ANALYSIS

Canadian federal–provincial/territorial funding of universal health care: fraught history, uncertain future

C. David Naylor MD DPhil, Andrew Boozary MD MPP, Owen Adams PhD n Cite as: CMAJ 2020 November 9;192:E1408-12. doi: 10.1503/cmaj.200143

s the coronavirus disease 2019 (COVID-19) epidemic con- tinues in Canada and financial pressures mount on all KEY POINTS levels of government, the federal–provincial/territorial • Federal–provincial and territorial cost-sharing arrangements cost-sharingA framework for universal publicly financed coverage that support publicly financed health services in Canada have of physician and hospital services — commonly referred to as evolved over the course of more than 60 years and remain — has once again become a point of contention. In contentious today. September 2020, just days before a federal Speech from the • The fraught history of cost-sharing illustrates why the federal and Throne, Canada’s provincial and territorial premiers called for provincial and territorial governments have divergent views on a fair deal to support Canada’s health care systems. the federal government to become “a full funding partner” in health care spending, raising its contribution to provincial and • Examination of the benchmarks used historically for cost sharing shows that there is a ~$20 billion variance in the level of territorial health spending from 22% to 35%, an increase of current federal support depending on whether credit is given $28 billion per annum.1 Yet, to the expressed disappointment of for tax points transferred in 1977, and on a cash-only basis, the premiers,2 the Throne Speech offered no increases in federal discrepancies against benchmarks range from ~$15 billion in funding for health. Instead it reiterated the Government of Can­ surplus to a ~$23 billion deficit. ada’s previous commitment to “a national, universal pharmacare • These discrepancies and ongoing federal–provincial and program” and set out some steps toward that goal. territorial disputes about cost sharing pose challenges to the jurisdictional collaboration that is essential for expansion of Although Medicare remains one of the social programs that public coverage and successful reforms in health care. Canadians value most highly, its stability, and any potential • A rational process to determine a fair deal for interjurisdictional expansion of Medicare services, such as pharmacare, depends on funding of Canada’s publicly financed health services is urgently a robust federal–provincial/territorial cost-sharing framework. needed. Yet, the conflicting perspectives of different levels of government pose major challenges to any expansion of public coverage or pursuit of national health care reforms. universal medical services insurance in 1962. This constitutional We review the history of federal–provincial/territorial bargaining reality means that Canada has 13 somewhat distinctive provincial that led to the current Medicare system and consider what consti- or territorial health care systems. Those systems have much in tutes a fair deal in the current climate, drawing on a variety of print common, however, given shared fiscal and legislative DNA arising and online sources (Appendix 1, available at www.cmaj.ca/lookup/ from a series of agreements that, since the late 1950s, have set doi/10.1503/cmaj.200143/tab-related-content) as well as the first- out terms and conditions for sharing of specified costs between hand observations of 2 of the authors starting in the 1980s. the Government of Canada and provinces and territories.

What is the history of Medicare bargaining in Full cost sharing (1957–1976) Canada? The Hospital Insurance and Diagnostic Services Act, which received Royal Assent in April 1957,3 offered funding to partici- Nothing in the 1867 Canadian constitution anticipated national pating provinces at roughly 50% of the per capita cost of eligible health insurance programs. The constitution instead assigns services delivered at general hospitals. Cost sharing initially authority for oversight and delivery of health care services to meant that richer provinces received more funding because of provinces and territories. Hence, provinces moved at different higher per-capita outlays on hospital care. This was mitigated by speeds to implement public coverage of health care, with Sas- using national average spending levels as a benchmark for half katchewan pioneering universal hospital insurance in 1947 and the allocation.

