincial governments coming together and developing a coordinated or joint
approach. The federal government has played a role from time to time in this
process, but it has primarily been led by the Council of Ministers of Education.
That post-war system had real strengths. If you wish to discuss those in
greater detail, we can. It performed best in terms of social policy values. This
mix of models performed well in allowing us to build a common, pan-Canadian
framework for social policy. It allowed us to make a statement that there is a
common approach here in general terms, and it also provided considerable
flexibility on many programs for regional variations. I like to think that
social policy was critical to the development of a common set of social benefits
across the country, and I think we have a broader set of social benefits than we
would have had if we had stuck with the more decentralized system of the
On the other hand, this mix of models has raised many issues relating to
democracy and the democratic values I referred to in terms of confusion about
who was accountable. It constrained transparency. We were less clear about who
was doing what and who we should hold accountable if we did not like our health
care system. It constrained participation because many decisions were made in
closed meetings of federal-provincial officials.
With respect to democratic values, a critique was established. With respect
to values of federalism, the system said that there is a community of Canadian
citizens and there should be a set of benefits that citizens across the country
can hold in common. There is no question that there were tensions between our
federal and provincial governments. Although there are people who have critiqued
the system for its constraints on democratic openness, federal-provincial
tensions eroded the system.
I will not go through each of these crisis points in detail, but I would
simply note two or three key turning points historically.
In some ways, the most important date is 1977 and the introduction of block
funding, which did three things. First, it reduced the tension in the system.
Until then, provinces had come forward to present detailed reports on their
programming, and federal officials had to make decisions about whether this
particular program -- for example, a particular home for the elderly -- fell
inside or outside the terms of the shared-cost program. Many detailed decisions
were being made in Ottawa, which, in effect, was a deeper intervention and
deeper administrative control over provincial jurisdiction. The provinces found
this very frustrating.
The federal government found the old 50-50 cost sharing frustrating because
it could not control its budget. How much it spent on health care depended on
how much the provinces spent. The provinces showed up and said, "We spent X
millions of dollars last year and you have to match it." If you are the
federal Minister of Finance, that is not much fun because a lot of your budget
is controlled by decisions made elsewhere.
For this reason, the two governments agreed in 1977 to move to a new system.
In many ways, we have been seeing the 1977 compact unfold. The new system,
called block funding, said that the federal government would make a general
contribution to the provinces to cover health and post-secondary education.
There would no longer be an exact fit between expenditures and transfers -- that
is, the federal government would make a general transfer that would not be based
on what the provinces were spending but would grow over time with the rate of
growth in the economy. The amount transferred would be unrelated to how much the
province had actually spent.
Second, on the provincial side, the provinces did not have to come forward to
get approval for each program, with all the irrationalities and constraints that
were built into their program structure. It was a deal made in heaven. It took a
lot of negotiating and there was a lot of conflict around it, but that was the
In many ways, it was a slow-acting poison pill. It built into our system the
potential for deep conflict between the federal and provincial governments
because it separated expenditures from the policy role of the federal
government. The federal government still could attach conditions to the transfer
of funds. Nothing happened in 1997. The conditions attached to what then was the
health insurance legislation remained intact and the provinces had to agree to
meet those conditions to get the funding. However, the feds were not committed
to 50-50 funding anymore. The federal government had an undiminished policy
role, but there was not the same commitment on the financial side. Essentially,
those financial transfers to the provinces declined, but the policy role
remained in tact.
The other reason the 1977 compact was a slow-acting poison pill is that it
introduced the big division between cash and tax points. Senators may be
familiar with this, and perhaps I should just go over it. The 1977 decision to
transfer some of the federal contribution in the form of a cash transfer and
some of it in the form of tax points built into our politics an enduring
There is no single answer to the question as to what is the federal
contribution to health care. The provinces have taken the view that the
transferred tax points are simply part of the tax base of the provinces and that
the federal contribution is therefore the cash contribution. The federal
government says that, no, its contribution is both the cash transfer and the
value of the tax points transferred in 1977, as escalated by growth in the
economy. As a consequence, there are two answers to the question regarding the
federal contribution to health care.
Both the provinces and the federal government are right. They both define the
system differently and, in their terms, they are both correct. Again, there is
no longer a single answer to the question. There is no agreement on the
question. A lot of bitterness has been built into our federal-provincial
relations because of the structure of the 1977 agreement.
