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

of the delivery of quality health services in the provinces by joint meetings and other exchanges resulting in cooperative relationships and policy developments (including federal funding decisions) between federal and provincial governmental officials (D. Adams 2001; Bakvis, Baier, and Brown 2009; Banting, Brown, and Courchene 1994; Heuglin 2003; O’Reilly 2001; Ryan 2003).

More recently, federal and provincial authorities have often taken up adversarial postures (D. Adams 2001; Boessenkool 2010; Grey 1998; Ryan 2003). To some extent, the constitutional obligation of federal asymmetrical “equalization payments” to enable poorer provinces to achieve comparable levels of health care services has contributed to these strains (Bird 1994; O’Reilly 2001). Governmental officials in the “have” provinces have felt that they could make use of more revenue to meet citizen demands on the health care delivery system, whereas those in the “have not” provinces have felt that the federal government should be more generous in providing them with revenue. Quebec, in some situations, is in an asymmetrical relationship with the other provinces and the federal government and, in other situations, in a more symmetrical relationship. For instance, in the September 2000 meeting of provincial premiers and federal officials, Quebec agreed to a national health accord but not to the accord on early childhood development policy (Cameron and Simeon 2002; Detsky and Naylor 2003; for a discussion of the complexities of regional and cultural asymmetries in a federal state, see Swenden 2002). In addition, Quebec is unique among the provinces in that it does not participate in reciprocal-billing agreements among provinces for medical care—agreements that allow patients to receive physician services in another province by simply showing their home province’s health card—although it does participate in reciprocal agreements for hospital care (Canada Health Act Report 2010). However, the unwillingness of Quebec’s government to reimburse physicians who provide services in hospitals outside Quebec has led increasingly to Quebec patients’ being turned away from Ontario hospitals or being charged for use of Ontario emergency rooms at hospitals near the Quebec–Ontario