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Paradigm Freeze Why It Is So Hard to Reform Health-Care Policy in Canada

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Paradigm Freeze Why It Is So Hard to Reform Health-Care Policy in Canada Paradigm Freeze WHY IT IS SO HARD TO REFORM HEALTHCARE POLICY IN CANADA Edited by Harvey Lazar John N. Lavis, Pierre-Gerlier Forest, and John Church Institute of Intergovernmental Relations The Institute of Intergovernmental Relations The Institute is the only academic organization in Canada whose mandate is solely to pro- mote research and communication on the challenges facing the federal system. Current research interests include fiscal federalism, health policy, the reform of federal political institutions and the machinery of federal-provincial relations, Canadian federalism and the global economy, and comparative federalism. The Institute pursues these objectives through research conducted by its own associates and other scholars, through its publication program, and through seminars and conferences. The Institute links academics and practitioners of federalism in federal and provincial govern ments and the private sector. The Institute of Intergovernmental Relations receives ongoing financial support from the J.A. Corry Memorial Endowment Fund, the Royal Bank of Canada Endowment Fund, the Government of Canada, and the governments of Manitoba and Ontario. We are grateful for this support, which enables the Institute to sustain its program of research, publication, and related activities. L’Institut des relations intergouvernementales L’Institut est le seul organisme universitaire canadien à se consacrer exclusivement à la recherche et aux échanges sur les enjeux du fédéralisme. Les priorités de recherche de l’Institut portent présentement sur le fédéralisme fiscal, la santé, la modification des institutions politiques fédérales, les mécanismes des relations fédérales-provinciales, le fédéralisme canadien dans l’économie mondiale et le fédéralisme comparatif. L’Institut réalise ses objectifs par le biais de recherches effectuées par ses chercheurs et par des chercheurs de l’Université Queen’s et d’ailleurs, de même que par des congrès et des colloques. L’Institut sert de lien entre les universitaires, les fonctionnaires fédéraux et provinciaux et le secteur privé. L’Institut des relations intergouvernementales reçoit l’appui financier du J.A. Corry Memo- rial Endowment Fund, de la Fondation de la Banque Royale du Canada, du gouvernement du Canada et des gouvernements du Manitoba et de l’Ontario. Nous les remercions de cet appui qui permet à l’Institut de poursuivre son programme de recherche et de publication ainsi que ses activités connexes. Library and Archives Canada Cataloguing in Publication Paradigm freeze : why it is so hard to reform health-care policy in Canada / edited by Harvey Lazar, John N. Lavis, Pierre-Gerlier Forest, and John Church. (Queen’s policy studies series) Includes bibliographical references. Issued in print and electronic formats. ISBN 978-1-55339-324-5 (pbk.)—ISBN 978-1-55339-338-2 (ebook). ISBN 978-1-55339-339-9 (pdf). 1. Health care reform—Canada. 2. Medical policy—Canada. 3. Medical care— Canada. I. Forest, Pierre-Gerlier, editor of compilation II. Lazar, Harvey, editor of compilation III. Lavis, John, editor of compilation IV. Church, John, 1961-, editor of compilation V. Queen’s University (Kingston, Ont.). Institute of Intergovernmental Relations, issuing body VI. Queen’s University (Kingston, Ont.). School of Policy Studies issuing body VII. Series: Queen’s policy studies series RA395.C3P36 2013 362.10971 C2013-904389-6 C2013-906525-3 © Copyright 2013 Institute of Intergovernmental Relations, School of Policy Studies, Queen’s University at Kingston, Canada Contents List of Tables and Figures v Foreword vii Preface ix Glossary xi Abbreviations xv Chapter 1 Why Is It So Hard to Reform Health-Care Policy in Canada? Harvey Lazar 1 Chapter 2 Studying Health-Care Reforms John N. Lavis 21 Chapter 3 Health Reform in Alberta: Fiscal Crisis, Political Leadership, and Institutional Change within a Single-Party Democratic State John Church and Neale Smith 35 Chapter 4 Saskatchewan’s Health-Care Policy Reform in the Romanow Era: From Restraint to Restructuring Tom McIntosh and Michael Ducie 65 Chapter 5 Health-Care Reform in Ontario: More Tortoise Than Hare? John N. Lavis, Dianna Pasic, and Michael G. Wilson 89 Chapter 6 Quebec Reforms from Rochon to Couillard: The Long and Winding Road Marie-Pascale Pomey, Elisabeth Martin, and Pierre-Gerlier Forest 113 iv Contents Chapter 7 Between a Rock and a Hard Place: The Difficulty of Reforming Health Care in Newfoundland and Labrador Stephen G. Tomblin and Jeff Braun-Jackson 147 Chapter 8 Canadian Health-Care Reform: What Kind? How Much? Why? Harvey Lazar, Pierre-Gerlier Forest, John N. Lavis, and John Church 171 Chapter 9 Patterns in the Factors That Explain Health-Care Policy Reform Harvey Lazar and John Church 219 Chapter 10 Verifying the Reliability of Research Results Harvey Lazar and John Church 253 Chapter 11 Health-Care Reform: Where Things Stand Harvey Lazar 283 