Romanow's interim report: sidestepping the federalist question

Roy Romanow has added his interim report on the future of medicare to the pile of reports already released by provincial commissioners Fyke, Clair and Mazankowski. [For links to all reports and more see our Romanow pages at eCMAJ www . cmaj. ca] Fyke, reporting from Saskatchewan, the womb of medicare, proposes hospital closures and major reforms, including the creation of primary care networks with budgets integrated into regional health planning districts. In Quebec, Clair offers the creation of new public funds for home care along with entrepreneurial marriages of the provincial health plan with private industry in an effort to improve technologic capability. Mazankowski, in Alberta (the tomb of medicare?), sees a need to open up the “unregulated monopoly” of health care. (Alberta's physicians might have a word or two to say about being an unregulated monopoly. We doubt there exists any government-run program more regulated than medicine.) And Romanow, long a committed federalist, has proposed (pardon us if we yawn) “new and more collaborative governance approaches.”

Perhaps we should not have expected any surprises in these reports, whose themes — user fees, professional manpower, primary care, waiting lists, technology, drugs — have been almost continuously replayed since even before Justice Hall issued his report in 1964. But there were a couple. Mazankowski suggests that Alberta (Canada's leading beef producer) “take the lead in updating Canada's food guide” — apparently because the current version devotes little attention to “optimization of foods like meat.” (This is followed by a thankfully brief digression on chicken skin.)

A more significant surprise was Romanow's unwillingness to divulge his interim thoughts on what is surely the most important part of his mandate: the future role of the federal government in medicare. Clearly, the provinces are riding off in all directions. Should there be a federal role in health care? If so, what is it, and how can Romanow generate the political will to maintain it?

We have already suggested1 that one role of the federal government, with its relatively deeper pockets and ability to access debt, is to create mechanisms for stable funding. Thus, in addition to assuring transfer payments to have-not provinces — surely a federal role that most Canadians would want to preserve — the federal government could create a medicare fund to assure stable financing during economic downturns.

Medicare was created in Canada with considerable political anguish. But that anguish is so long forgotten that we see public universal health insurance as an expression — indeed, the clearest expression — of the social values that define us. We must of course remember that Mr. Romanow was one of the main arm-twisters in the night-of-the-long- knives constitutional accord in 1981. He is a deal maker and for now may simply be staying his medicare hand.

He undoubtedly knows that his central task is not to solve the conundrums of user fees, drug costs or waiting lists, but to understand and articulate Canadian values in such a way that few politicians — provincial, federal or separatist — will have an impulse to debate them. — CMAJ