Personally, I lean to the federal view that we should count the value of the
tax points transferred. Politically, however, our citizenry will never fully
grasp the complexities of that financial deal. In 1977, we built into our system
slow-acting poison pill, which has now come to full fruition in the level of
conflict we see.
These things unfolded quickly after 1977, as the federal government for a
variety of reasons had to restrain its transfers because its deficits became a
larger and larger problem. This began in the 1980s and accelerated in the 1990s.
However, the federal government maintained its policy role and reinforced it in
1984 with the Canada Health Act, where it stiffened the terms and conditions
attached to the transfer in the health care sector with provisions that
effectively eliminated what was called balanced billing or extra billing and
These trends came to a head in the 1995 budget, which introduced the CHST. It
took the social assistance component, folded it into the block transfer and
significantly reduced the federal cash transfer. There were no changes to the
conditions attached on the health care side, but the aftermath of the CHST
experience was to take these building tensions and just explode them. The result
was a period of deep distrust in our federal-provincial relations, a distrust
which remains deep and is not declining very quickly, if at all.
In effect, the provinces were beginning to say that the old, post-war model
was gone and that they needed a new social union. The social union that emerged
from the bargaining between federal and provincial governments was an attempt to
re-establish the system. Of interest to me was to which of those four models
would we jump?
If the old cooperative federalism model was no longer working well in the
forum of the 50-50 conditional grants, with the possibility of unilateral action
on either side, and if that model was not one with which people were willing to
live, to which model would we jump? Would we jump to classical federalism where
the idea was to avoid overlap and duplication, or would we jump to the
co-determination model, where the idea was to build a deep set of joint controls
The provincial consensus, known as the consensus bargaining position that
came out of the ministerial council established by the premiers -- the consensus
position which the Quebec government joined at the last moment -- fundamentally
said that we are not going to classical federalism. That is why it was very
surprising that Quebec joined. The consensus was an acceptance that
interdependence is the nature of the world and that both governments will be
involved. What the provinces wanted, essentially, was joint decision-making.
They wanted, in my language, co-determination. The provincial governments wanted
joint decision-making over federal government transfers to individuals and to
the provinces, as well as joint interpretation, implementation and enforcement
of programs like the Canada Health Act.
The provincial position was the strongest assertion of what I am calling
co-determination or the joint decision-making model; in other words, the CPP
model exported to the whole sector.
The federal government was reluctant to get into negotiations and went into
them slowly. When it did go in, its priorities were very different, having to do
much more with mobility and accountability issues.
The deal that was struck in the end came closer to the federal model than to
the provincial model, but there are elements of that provincial push in what we
have established today.
The next model talks about the deal. I talk about the nature of the Social
Union Framework Agreement. I do not know if senators have had a look at that in
this context. We can talk in detail about the elements of the agreement, but it
sets out principles.
The next two sections of the agreement are the ones the federal government
was and is today still most interested in -- mobility and public accountability.
Then there are sections dealing with the federal spending power and dispute
avoidance and resolution.
This is where the provinces put their weight. They remain most interested in
the agreement that was struck. I will not go into the financial components of
the deal, but we can come back to that if you wish.
I suggest that we skip to the last chart I circulated. We can come back to
whether any of this matters to the nature of our democracy in a moment, if you
wish. Let me talk about where we ended up on the models of federalism that I
Under the Social Union Framework Agreement, we retained the mix of models.
One of the refreshing things about Canada is that it has always refused to make
up its mind about federalism. We do not have a single philosophy about what a
federal state is about. We have always mixed different concepts of federalism.
There has been a strength in that position in that it has allowed a flexibility.
If one process is not working, we can shift to another. As I said early earlier,
a neat and tidy mind is a serious deficiency in this area.
We continue to mix the three models, and elements of the classical model
remain. In the federal spending power there is the capacity of the federal
government to make payments to individual citizens and to institutions, such as
research institutions, et cetera, through its granting councils. That is
undiminished. The only requirement is that there be advance notice and
consultation on such transfers.
In terms of transfers to the provinces, a much more elaborate agreement has
been struck, which includes what one at this stage would have to call a faint
element of joint determination. Although I say "faint", there is some.
The federal government has agreed not to establish any new programs without the
support of a majority of provincial governments. Thus, the federal government
has bound itself not to move without a wider provincial consensus.