Chapter 12 Prospects for Health-Care Policy Reform Harvey Lazar and Pierre-Gerlier Forest 307 Annex 1 Analyzing the Nature and Extent of Health-Care Policy Reforms, 1990–2003 Harvey Lazar 331 Annex 2 Independent Variables Referred to in 30 Case Studies That Best Help to Explain Nature and Extent of Reforms Harvey Lazar and Julia Diamond 353 Annex 3 Some Observations on the Historical Development of Medicare Harvey Lazar 371 References 375 Contributors 397 List of tabLes and figures Table 2.1 Policy Issues under Study and Research Questions Asked 25 Table 2.2 Analytical Framework Used in the Study 27 Figure 3.1 Percentage of Albertans Reporting Access to Health Care as “Easy” or “Very Easy,” 1995–2004 48 Table 4.1 Changes to the Saskatchewan Provincial Drug Plan, 1987–1993 72 Table 5.1 Research Questions Asked and Policy Decisions under Study and Their Significance 91 Table 5.2 Timeline of Major Changes to or within the Governing Party and the Policy Decisions under Study in Ontario 94 Table 6.1 Changes in Responsibilities of Three Levels of Government before and after 2004 133 Table 8.1 Nature and Extent of Provincial Policy Reform Decisions Relative to Grey Literature Standards, 1990–2003 176 Table 8.2 Number of Times Categories of Independent Variables Were Major Influences on Reform Decisions in 30 Cases 181 Table 8.3 Distribution of Major “Change in Government/ Leader” Independent Variables on Reform Decisions in 30 Cases 183 Table 8.4 Distribution of Fiscal Crisis Independent Variables on Reform Decisions in 30 Cases 187 Table 8.5 Distribution of Major Public Opinion/Civil Society and Media Independent Variables on Reform Decisions in 30 Cases 190 Table 8.6 Distribution of Major Values, Knowledge, and Institutional Independent Variables on Reform Decisions in 30 Cases 195 Table 8.7 Distribution of Major Insider Interest Independent Variables on Reform Decisions in 30 Cases 213 Table 9.1 Influence of Major Factors on Reform by Category, Saskatchewan (1991–2003) vs. Newfoundland and Labrador (1989–2003) 227 vi List of Tables and Figures Table 9.2 Influence of Major Factors on Reform by Category, Saskatchewan (1991–1995) vs. Ontario (1990–1995) 232 Table 9.3 Influence of Major Factors on Reform by Category, Saskatchewan (1991–2003) vs. Alberta (1992–2003) 235 Table 9.4 Influence of Major Factors on Reform by Category, Alberta (1991–2003) vs. Ontario (1995–2003) 240 Table 9.5 Categories of Variables That Substantially Influenced Extent of Reform: 14 Cases Assessed as Moderate, Significant, or Comprehensive Reform 242 Table 9.6 Criteria for Distinguishing Decisions That Are Mainly Political from Decisions That Also Involve Technical Expertise 247 Table 9.7 Categorization of Health Reform Case Studies as Mainly Political or Technical/Political Based on Six Criteria 248 Table 10.1 Comparing Health Reform across Five Periods, 1944–2003 264 Table 11.1 Direction and Extent of Momentum Change in 30 Cases in 2004–2011 Relative to 1990–2003 Assessment 285 Table 11.2 Comparing Independent Variables Discussed in 2004–2011 (P2) to 1990–2003 (P1) 291 Table 12.1 Shares of Total Health Expenditures Allocated to Private Payment, Provincial/Territorial Payment, and Canada-wide Public Payment 316 Table A1.1 Nature and Extent of Reform: Applying the Definitions to the Cases 352 Table A2.1 Independent Variables Observed as Influences on Policy Outcomes in 30 Case Studies: Five Province Roll-up 356 Table A2.2 Categories of Independent Variables That Influenced Policy Reform Decisions in 30 Case Studies: Five Province Roll-up 359 Table A2.3 Independent Variables Observed as Influences on Policy Outcomes in Alberta Case Studies 360 Table A2.4 Independent Variables Observed as Influences on Policy Outcomes in Saskatchewan Case Studies 362 Table A2.5 Independent Variables Observed as Influences on Policy Outcomes in Ontario Case Studies 364 Table A2.6 Independent Variables Observed as Influences on Policy Outcomes in Quebec Case Studies 366 Table A2.7 Independent Variables Observed as Influences on Policy Outcomes in Newfoundland and Labrador Case Studies 368 foreword The Institute of Intergovernmental Relations is pleased to publish this book on health-care policy reform. It continues a collaboration between Harvey Lazar and me on health policy that started in the 1990s when we worked together on an Institute book on health and federalism. Harvey was then the director of the Institute and I was head of policy at Health Canada. This is, of course, not the main reason that the Institute of Intergovern- mental Relations agreed to publish this book. Health care remains a major issue in Canadian federalism, even though a key finding of the authors is that federalism has not been a major factor in explaining the success or failure of reform in the 30 case studies presented in this book. I strongly believe that this is a useful and important clarification that should not, however, be interpreted as supporting or opposing even a modest federal role in Canadian health care. There remain many areas where the nature of a federal role is worthy of a serious discussion.
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