E1408 CMAJ | NOVEMBER 9, 2020 | VOLUME 192 | ISSUE 45 © 2020 Joule Inc. or its licensors ANALYSIS 19 A 14 21 No 17 20 This This E1409 Estab- 13 15 18 ISSUE 45 ISSUE | territorial working group estimated that these new rules after which a separate Canada Health Transfer was reinsti- after which a separate Canada Health Transfer 16 The re-elected government convened the Romanow Commis- The re-elected government First ministers reached a second Health Accord in February Accord in February First ministers reached a second Health The Romanow Commission had tied the 25% federal cash 25% federal cash The Romanow Commission had tied the of 2004 thatAt another First Ministers’ Meeting in the summer With a November 2000 election looming, the premiers’ com- With a November 2000 tuted in the federal budget, augmenting health funding by by funding health augmenting budget, federal the in tuted $34.8 billion over the next 5 years. However, most new funding was care. Only $9.5 billionfor short-term boosts to primary and home Health Transfer. was dedicated to base increases in the Canada sion on the Future of Health Care in Canada in April 2001. Among Health Care in Canada in April 2001. Among sion on the Future of observed that federal cash trans- other findings, the commission territories’ and provinces’ 18.7% of only covered in 2001/02 fers the Given services. physician and hospital on expenditures - lished Programs Financing Act agreement, the commission rec should transfer cash federal the “at a minimum” that ommended costs. be raised to 25% of those provincial and territorial 2003, contribution to only medical and hospital services. However, the However, services. hospital and medical only to contribution 2003 that the recent provinces and territories announced in July from 14% of total federal budget had only raised federal funding to 16%. provincial and territorial health spending thataccord 10-year third on a agreed the parties health, focused on for a generation.” ThePrime Minister called “the fix in the Canada Healthnew spending totaled $41.3 billion. Growth from initial one-timeTransfer accounted for $35.3 billion, arising increases spread over 2 years, and then application of a 6% annual escalator to the new base. The further increase was through term- limited funds for medical equipment and reductions in wait times. provincial/ New governments, old issues (2006–2018) repeatedlyhad Canada of Government the 1950s, the in Starting socialnational of adoption catalyze to capacity fiscal its leveraged A more cautious approach toterritories. provinces and programs by fiscal federalism ensued when a Conservative government took office in 2006. However, seeking re-election in 2011, Prime Minister Accord. Health fourth a negotiate to pledged Harper Stephen concern has been a core element of premiers’ arguments for for core element of premiers’ arguments concern has been a ever since. more federal funding to ignored and a First Ministers Meeting led plaints could not be combined the raised accord 2000 The Accord. Health first the from $15.5 billionhealth and social transfer in 2000/01 to $21 bil- - with one-time funding for medical equip lion by 2005/06, along technology and primary care reform. ment, health information negotiations ensued. Instead, at a December 2011 gathering of fed- Minister Federal ministers, finance territorial and provincial eral, in expired accord 2004 the when that announced Flaherty James 2014, the Canada Health Transfer escalator would remain at 6% until 2017 and then grow for the next decade at the higher of 3% per annum or the 3-year moving average of nominal GDP growth %. a vertical fiscal imbalance by economist G.C. Ruggeri in August August Ruggeri in G.C. by economist imbalance fiscal a vertical available at www.cmaj.ca/lookup/doi/10.1503/ 2000 (Appendix 2, vertical defined Ruggeri cmaj.200143/tab-related-content). face spend- governments as arising when subnational imbalance while revenue-raising