'Where'd the love go?': Premiers claim Ottawa is turning its back on a health system in crisis

It's hardly the first relationship to struggle under the pandemic's health and financial pressures, but Canada's dysfunction-prone federation appeared to be in need of a skilled mediator or two this week.

Like aggrieved partners now speaking only through lawyers, premiers gathered in Victoria, B.C. on July 11-12 to reprise their call for an urgent First Ministers meeting to negotiate an increase to the Canada Health Transfer (CHT). As premiers made their pitch to assembled journalists, senior federal ministers popped up in the media to blow off their demands.

"Where'd the love go?" soon-to-retire B.C. Premier John Horgan said in his final press conference as chair of the Council of the Federation. "Everything was so fine. And then it wasn't."

To reporters who covered the several dozen first ministers' meetings held during the COVID scramble, it seems a bit revisionist to say the relationship was "fine" during the pandemic.

Sure, the first ministers talked a lot (virtually). But it took a lot of talking to hold together all that was coming apart in that emergency, and to pursue border restrictions and vaccination policies.

Patience is frayed now because Prime Minister Justin Trudeau hasn't been meeting with the premiers in person. One-time funding for specific things like surgical backlogs was announced by Health Minister Jean-Yves Duclos in March but Finance Minister Chrystia Freeland's spring budget offered nothing longer-term.

"Ghosted," is how Horgan described — "with sadness, not anger" — what he sees as a lack of federal engagement.

Horgan said federal Intergovernmental Affairs Minister Dominic LeBlanc only got around to calling him to check in prior to the meeting last Sunday morning, as premiers were already winging their way to Victoria.

"Is there anything else on his docket beyond the 13 of us?" the premier said. "I wouldn't think so, but here we are."

The day after the premiers went home, Freeland's office issued a press release confirming she'd just transferred the $2 billion top-up to the CHT Duclos promised. It gave reporters a chart describing how transfers break down by jurisdiction. And then Freeland left for the G20 finance ministers meeting in Bali, Indonesia.

Practitioners and patients agree — the health care system is breaking down. But the governments responsible appear to be in a stalemate, counting on each other's inaction to distract from their own ineffectiveness.

'Fake' figures and 'triple Rs'

The shots fired this week were aimed at two things: math and accountability measures.

LeBlanc called the premiers' figures on the federal contribution to health care "fake."

The premiers are still using the same favourable-to-them calculation they've put out for months to make the case that Ottawa is no longer paying its share.

Was the CHT ever intended to pay for half of rising health costs? Not really. But did LeBlanc really need to use a provocative term like "fake"?

Both sides agree new investments are needed. Trudeau maintained Wednesday they're still coming.

"The federal government will be there to invest in health care," he said, "but we are going to make sure that those investments deliver for Canadians."

And that's where the accountability fights start.

The federal instinct to attach strings and safeguards is understandable. Ask Stephen Harper how it feels to reform equalization payments at the request of lobbying premiers — only to watch one use the new money to roll out a big provincial tax cut. More recently, provincial watchdogs concluded that billions of dollars in federal COVID support for the provinces was not spent as intended by Ottawa.

But federal ministers who try to tell provinces how to spend in an explicitly provincial jurisdiction like health can expect some pushback. That may explain why Duclos, in a recent interview with CBC News, sounded like a management consultant giving a Ted Talk — framing his arguments around what he called a "triple-R rule": respect for jurisdiction, shared responsibility, and a focus on results.

"The federal government is unable and will never try to micromanage the health care system in Canada," he said.

Negotiations have to be "sequential", Duclos said. Health ministers must first meet to set the "results" they want to achieve — a process that's not finished yet, apparently — before anyone can talk money, he added.

'Ragging the puck'

Premiers pushed back hard at the suggestion that they can't be trusted to spend health transfers on health. Their books are public, they told reporters in Victoria, and they should be scored by the voters who elect them, not according to some checklist on Duclos' desk.

Horgan accused Ottawa of claiming a problem that doesn't exist. Holding back federal money until certain conditions are met would be a "cop out," he said, and attaching strings to new health care funding makes it seem as if the two levels of government have a master-and-serf relationship. (He's not wrong. Constitutionally, the provinces are not subordinate to the federal government, even if the federal government has demonstrably more fiscal capacity.)

Alberta Premier Jason Kenney, a lame duck premier now free to speak as he will never again have to negotiate with the feds, put it bluntly.

"If they've got something to say to us about conditions, come and sit down and say it," Kenney said. "But so far, it just looks like they're ragging the puck because they have no intention of paying their share."

To sum up: the feds say they won't negotiate the cash until they've worked out the conditions, while the provinces remain wary of any conditions and say they can't proceed without more cash.

Trudeau's vague explanation for not meeting with the premiers to discuss the CHT is based on bandwidth: a pandemic, he said, isn't the time.

But when the federal government wanted a national child care program in the middle of the pandemic, it put up the money first and then found the time and energy to negotiate a custom slice for each province.

Freeland's current fiscal framework lacks a CHT hike and she's warned more restraint is required to counter high inflation. What message does that send about her intentions?

The federal government also pointed to election timing as one reason for the lack of engagement between the PM and premiers on health spending. The Liberals say they fought a bruising federal election last fall and didn't want to meddle in the Ontario and Quebec election campaigns this year.

Will Trudeau's calendar suddenly free up after Quebecers vote in October? Or was that just an excuse to kick the can?

Pushback and payback

Two signs emerged this week that the provinces want to raise the political cost of federal inaction. One was a public relations gambit, while the other threatens to take hostage some Liberal policy priorities.

CBC News reported that the premiers are considering a national advertising campaign to make the case to Canadians that their health care system will suffer if the federal government doesn't spend more on it.

A new "blame Ottawa" offensive could redirect anger away from provinces responsible for backlogs and bad health care experiences. But it ignores a point made by health care advocacy groups — that some reforms, such as interprovincial recognition of professional licences and credentials, can happen without an argument with Ottawa over money.

The potential hostages are the Liberals' pledges to implement national pharmacare and dental care coverage – two conditions set by the federal NDP earlier this year in return for its support on confidence votes in the House of Commons.

Adding drug and dental coverage, Horgan said, isn't possible without a "firm foundation" of financing for the services already covered.

"You can't get to one without the other," he told reporters. 

Since federal officials need provincial cooperation to implement national schemes outside federal jurisdiction, could these programs slow-walk or stall until the CHT increases?

That might test the patience of the federal New Democrats currently protecting Trudeau from snap election threats.

Announcement-free event

The first big win for the Council of the Federation (COF) in 2004 was a deal with Paul Martin's Liberal government on health funding.

At its inception, COF was supposed to be about leading in its own right, not waiting for Ottawa to solve national problems. And Canada's premiers showed themselves capable of more than lobbying the feds by coming up with an agreement on bulk drug purchasing and the imperfectly implemented interprovincial trade deal.

But there were no actions or announcements approaching the significance of those measures in this year's COF communiqué. Instead, it piled on more demands for Ottawa beyond health care, on things like infrastructure and immigration.

Did losing a few years' worth of in-person meetings make it difficult to advance other files? Perhaps.

Victoria's Empress Hotel was full of officials getting face time again with their colleagues across the 13 jurisdictions. Media were denied access to not only their meetings but also their social and networking events, so it's possible reporters simply couldn't get a line on other work going on behind the scenes.

The earnest rhetoric in Victoria made evident the premiers' collective determination to prevail in a 2022 rematch of the health transfer payment fight. But it's possible they focused on federal demands because they had no progress to announce on other things under their control.

A First Ministers meeting won't fix that.