"An election is no time to debate serious issues."
Kim Campbell, 1993

Health care was at the top of the list of concerns for voters in the federal election. It is likely to continue to occupy top spot for the May 17, 2005, provincial vote. It is possible for health care to be top of mind without being vote determining; if differences between the parties are not clear, health care can be cited as the top issue by voters without it having any effect on determining party preference.

When governments talk about health care, what they frequently mean is "federal-provincial fiscal arrangements". The federal government can shell out more money for health care so as to fund provincial tax cuts without a dime more going into health care. Of course, all of the provincial governments will deny that, and the federal government will be accused of intruding in provincial jurisdiction when it tries to attach strings to the money.

In 1981, the "Report of the Parliamentary Task Force on Federal-Provincial Fiscal Arrangements" was published. Dr. Rodney Dobell of the University of Victoria headed the group of advisors to the parliamentary committee; Rodney is the brother of Premier Campbell's chief Deputy Minister. One of the conclusions of the Task Force was "that there is an overriding national interest in the operations of health insurance plans and in the effectiveness of health care delivery, and that the proper role for the federal government is the formulation, monitoring and enforcement of conditions on its financial support of provincial programs." It reached that conclusion three years before the Canada Health Act was adopted so as to increase the power of the federal government to financially penalize provinces which fail to meet national standards for the "five principles of Medicare": public administration, comprehensiveness, universality, portability, and accessibility.

When the Canada Health Act was adopted, BC had daily hospital user fees which were contrary to the Act; Alberta and Ontario had increasing incidents of extra-billing by physicians. It took three years after the passage of the Act with its threat of financial penalties to bring an end to extra-billing, and an end to hospital user fees. That was 20 years ago when Medicare was still considered to be little more than public health insurance. Since then governments have moved to make a real "system" of health care, using their monopoly power not only to pay the bills, but to control most aspects of health care delivery.

When the first ministers sit down this summer to discuss increased federal funding for health care, they will be a long way from the environment of 1984 which saw unanimous support for the Canada Health Act. Efforts are now made to apply the principles to completely different situations such as stand alone surgery centres, pharmaceuticals, shortages of professionals, regional differences in accessibility and unacceptable wait lists. The world of 2004 is a lot more complicated than an insurance model with a few extra charges.

An honest debate about the future of Medicare needs to recognize 20 years of change, and it needs to separate the redistribution of revenue and the powers of taxation from national standards for Medicare. Do Canadians want the 10 separate provincial schemes to grow increasingly different, or is there still a desire for some common standards? Does anyone care as long as they can get their procedure when and where they need it? Is it possible to satisfy enough people so that the demand for private queue jumping clinics is reduced enough so as to make them uneconomic? If not, should the size of one's wallet determine who has to wait?

It is not just health care that has changed in the past 20 years. It probably is time to redefine the five principles of Medicare in the context of what problems people most want to solve in 2004. The reason for the principles is to establish the grounds for which the federal government can financially penalize the provinces. Shouldn't that clout be related to today's problems? Extra billing and hospital user fees may be a thing of the past, if we aren't rushing back to 1984. Today's problems are unacceptable waiting lists, and uninsured pharmaceuticals. Uninformed references to a 20 year old statute won't help to advance the debate.