Contemporary Issues in Canadian Federalism Series: Health Care and Federalism (TRN5-V39)

Transcript: Contemporary Issues in Canadian Federalism Series: Health Care and Federalism

[Video opens with CSPS logo.]

[Charles Breton appears full screen.]

Charles Breton: Hello, everyone. My name is Charles Breton, and I am the Executive director at the Institute for Research on Public Policies: Centre of Excellence on the Canadian Federation. Very long title. This event is the sixth in a series created through a partnership between the School and the Centre on Contemporary Issues in Canadian Federalism. I'll just say a few words to introduce today's discussion and then pass it over to your moderator for today.

Let me start, however, by acknowledging that the land from which I'm talking to you is the unceded traditional territory of the Kanien'kehaká. I recognize that we all work in different places, and therefore you work on the different traditional Indigenous territory, so please take a moment to consider the First Peoples of the land that you're in.

I'm pleased to introduce today's event: Healthcare and Federalism, a hot button issue if there was ever one in this series. So over the course of this series, we've covered several issues in federalism, and a couple of teams have emerged. So, a core dynamic within Canadian federalism, and we talked about it during the event on fiscal federalism a bit more, is that provincial and territorial governments may be better placed to understand the specific needs and conditions of their locale, but they're more limited, or face more constraints in their ability to generate own source revenue compared to the federal government. And while provinces know their context better, the federal government also wants to make sure that Canadians can enjoy similar quality of services across the country, so today we talk about an area that zeroes in on this tension: healthcare.

So, healthcare is perhaps one of the most complex and important areas under the purview of governments. It's an important expenditure for the federal government through transfers especially, and the largest expenditure for provincial and territorial governments. So with the country facing an aging population, labour shortages and other pressures, there's a necessity to improve the current system to one that is better equipped to endure through these challenges and potential future shocks. There are also historical, structural issues that have persisted in the past, but been aggravated by the Covid 19 pandemic. We'll explore some of those today. And so, to understand how federalism influences the way we approach the healthcare system, we're going back to first principles in a way. What makes an effective healthcare system and how does federalism complicate or help that dynamic? What are the different roles of each level of government and the stakeholders they interact with, and how do they work or don't? We'll investigate these questions in today's talk.

So, we have a great discussion planned for you today and want you to have the best possible experience, so I have just a few housekeeping items to go over. Today's event will be in English; simultaneous interpretation, as well as the service of CART, real-time captioning is available should you need it and want to follow in the language of your choice. To access these features, please click on their respective icons directly from the webcast interface, or you can refer to the reminder email that was sent by the School. To optimize your viewing experience, we recommend that you disconnect from your VPN or use a personal device to watch the session when possible. If you're experiencing technical issues, it is recommended to just relaunch the webcast link provided to you.

So, during the event, you may submit your questions at any time by pressing the text bubble icon located in the top right-hand corner of your screen. We've planned some time for a question and answer period at the end of this session. And so, finally, also, we've turned all of the past events in this series in shorter podcasts. So for those interested, you can find it on our website at irpp.org or on the CSPS event page. So I encourage you to go back and listen if you haven't. So now without further ado, we will start today's event with our moderator, Jo Voisin. Jo, over to you.

[Jocelyne Voisin, Dr. Chaim Bell, and Katherine Fierlbeck appear in video chat panels.]

Jocelyne Voisin: Hi. Thanks, Charles, and hello. Good afternoon, everyone. My name is Jo, or Jocelyne, and I'm the Assistant Deputy Minister of Strategic Policy Branch at Health Canada. I'm pleased to be the moderator for today's event. And I'm joining you today from the traditional land of the Algonquin Anishinaabe,

[Jocelyne Voisin appears full screen.]