There are also provisions relating to the nature of the programs that can be
built under the new system. Governments will negotiate objectives. In effect,
they will build an array of ways of meeting those objectives. Provinces that
already have programming in place will be able to receive funding, even for
programming already in place. Any government that agrees to work on the
objectives and agrees to the accountability mechanisms will receive its fair
share of the funding.
In some ways, this is a weak form of joint decision-making. It certainly
changes the rules that govern new initiatives.
In the agreement, there are also what the provinces regard as weak provisions
relating to dispute avoidance and dispute resolution, which, fundamentally, were
about the Canada Health Act. That is what the provinces were interested in when
they pushed that area. By provincial standards, they are relatively weak. We can
come back to that and discuss them in detail, if you wish.
I will end my comments with two points. First, one of the interesting things
about the SUFA and the new federal-provincial relationship we have established
is how general the rules are and how it is impossible to tell in detail how it
will work out because the established rules and norms are quite general. Much
will depend on the political will that federal and provincial governments pour
into the agreement. What they want it to be will be as important as what is on
Given the general nature of the terms, there have been wildly conflicting
interpretations of what happened. In parts of Quebec, the SUFA has been seen as
a centralizing document, with predictions that this instrument will lead to a
major expansion of the federal role. This has come from the Quebec government
and a number of sovereigntist intellectuals in Quebec who see this as the new
face of centralism.
Elsewhere, people have argued that this is a major decentralizing device. For
example, Tom Kent was an advisor to the Government of Canada in the days of the
introduction of medicare. He was a principal advisor to Mr. Pearson. He has said
that this is the end of shared-cost funding, period, and that we will never see
it again. No government in its right mind, quote, unquote, would ever transfer
funds to the provinces under these terms and that all that is left to the
federal government is direct transfers to citizens.
Those are two diametrically opposed interpretations, each consistent with the
details of what is written on paper.
Given these wildly conflicting interpretations, what has the experience been
in the last 13 months since the agreement was struck a year ago in February? I
say it is too early to tell, but it is clear that there are many tensions
surrounding the agreement.
The Social Union Framework Agreement was never intended to end conflict.
There will be conflict. You do not violate the SUFA if the provinces campaign
for the federal government to raise its expenditures on health care. Similarly,
I do not think it violates the SUFA for the federal government to speak
politically about the intentions of the Government of Alberta in the area of
private sector clinics.
The issue is whether the SUFA will provide rules that will help us manage
those conflicts. My own sense is that we are a long way from having those rules
fully worked out. The federal government is much more interested in the mobility
and accountability provisions. The provinces want to strengthen the
dispute-resolution portions of the agreement. They see those as weak and are
working now to try and strengthen them, to get in place a more fully developed
code that would indicate, in much more detailed terms, when a dispute is
actually triggered and how it will be resolved. This code would be, by analogy,
much like our international trade agreements. For example, how do we resolve
disputes in international trade? That is the kind of formality they would like
to see built into the agreement. They find the existing terms not sufficiently
clear and defined to be triggered with clear ease.
The other big issue is whether, in the current context, governments, and
particularly provincial governments, will actually want to use the terms of the
SUFA to discuss the future of health care. The goal of the provinces, I believe,
will be to increase the federal contribution through the CHST, which is
relatively undefined, rather than enter into detailed negotiations about the
future of Canadian health care where the process of defining will be a joint
In a strange way, although the provinces pushed hard for joint
decision-making and joint rules, sometimes one must worry a little about what
one asks for because one might get it. It is a little unclear whether they
welcome the opportunity to sit down jointly with the federal government to
define the new health care system of the future. They may prefer the maximum
freedom to move on their own through the CHST transfers.
It is not clear to me whether the SUFA will actually constrain the way in
which this issue is worked through. On the other hand, it is clear to me that
the way it is worked through on the health care side will determine the weight
of the SUFA. Child benefit improvements have been wonderful, but the reality is
that future federal-provincial relations will turn heavily on the resolution of
this question of how to resolve federal-provincial health relations in the next
The Deputy Chairman: Thank you for an excellent presentation. You talk about
the Canadian way and the retention of mixed models and going back to
co-determination. Polling results released yesterday by Environics and by
Goldfarb said that the Canadian public will not tolerate one level of government
blaming the other. They are sufficiently concerned with this issue, but, again,
they want an agreement. You talked about co-determination. In reading the
provinces' comments, they seem to want to follow that model.
Senator Cohen: I repeat the question I asked of the previous group because I
think the answer of national standards has already been given.
