The federal context

The federal context in Canada warrants attention as it influences the negotiating space for provincial governments and medical doctors. While healthcare services are mostly under provincial jurisdiction (Section 92, Constitution Act 1867), the federal government plays an important role, particularly by using its spending power to uphold national standards (for example, with respect to insurance coverage for services provided in hospital or by medical doctors via the Canada Health Act, 1985).1 To various degrees and at different times in the history of Medicare in Canada, provincial governments have seen federal spending intervention as an attempt to exert control in a provincial domain (see Commission d’enquête sur la santé et le bien-être social, 1967– 1972, for example). Frustrations were especially high when the federal government significantly reduced its financial contribution to provincial health systems during the recession of the 1990s (CPHA, 1995; Snoddon, 1998; BCMA, 2000: 14) while still requiring that provinces meet the same national standards.

Spending power is the federal government's main means of influencing provincial or territorial health insurance plans. As part of the reformative social policy agenda that emerged after the Second World War, the federal government adopted the Hospital Insurance and Diagnostic Services Act in 1957. Under the Act, the federal government would cover approximately 50 per cent of provincial and territorial expenses for hospital and diagnostic services, conditional on provinces or territories respecting criteria such as universality (such criteria would later be integrated into the Canada Health Act). As Medicare historian Malcolm Taylor describes, ‘the majority of provincial governments, previously relatively unconcerned with the economic and health problems of their citizens, now had to face both an aroused public opinion and, for the first time, the prospects of the compelling pressures of provincial grants inducing them to action in an area clearly of provincial constitutional jurisdiction’ (Taylor, 2009: 68). In 1966, the federal government passed the Medical Care Act. Again, the federal government would finance approximately 50 per cent of the costs of medical services provided in provincial programmes that met certain criteria. Ultimately, these federal Acts forced the establishment of publicly funded provincial health insurance regimes across the country between 1968 and 1972, primarily focused on curative care.