The Political and Economic Sustainability of Health Care in Canad ...

covered). In 1996 Quebec introduced an individual mandate for pharmaceuticals, leaving consumers to decide between private plans and a public option financed in part through premiums, but the long-term sustainability of the program is doubtful (Pomey et al. 2007). British Columbia, Saskatchewan, Manitoba, and Ontario provide catastrophic coverage for drug expenses beyond income-related deductibles. Moreover, there are programs that cover pharmaceutical costs for low-income seniors in every province (Tuohy 2009b). However, a 2004 study indicated that for senior households, the percentage of prescription drugs expenditures that was over 4.5 percent of annual income ranged from 0 percent in British Columbia, Saskatchewan, Manitoba, and Ontario to 40 percent in New Brunswick. For nonseniors, the range was from 0 percent in the same four provinces to 12 percent in Nova Scotia (Coombes et al. 2004). Calls for a national “pharmacare” program, integrated or not with the CHA, have appeared on the political agenda since the end of the 1990s—but to no avail. This leads to provincial asymmetries, such as one noted by Fierlbeck: “My sister in Ontario gets Lucentis for her wet macular degeneration; why am I denied this treatment, just because I live in Nova Scotia?” (Fierlbeck, forthcoming).

Within different Canadian constituencies (as well as globally), federalism is interpreted quite differently. Daniel Elazar has termed this phenomenon a prismatic view of federalism (Elazar 1999; Gagnon and Iacovino 2007). Nevertheless, the federal–provincial relationship in health care service delivery has often been viewed as cooperative federalism, collaborative federalism, or partnership. Cooperative federalism implies cooperation among the federal, provincial, and territorial levels of government but with initiative and financial leverage exerted by federal officials (Cameron and Simeon 2002). The terms collaborative federalism and partnership imply a more equal provincial–federal or territorial–federal relationship, one closer to “codetermination” (Bakvis, Baier, and Brown 2009; Cameron and Simeon 2002; Gagnon and Iacovino 2007; Pelletier 2004; White 2002). Regardless of the particular nuance applicable in a given situation, the federal–provincial relationship involves the facilitation