When I travelled the country as part of the task force on poverty, everywhere
we went witnesses said they wanted to see national standards back on the public
agenda. I know that "national standards" is a term that no one wants
to hear anymore. The provinces really do not like the term.
Do you think the idea of national standards is completely out of the picture,
or is there a place for national standards with the hook of transfer payments to
the provinces? Your argument has already changed my viewpoint somewhat.
Mr. Banting: I am actually a supporter of the proposition that there should
be a framework setting the broad parameters of core social programs, such as
health care, in this country. I will come to the issue of national standards in
a moment, but I think of it as a broad framework.
The argument can be made on two grounds. First, one can make the argument on
efficiency grounds. It is economically inefficient to have a set of social
benefits that are so diverse across the country that citizens who want a more
expansive health care system actually must move from one province to the other
to get it.
People who believe in the classical model of federalism say that it provides
various levels of social benefits, where people who like a large social benefit
package can gravitate towards the region that has the large benefit package and
those who prefer a more modest benefit package with lower benefits and lower
taxes can gravitate to another region of the country.
I am not an economist. I have many good friends who are economists, but I
think only an economist would think that one would move one's family over issues
such as those. I think it is economically inefficient and would lead to an
irrational allocation of resources across the country if people were, in a
sense, needing to move for those kinds of fiscal reasons.
Companies work not just nationally but internationally. To build a private
company benefit package to compensate for variations across provinces in key
areas like health care insurance strikes me as economically inefficient.
An economic case can be made for a broad framework of programs where there is
broad comparability across the country. The strongest case, however, is the
social case, which is rooted in the proposition that for all of our regional
communities and cultures, for all of our differences, there is actually a
community of Canadian citizens. Citizens in Canada have a broad common attitude
or approach to these issues, and we should reflect that in our policy
structures. There are no radical variations in the preferences of Canadians on
health care from one region to another. There is actually a striking consensus
across the country. Citizens may wish programs to be delivered locally if they
believe their governments are more responsive, but on the broad structure of
health care, there is a pretty solid consensus across the country.
I was quite heartened to see that this committee plans to look at other
countries. I hope you will also look at other federal systems. We have been
doing some work on this question. It is almost impossible to find a modern
federation in which there are radically different levels of health benefits from
one region to another. There is something inherent in democracies which says
that citizens, wherever one lives, should have something like a common package.
That leads me to be in favour of a common framework. Does that mean I am in
favour of national standards? I would say that as long as there is a common
framework, there must be a lot of flexibility in how it is delivered.
I am quite comfortable with the language of the social union agreement, which
says that what we need in common are objectives and a broad framework where we
can have considerable variation in how people deliver them. I think the Canada
Health Act is quite consistent with variation in delivery mechanisms and is
designed so we can use community health services, and so on.
"National standards" as a term carries a lot of political baggage,
but with a language of common norms, goals and objectives, as long as we keep it
at that broad framework level, would be my preference.
Senator Cohen: I like the language and am very comfortable with it. I thank
you for your explanation.
Mr. Banting: I apologize for the length of my explanation, but I do hope you
will look at other federal systems.
The Deputy Chairman: Are there any examples you could give us?
Mr. Banting: We are part way through a project. We should have a book out at
the end of this year. I would be happy to make it available, if senators would
find it interesting. The countries we are looking at are Germany, Belgium,
Australia and the United States. We are not looking at Switzerland only because
our colleague from Switzerland became ill and was unable to complete the
project, but that would be another country worth looking at.
It is striking in all of those systems that a common health care system
exists. There is a broad similarity of approach. In some countries, there is a
heavy public orientation. In some countries, as in the United States, there is a
different approach with a different mix of government and markets. However, in
each country there is a common approach across the country with, in many cases,
local delivery. In Germany, there is a structured national system with local
delivery and much smaller delivery systems than provincial governments.
The Deputy Chairman: That is interesting. If you were to ask Canadians about
the United States, they would not believe that there is a common health care
system in place there.
Mr. Banting: There is not a universal health care system in which all
Americans are enrolled, but the mix of government and private sector health care
is broadly the same across the states. There is variation at the state level,
but it is not large. If you ask what proportion of the population is uninsured
in the United States, there is a minor variation between states, but it is
broadly a common picture.
Not many states have universal coverage. You will not find states with
universal coverage on one hand and other states with virtually no coverage on
The Deputy Chairman: Thank you for your comprehensive presentation and