capacity that outstrip their ing pressures time. surpluses over government produces the national VOLUME 192 VOLUME | To this To 5 Further Further 10 - These 2 fed 4 NOVEMBER 9, 2020 NOVEMBER | 6,7 CMAJ 8 His findings led to the 1984 His findings led to the 1984 9 11 Provincial and territorial officials Provincial and territorial officials 12 calculated that health transfers cumula- In 1979, Justice Emmett Hall was asked by the Government of In 1979, Justice Emmett Hall was asked by Several provinces worried that moving from 50:50 cost shar- Several provinces worried that moving from Sparked by the 1964 report of a Royal Commission chaired by chaired Commission of a Royal 1964 report by the Sparked In 1976/77, the last year for which funding for these 2 Acts isIn 1976/77, the last year Six federal budgets between 1985 and 1995 variously scaled Six federal budgets between 1985 and 1995 variously scaled Canada to revisit his 1964 report. ing to block grants would expose them to unilateral federal cuts. ing to block grants would expose them to who argued that block Others agreed with federal negotiators to reduce spending grants and tax points would allow provinces in favour of more cost- on medical services and general hospitals the provinces effective services such as home care. Ultimately, version of the and territories agreed to a slightly more generous - Financ Programs federal proposal, embodied in the Established ing Act that took effect in April 1977. Justice Emmett Hall, in 1966 the Government of Canada passed Government of Canada Hall, in 1966 the Justice Emmett of the national to cover 50% Act. This Act offered the Medical Care net of insured medical services, capita cost of all average per patient premiums. costs and plan administration reductions through to 1998/99 trimmed another $11.2 billion rel- ative to the 1977 agreed terms. eral initiatives underpin Canada’s national Medicare plan. national Medicare underpin Canada’s eral initiatives the Public Accounts of Canada, the coveragerecorded distinctly in spending. 49% of physician and of hospital spending was 48%

Partial restitution and health accords (1996–2006) As federal finances improved, the 1999 federal budget provided a base increase in combined health and social cash transfers of $11.5 billion over 5 years. –1995) The new deal (1976 it federal government began weighing how As early as 1970, the of in its share of health spending to the rate might limit increases product (GNP). (Gross national productgrowth of gross national from abroad to gross domestic productadds net income receipts - adopted as the preferred national bench [GDP], which was later Meeting in 1976, Primemark for cost sharing.) At a First Ministers 50:50 cost-sharing Minister Pierre Trudeau proposed replacing cost- 3 for payments 1975/76 the of One-half regime. new a with Act, shared programs (Hospital Insurance and Diagnostic Services as aAct and postsecondary education) would be paid Care Medical with a 3-year mov- block grant, escalated annually in accordance half other The growth. GNP capita per nominal of average ing taxes, allowing prov- would be offset by reducing specified federal immediate changesinces to take up those revenues without any to taxes paid by individuals and businesses. , consolidating earlier legislation and, for the the for and, legislation earlier consolidating , first time, giving the federal government authority to make ­dollar-for-dollar deductions of transfers to provinces that allowed user charges for publicly insured services. back the GNP escalator on combined health and social cash background 1991 a In payments. froze completely or transfers paper, Alistair Thomson tively reduced by $30 billion from 1986/87 to 1995/96. point, the federal government had honoured its 50:50 commitment. point, the federal government called for more investment based on previous benchmarks and called for more investment based on previous benchmarks and of concept the