Jocelyne Voisin: a land I enjoy very much in cycling and skiing outside. And I hope people enjoy the land on which they live and work as well. So today's event is timely I think as Charles kind of set up for us. Healthcare and federalism is playing out and getting a lot of attention these days in the press. And I actually am the ADM responsible for healthcare <laugh> in the federal government. And so, the recent announcement the federal government made for 198.6 billion over 10 years to provinces and territories to improve the healthcare system. So, a large part of the policy work that we do here in my branch and then I lead on, as well, all sorts of related health system files.

So, we know that federalism can create a tension between the federal and provincial and territorial governments. We've also seen throughout the pandemic that it's supported great collaboration. So I'm really looking forward to hearing from two fantastic speakers today who are going to talk to us about these issues.

[Katherine Fierlbeck appears full screen.]

Jocelyne Voisin: So first we have Katherine Fierlbeck who is a McCulloch research professor and Chair of the Department of Political Science at Dalhousie University.

[Jocelyne Voisin appears full screen.]

Jocelyne Voisin: And we also have Dr. Chaim Bell,

[Dr. Chaim Bell appears full screen.]

Jocelyne Voisin: who is Physician in Chief at Sinai Health and Professor of Medicine and Health Policy Management and Evaluation at the University of Toronto.

[Jocelyne Voisin appears full screen.]

Jocelyne Voisin: So, welcome to both of you.

[Jocelyne Voisin, Dr. Chaim Bell, and Katherine Fierlbeck appear in video chat panels.]

Jocelyne Voisin: And I'm going to start by turning it over to Katherine, who will be starting us off with a presentation on the structural issues federalism presents for healthcare, before we turn it over to Dr. Chaim for a brief summary of his experiences with the federal system. And we'll have, as we noted, questions and answers to follow. So, turning it over to you, Katherine.

[Katherine Fierlbeck appears full screen.]

Katherine Fierlbeck: Thanks, Jo. I thank you for your invitation, and I'm quite delighted to be able to chat with you today. I'm also looking forward to your comments and observations especially those of you within the healthcare portfolio. I've always thought that it would be good fun to structure a talk around the three questions that I hear most whenever I talk about healthcare federalism. And today I'm going to put that thought into operation.

[Split screen: Katherine Fierlbeck, and title slide "Health Care and Federalism"/ "les soins de santé et le fédéralisme".]

Katherine Fierlbeck: Now, in doing so, I don't mean to disparage those who've asked these questions. On the contrary, these questions are asked because the context involved can be so incredibly complicated and confusing, nor do I intend to insult your intelligence. While the preliminary observations seem fairly obvious, my intent here is to show how these basic observations can become very complicated very quickly.

[Split screen: Katherine Fierlbeck and slide, as described.]

Katherine Fierlbeck: So, the first question I get a lot is, why doesn't Ottawa just take over healthcare since the provinces can't seem to get their act together? Well, and of course, all of you know the answer to this one. Although it's one of the most common questions I get, as well as a very common trope in letters to the editor and in phone and shows. And I generally just answer with two words, civil war. We do have very important structural constraints regarding what each jurisdiction can and can't do. And of course, the most fundamental of these takes the shape of the Canadian Constitution with its division of powers.

[Split screen: Katherine Fierlbeck and slide, as described.]

Katherine Fierlbeck: Yet at the same time, it's also not true that the Constitution simply hands healthcare over to the provinces. The words healthcare don't actually appear in the Constitution. The closest that we get are hospitals, asylums, charities, and [INAUDIBLE] institutions in Section 92(7). And that famous catchall at the end of Section 92 generally all matters of a merely local or private nature in the province, Section 92(16).

The problem, of course, is that healthcare, per se, is now neither merely local nor private. It's largely public and national in scope, which is, in a sense, the fundamental irony of the historical development of healthcare in Canada. It was handed to the provinces because it was private and local, although now it's neither. Moreover, much of the provincial authority over healthcare is largely inferred or indirect. So, for example, when provincial healthcare became a system with the establishment of public health insurance, it was understood that insurance per se, was within the exclusive jurisdiction of the provinces as matters of property and civil rights. So, Section 92(13), no matter that health insurance at this point was largely public, while the original intent of 92(13) was to regulate the individual contract of private insurance. So, another historical irony.

