Canada, Health and Historical Political Economy

Healthcare in Canada is at an important political and economic crossroads. In 2014, the 10-year Canadian Health Accord will conclude, and the role of the federal government in supporting both health research and health delivery--the latter being a responsibility of the provinces should be the subject of intense public discussion. The 2004 Health Accord responded to a perceived crisis in the Canadian system, known as Medicare, by guaranteeing stable additional federal funding for the provinces and setting out a number of objectives oriented around quality of care. Over the next year, public figures and health experts from province to province will debate which financing models effect optimal health delivery in the face of rising, off-loaded costs. The federal government's refusal to bargain with provincial Premiers as a whole on federal funding, as well as its ongoing encouragement of 'experimentation' across provincial health systems, will increase pressure towards system transformation (Barlow and Silnicki 2012). That said, institutional practice, political culture and social resistance can make short order of reformers' attempts to alter the basic character of health delivery. This is why understanding health care delivery in historical context gives us greater insight into the system's vulnerability to change, and the extent to which the limits of reform can be assessed. In historical and practical terms, Canada presents a comparative analytical conundrum. Its proximity and deep historical interrelation with the United States should reinforce and ensure a trajectory along Anglo-American liberal lines. In large part, this has proven true, albeit with important historical specificities unique to Canada. But this otherwise thriving liberal-capitalist ethos within Canada does not square easily with the political strength of its universal and solidaristic health insurance. Chiefly, it appears to run counter to influential U.S. trends, where: By taking the most costly and difficult-to-insure populations out of the private insurance system, Medicare and Medicaid at once strengthened private insurance and removed much of the remaining political pressure for reform. This was not the only reason that proposals for universal health insurance failed in the 1970s and 1990s, but it did contribute to these political defeats and, more subtly, to a continuing transformation of the goals of reformers (Hacker 2002:290). It could be argued that U.S. bolstering of private health care is the exception in the advanced industrial world, but surely it remains a highly significant 'exception' for Canada and Canadians. (1) If the U.S. is a uniquely liberal example of state involvement in social policy, why has Canada not followed suit, given its deep integration, as well as geographic, linguistic and philosophical propinquity? In blatant contrast to the U.S., universal, state-run insurance schemes emerged and expanded across the Canadian provinces, culminating in legislation and involvement of the Federal Government and reducing private insurance to a complementary role. Not surprisingly, this distinction makes up an important component of national identity construction, wherein 'being Canadian' becomes, in part, mere differentiation with facets of American societal organisation--as one significant survey report made clear, the majority of Canadians believe that 'Medicare embodies Canadian values' (Mendelsohn 2002:vii). Nevertheless, this article argues that the entire Canadian health model does indeed fit faithfully into the Anglo-American trajectory, even if it is conditioned by certain historical peculiarities. Health in the Canadian context exhibits strong pressures towards accelerated biomedical accumulation as well as increasing privatisation of health care delivery. Indeed, the use of historical political economy is valuable here, precisely because it points towards common global pressures across the health domain while remaining sensitive to the historical and institutional peculiarities of specific national contexts. …

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