to introduced being after argument new a offered ANALYSIS vincial andterritorialgovernments, and promised,if elected, to negotiate a new HealthAccord with pro- criticized theHarpergovernmentforitsactiononhealthfinancing E1410 the 1980sand1990s, andagainin2011.Furthermore, legalredress ashappenedrepeatedly in and otherwisecontainitspayments — eral governmenttounilaterally changetheblock-grantescalator cost-shared services.However,it alsoopenedthedoorforfed- to invest preferentially in physican and hospital services as the only tional costsharingandmitigated aperverseincentiveforprovinces ously bundled or uncoupled from social transfers, ended propor- Canada’s cashtransfer,therebydrivingdownthefederalshare. spending outstripped generous increases in the Government of rose by almost 20%. From 1999 to 2009, provincial and territorial year 1974alone,outlaysforthe2cost-sharedhealthprograms seeking waystocontainitsfinancialexposure.Indeed,infiscal hospitals tophysicianservices,theGovernmentofCanadabegan ofextendingitspromise50:50costsharingfrom general 2 years risk ifthesubnationalpartnersfailtocontrolspending.Within Cost sharing on a proportionate basis puts the national partner at Federal attemptstocontainspendingonhealth care initiatives? What doesthismeanforpan-Canadianhealth annual escalatorof5.2%insteadtheprevailing3%. response, thepremierscalledforanewCanadaHealthTransfer In the GovernmentofCanadaandprovinces(Appendix 2). cerns aboutanimbalanceofrevenuesandresponsibilitiesbetween Conference Board of Canada that supported their ongoing con work donebytheOfficeofParlimentaryBudgetOfficerand costs inanynationaldrugcoverageplan.Theyalsohighlighted emphasized theneedforlong-termcoverageofescalationdrug /implementation-national-pharmacare/final-report.html), about-health-canada/public-engagement/external-advisory-bodies care, availableatwww.canada.ca/en/health-canada/corporate/ of theAdvisoryCouncilonImplementationNationalPharma- In July2019,withpharmacareonthefederalagenda(FinalReport The currentprovincialposition(2019–2020) place from2014/15through2023/24. as comparedtothoseexpectedhadthe6%escalatorremainedin would reducefederaloutlaysforhealthbyacumulative$36 billion provincial andterritorialannualoutlay. goal ofraisingfederalcontributionsfroma22%to35%sharethe began toapplymorepressureonthefederalgovernmentwith with thearrivalofCOVID-19,provincialandterritorialpremiers majority intheOctober 2015 federalelection. a the LiberalSpeechfromThroneaftertheysuccessfullywon health spending. increase theCanadaHealthTransferenvelopetocover25%ofall home careandmentalhealthinitiatives. for over 10 years while providing term-limited fundingof $11 billion the CanadaHealthTransferescalatorsetbyHarperGovernment summit occurred.The2017federalbudgetreaffirmedthedropin The adventofblockgrantsin1977/78,withhealthtransfersvari- In July 2015 premiers again called on the federal government to In July2015premiersagaincalledonthefederalgovernmentto 23 The Liberals during their campaigning soon after, TheLiberalsduringtheircampaigningsoonafter, 24 22 a commitment reaffirmed in acommitmentreaffirmedin 1 26 CMAJ 25 Yet again, no health Yet again, no health | NOVEMBER 9,2020 27 premiers premiers In 2020, In2020, - ​ | VOLUME 192 1977 cost-sharingagreement. federal officials seldom invoke this element of the cornerstone have shifted dramatically over the course of 4 decades. Today, provincial andterritorialtaxationpoliciesrevenuebases values foranygivenprovinceischallengingbecausefederaland impute anoverallvaluetothatcontribution.Butimputingfair federal authoritywasupheldbytheSupremeCourtofCanada. challenged unilateralfederalchangestohealthandsocialtransfers, proved impossible:in1991,whentheprovinceofBritishColumbia vation — andasourceoffrustrationtothoseworkinginthem. ture thatisarecognizedimpedimenttoefficiency,qualityandinno- tems areweaklyintegratedwithafragmentedbudgetaryarchitec- observed thatCanada’sprovincialandterritorialhealthcaresys- are