| Chapter 1: | Examining Provincial Variability |
it is necessary to review the institutional and historical development of Canadian provincial health care policies in the context of Canadian federalism. Thus as Fierlbeck noted regarding patterns of federal policy change the area of health care in the Canadian context,
one must identify three interrelated elements. The first is the set of power dynamics between the provincial, territorial and federal governments. Health care federalism is irreducibly interwoven with fiscal federalism. Thus, one must consider the armature of laws and institutions upon which political action is structured; the fiscal capacity of each government; the pressures each administration faces from the electorate and political interest groups to achieve particular goals.
(Fierlbeck, forthcoming)
She went on to characterize some past and present trends: “the disentangled federalism of ‘watertight compartments’ gave way to the collaborative federalism of the postwar years [post–World War II]; the breakdown of collaborative federalism in the 1990s led to discussions of interprovincial federalism; and the bilateral ‘hourglass’ federalism of the Martin years was superseded by declarations of ‘open federalism’ under the Harper administration” (Fierlbeck, forthcoming; also see Bickerton 2010).
The functioning of Canadian federalism in the area of health care service delivery is characterized by a dynamic relationship between national fiscal power and the formal constitutional responsibility of the provinces to provide for health care services and regulate health care providers. The federal government, however, has clear constitutional responsibility for the regulation and market entry of health care products (drugs, medical devices, etc.), as well as for the market activities of manufacturers. This arrangement was recently described as “Canada’s ‘co-dependent’ constitutional relations” by a prominent conservative analyst who added that “the result of this fiscal churning is that no government has clear responsibility for delivering key programs and both sides readily blame the other when something goes wrong” (Boessenkool 2010, 3).