| Chapter 1: | Examining Provincial Variability |
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border (Alphonso 2010; Picard 2006). Given concerns about separatist sentiment in Quebec over the past twenty years, the federal government has been unwilling to take action.
Recent trends at the federal level, under the current Conservative government, have supported a limited role for government—and of course, an even more limited role for the central government—with regard to the various elements of Canada’s health care system (Graefe and Downs 2009; Picard 2010). Although future negotiations between provincial and territorial health ministers and the federal government remain speculative, by articulating a federalism in the area of health care that allows provinces to exercise a great deal of initiative regarding the characteristics of their health care systems but without corresponding future expansion of federal funding, the Conservative Harper administration has encouraged the utilization of the market system in the delivery of health care services that could be made at provincial and territorial levels if sufficient federal revue support is not forthcoming (Fierlbeck, forthcoming; also see Bickerton 2010).
Meeting provincial obligations regarding the delivery of health services has been complicated by the fact that in the decade after the passage of the Canada Health Act, the average level of federal spending for health care in the provinces declined from about 33 percent to 24 percent (Commission on the Future of Health Care in Canada 2002). In addition, the Canada Health and Social Transfer federal payment system for the provinces and territories initiated in 1995 involved a substantial reduction of cash transfers and lacked an automatic escalator to guarantee a cash floor. This situation led to periodic provincial–territorial–federal government meetings and corresponding negotiations on federal health transfers to the provinces and territories (Marchildon 2004a). Faced with criticism from provincial governments in 1999, the federal government increased the level of federal funding.
The First Ministers’ Health Accords of September 2000 provided federal funds for the specific objectives of enhancing primary care and