notstrongperformers. waiting timesforawidevarietyofservices,Canadianhealthsystems pared withpeernationsonmanyperformancemeasures,suchas original arbitrarily cuttransfersinrepeatedabrogationoftheterms if theireffortsattimeswereunderminedbyfederaldecisionsthat they bearprimaryresponsibilityforthestateofthesesystems,even over deliveryofhealthservices.Thatauthorityinturnmeansthat Provinces andterritoriesrightlyasserttheirconstitutionalauthority Piecemeal provincialreforms ment ofCanada.” unequivocally withtheprovincialgovernments,notGovern- dering. Thepoliticalresponsibilityofimposingthesetaxesrests part oftheoveralltaxburdenprovince’sresidentsareshoul- ince aboutexcessivelyhightaxlevels,thosepointsaresimply vincial taxregimes:“Ifthereisapoliticaldebatewithinprov- the 1977taxpoints,claimingtheywerenowsimplyapartofpro- Imbalance rejectedallfederalclaimsabouttheongoingvalueof tax pointsareopaquecomparedwithannualcashtransfers. controlled endowmentforcost-sharedprogramsin1977.However, of Canadasoughttocreateapermanentprovinciallyorterritorially ent ofjointfederal– By assigningrevenuedirectlytoprovincesfromthefederalcompon­ Why docashtransfersdominatenegotiations? based onmedical andhospitalcosts. accepted specificallytountether spendingfromabenchmark foundational cost-sharingarrangement waspresentedand federal government.However, italsomakeslittlesense,asthe this benchmark represents a substantial surplus in favour of the physician andgeneralhospital services. AsTable1,row2shows, scaled initiallytobe25%ofaverageprovincialspending for Programs FinancingActdefinedcost-sharingcashtransfers Table 1 examinescost-sharingoptionsandbenchmarks. ), and health carefundsprojectedfor2019/20(seealsoAppendix 1 Figure 1showssomeoftherelevantflowsfederalandprovincial What isafairdeal? Indeed, by2006,thepremiers’AdvisoryPanelonFiscal As noted by the Romanow Commission, the Established ProgramsFinancingActlegislation.Whencom- | ISSUE 45 provincial/territorial tax returns, the Government provincial/territorial taxreturns,theGovernment 31 Predictably,financeofficialscontinuedto 29,30 Provincial and federal reviews have Provincialandfederalreviewshave Established 30 28 ANALYSIS E1411 (3062.80) (3940.50) 14 857.70 (23 912.00) (shortfall), $ (shortfall), Federal surplus Federal F value, $ value, 43 435.80 25 515.30 64 285.00 64 285.00 Benchmark Tax points $19 971.50 G GoC total $60 344.50 E C CHT 75% of total health spending). This historic 75% of total health spending). This historic $40 373.00 $186 332.20 Total public ISSUE 45 ISSUE | If the historic benchmark is applied and federal coverage of 37% I to 50% of the proportion of provincial and territorial spending to 50% of the proportion of provincial and territorial spending the when 1977/78 of as physicians and hospitals to attributable Act was struck (which at the time Financing Programs Established represented 74%– benchmark would thus see the Government of Canada covering no less than 37% of all provincial and territorial health spending. of provincial and territorial health spending is deemed a fair deal, the key question then becomes how tax points are tallied. If, as the VOLUME 192 VOLUME | Total CHA $102 061.00 A D Benchmark Total PT $173 743.20 $264 436.20 H Total health spending Total health $71 682.20 Total other NOVEMBER 9, 2020 NOVEMBER | CMAJ showing the total support provided by the GoC. (H) Provincial and territorial spending on services not covered by theshowing the total support provided by the GoC. (H) B 25% of total PT health spending health PT 25% of total 25% of PT health spending on physician and general hospital services hospital spending on physician and general health 25% of PT spending* health PT 37% of total 37% of total PT health spending* health PT 37% of total $78 104.00 Total private - territories. It is calculated only for fiscal years (2019/20), thus all totals for (D) to (I) are on that basis. Differ is the annual federal cash transfer to provinces and