What can you buy with a $33 bill?

After the requisite amount of bickering, Prime Minister Jean Chrétien and the First Ministers have agreed on what no one would have had the nerve to scuttle: a new ”health deal” that will inject $23.4 billion into health and social programs over 5 years. This seems like a lot when you say it fast. But, assuming that all of it will be directed toward health care (and subtracting the amount earmarked for early childhood development) in fiscal year 2001/2002 this funding will amount to an additional health care outlay of $100 per capita (based on our population in 1999). Not a lot of money, considering that yearly expenditures for health care in Canada are $1959 per capita in public money, plus the $857 spent by the average Canadian directly from his or her own pocket (1999 projections).1 By the end of this fiscal year, only 1 billion dollars will have been handed over, and this specifically for medical equipment and information technology. That works out to about $33 per capita, which doesn‚t seem like much to crow about.

In arriving at this deal both levels of government hoped to deflect criticism that they have mismanaged and underfunded the health care system. This is especially important for the governing Liberals, for whom this will be a key election issue (page 1029). But we should have no illusions: the transfer of money from our federal left pocket to our (largely) right provincial and territorial pockets will have little effect on the underlying problems facing medicare in this country.2 The injection of cash is a political solution to a political problem.

Health care professionals and patients have seen the problems with our health care system up close. Bed shortages, emergency room crises, delays in introducing new technology and impossible demands on home care and long-term institutional care have become all too familiar since the mid-1980s, when the Conservatives, and then the Liberals, curbed transfer payments to the provinces.3 In the presence of an oppressive debt and under political pressure to deal with the deficit, the federal government had little choice but to slash its largest source of expenditures: health care. The provinces and territories, in the same situation, had no room to manoeuvre around the shortfall in federal funding. It is a credit to patients, health care professionals and health care managers that the system survived.

And, almost inadvertently, it may have even been strengthened. Hospitals, which suffered the bulk of the cutbacks, have had to seek alliances with community physicians, home care programs and other community resources. The barriers between different levels of care have started to come down, to the benefit of patients and health care professionals.

We hope that the provincial and territorial health ministers will not simply recreate the health care system that was, but will persevere with some of the important changes that have been made. We need to pay attention to what has happened, to encourage primary care reform and to make the health care system ... well, a system. — CMAJ