Since 2003 provinces and territories have used a benchmark of At no point has the federal government ever proposed to cover Note: CHT = Canada Health Transfer, PT = provincial/territorial. PT Transfer, CHT = Canada Health Note: was The expectation care. spending on health PT 74%–75% of total for services accounted physician and hospital Financing Act arrangement, Programs the time of the Established *At economic overall to in proportion escalate amount would of that a 50% share represented together that transfer of Canada cash and a Government points tax federal ceded that the 37% benchmark. services, hence funding all health for and be available growth Measure (value) Measure Table 1: Benchmarking the federal share of provincial and territorial publicly financed health spending (all values in millions in values spending (all health publicly financed and territorial provincial of share 1: Benchmarking the federal Table Canadian dollars) of CHT ($40 373.00) CHT + tax points ($60 344.50) points CHT + tax 25% of total health spending for cash transfers. As shown in Table 1 row 1, this leads to a shortfall in Government of Canada spending of $3062.80 million per annum, which is also questionable, as the initial agreement involved both tax points and a steadily escalat- ing cash transfer. 50% of all provincial and territorial health spending. An alternative baseline is its commitment to provide over time a block sum scaled conditions set out in the 1985 CHA. (I) Services covered by the 1985 CHA, specifically physicians’ services and general hospital care with related diagnostic services. conditions set out in the 1985 CHA. (I) Services covered - above 99% where both numbers are available). (F) Imputed value in 2019/20 dollars of tax points first trans ences are minimal (e.g., the calendar/fiscal ratio is Department of Finance Canada escalators of federal tax points transferred to provinces and territories in 1977.ferred to provinces and territories in 1977, based on (G) Combines the components in (E) and (F),

Schematic of current cost sharing relevant to Medicare in Canada, projected for 2019/20. Note: CHA = Canada Health Act, CHT =Figure 1: Schematic of current cost sharing relevant to Medicare Canada Health Transfer, All values are in millions of Canadian dollars. (A) Total public and private health spending in calendar yearGoC = Government of Canada, PT = provincial/territorial. sector shares for calendar year 2019. (D) Total provincial and territorial spending on health care. (E) The2019. (B and C) Breakdown of A into private and public CHT ANALYSIS

15. 14. E1412 References of Canada’spubliclyfinancedhealthcareserviceswillbebleak. pects foroverduechangesinthefinancing,organizationandscope rational benchmarksforfairinter-jurisdictionalcostsharing,pros- coverage ofmentalhealthservices.Absentaprocesstoagreeon Pharmacare, improvedsupportforlong-termcareorexpanded public fundsandnewcost-sharingarrangements,suchasuniversal drop fornewcooperativeinitiativesthatinvolvelargeoutlaysof not onlyexplainsrecurrenttensions.Italsocreatesadifficultback- about numerators and denominators for cost-sharing calculations, This history,alongwithpersistingmultibilliondollardisagreements strongly enhancevalue-for-moneyinpubliclyfinancedhealthcare. mental reformsthatmightcontainlong-termcostescalationand ada’s provincesandterritorieshavelargelyfailedtoeffectfunda- stripes haverepeatedlyabrogatedthe1977bargain,whileCan­ trations anddisappointments.Federalgovernmentsofallpolitical care iscolouredbyacomplex,decades-longhistoryofmutualfrus- The Canadianfederal– Conclusion smaller at$3940.50 millionperannum(Table1,row4). ceded bythefederalgovernmentin1977,deficitismuch row 3. If, however, an escalating value is imputed to tax points claimed bythepremiersinSeptember2020asshownTable 1, current negotiations,thefederalshortfallmovestowardlevels provinces andterritorieshaveargued,taxpointsareimmaterialto

13. 12. 11. 10. 2 7 1 6. 5. 4. 3. 9. 8. . . .

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Correspondence to:DavidNaylor,[email protected] Association, Ottawa.Therewerenospecific sponsorsforthiswork. Network, Toronto.OwenAdamsissupported bytheCanadianMedical versity of Toronto. Andrew Boozaryis supported by the University Health Funding: C. David Naylor and Andrew Boozary are supported by the Uni- accountable forallaspectsoftheworkanditsaccuracyorintegrity. tent, gave final approval of theversiontobe published andagreedtobe cle, draftedthework,reviseditcriticallyforimportantintellectualcon- Contributors: Alloftheauthorscontributedtoconceptionarti- Toronto, Ont.;CanadianMedicalAssociation(Adams),Ottawa,Ont. Health andSocialMedicine(Boozary),UniversityNetwork, Public Health(Naylor,Boozary),UniversityofToronto;Population Affiliations: DepartmentofMedicine(Naylor)andDallaLanaSchool This articlehasbeenpeerreviewed. Competing interests:Nonedeclared. /uploads/2017/09/report_fiscalim_mar3106.pdf (accessed2020Jan. 14). Federation Secretariat; 2006. Available: the irreconcilable:addressingCanada’sfiscalimbalance.Ottawa:Councilof The CounciloftheFederationAdvisoryPanelonFiscalImbalance. Panel onHealthcareInnovation.Ottawa:HealthCanada,2015. Unleashing innovation:excellent healthcare forCanada—ReportoftheAdvisory _2017​_jul_schneider_mirror_mirror_2017.pdf (accessed2020Mar. 9). .org/sites/default/files/documents/___media_files_publications_fund_report York: TheCommonwealthFund;2017.Available:www.commonwealthfund comparison reflects flaws and opportunities for better U.S. health care uploads/2013/03/aging_final.pdf (accessed2020Jan. 11). Secreteriat; 2015.Available:https://canadaspremiers.ca/wp-content/ Providing servicesforanagingpopulation.Ottawa:CounciloftheFederation _report_and_appendices_july.pdf (accessed2020Jan. 11). ca/wp-content/uploads/2017/09/cof_working_group_on_fiscal_arrangements​ Council oftheFederationSecreteriat;2012.Available:www.canadaspremiers. assessment ofthefiscal impact ofthecurrentfederal fiscal proposals. Ottawa: Report oftheCouncilFederationWorkingGrouponFiscalArrangements: www.fin.gc.ca/n11/11-141-eng.asp (accessed2020Jan. 11). able: investment inhealthcare.Ottawa:LibraryandArchivesCanada;2011.Avail- Department ofFinanceCanada.Harpergovernmentannouncesmajornew Ottawa: ConservativePartyofCanada;2011. Here forCanada:StephenHarper’slow-taxplanjobandeconomicgrowth. CMFiles/800042005_e1JXB-342011-6611.pdf (accessed2020Jan. 11). Conference Secretariat. Available: https://scics.ca/wp-content/uploads/ A 10-yearplantostrengthenhealthcare.Ottawa:CanadianIntergovernmental -priority/ (accessed2020Jan. 11). -produit/news-release-health-care-remains-premiers%E2%80%99-number-one governmental ConferenceSecretariat.Available:https://scics.ca/en/product Premiers’ Conference;2003July9–11;Charlottetown.Ottawa:CanadianInter- Health careremainsPremiers’numberonepriority.In:Proceedingsofthe44th The budgetplan2003.Ottawa:DepartmentofFinanceCanada;2003. pdf (accessed2020Jan. 11). tariat; 2003.Available:www.scics.gc.ca/CMFiles/800039004_e1GTC-352011​-6102. Conference Secretariat.Ottawa:CanadianIntergovernmentalSecre- 2003 FirstMinisters’AccordonHealthCareRenewal.CanadianIntergovernmental _and_Mental_Health_July11_FINAL.pdf (accessed2020Jan. 11). www.canadaspremiers.ca/wp-content/uploads/2019/07/Health_Sustainability be full,partner.Ottawa:CounciloftheFederationSecreteriat;2019.Available: Premiers committedtohealthcaresustainability,callonfederalgovernment ment ofFinanceCanada;2017. Morneau -04​-e#1 (accessed2020Jan. 11). https://sencanada.ca/en/Content/Sen/chamber/421/debates/002db​_2015-12 Debate oftheSenate.42ndParliament,1stsess,2015Dec.4.Available: Canada; 2015. Real change:anewplanforstrongmiddleclass.Ottawa:LiberalPartyof Schneider scc-csc/en/item/781/index.do (accessed2020Jan. 11). Supreme CourtofCanada;1991.Available:https://scc-csc.lexum.com/scc-csc/ Reference ReCanadaAssistancePlan(B.C.)[1991]2SCR525.Ottawa: http://webarchive.bac-lac.gc.ca:8080/wayback/20140806102655/http:// B EC, . Budget2017—Buildingastrongmiddleclass.Ottawa:Depart- | ISSUE 45 Sarnak DO, Squires D , et al. www.canadaspremiers.ca/wp-content​ Mirror, Mirror2017:international Reconciling . New ​ ​ ​ ​ ​ ​