[Split screen: Katherine Fierlbeck and slide, as described.]

Katherine Fierlbeck: And we all know that Ottawa has its own jurisdictional competencies in health-related areas. Covid made us very aware, for example, that some of these potential powers, including 91(11) gives Ottawa clear constitutional authority over quarantines. The pandemic also raised the possibility of declaring a national lockdown using the Emergencies Act, which is more or less authorized by the peace order in good government clause of Section 91, although exactly how far Ottawa could take this and for what reasons is perpetually in a dispute. Then of course, there is the practical side of how and when these powers could be deployed. You know, Ottawa could, according to some, have quite legitimately imposed a national lockdown during Covid in the face of provincial recalcitrants, which is fine on the face of it, except, well, exactly how would Ottawa operationalize this when the RCMP represents only about 30% of the police presence in Canada, and the federal government is banned from commandeering provincial or municipal police forces. So, whether Ottawa has jurisdiction over particular aspects of health governance is one issue, and whether it can or even wants to exercise this power, of course, is another thing altogether.

Now, most of Ottawa's activity in healthcare, of course, comes from its so-called expenditure power. Except again, there is no explicit expenditure power in the Constitution. It's inferred from its taxation powers in Section 91, which if you read them, essentially say that Ottawa can tax stuff. And again, constitutional experts love getting to the weeds on this one. So, while we think that the constitutional bases for the federal division of powers over healthcare are clearly stated in the Constitution, really, they're not. Provinces don't explicitly have authority over healthcare, and Ottawa doesn't explicitly have the authority to spend tonnes of money in this area to shape it a certain way. These are simply interpretations of inferences from archaic, and maybe arguably even obsolete constructions that we more or less now accept through practice.

[Split screen: Katherine Fierlbeck and slide, as described.]

Katherine Fierlbeck: Ottawa also has jurisdiction over pharmaceutical regulation, importantly, by virtue of its authority over patents in 91(23), where we saw a very recent dust up at the PMPRB, where the debate over constitutional authority played a role. And of course, Ottawa has authority over healthcare provided to the military in under section 91(7), where there was a spat a few years ago now, where Ottawa accused the provinces of price gouging on the health services for military personnel that it had contracted out to the provinces.

[Split screen: Katherine Fierlbeck and slide, as described.]

Katherine Fierlbeck: Now, things get even more complicated when modern healthcare takes the form of some mixture of two clear authorities in each jurisdiction. British Columbia's Insight Case is one example where the punitive authority over healthcare on the part of the provinces came head-to-head with Ottawa's power over criminal laws in 91(27), I think. Another example is the establishment of psychiatric hospitals in penitentiaries. There's a long and very interesting history of provincial and federal governments tossing psychiatric prisoners from federal to provincial institutions and vice versa. Hospitals are clearly provincial while penitentiaries are clearly federal. So what does one do?

[Split screen: Katherine Fierlbeck and slide, as described.]

Katherine Fierlbeck: And the second question I get a lot is, if the Canada Health Act has such a chokehold over healthcare reform, why don't we just change the Canada Health Act? Well, again, we have a few fairly straightforward observations that disintegrate into complexity, I think, within seconds here. The Canada Health Act is, of course, a federal statute that has absolutely no binding authority over provinces. Yet, it is nonetheless the glue that binds all the provinces together in some semblance of an identifiable national system of healthcare. And as it has no authority over the provinces, the only way that Ottawa can coax provinces to move one way rather than another is through its federal cash transfers. Now, I know that a lot of you had an excellent presentation on fiscal federalism, so I won't have to go into much depth on that side of things, thankfully, so let's focus on what the Canada Health Act does or, or does not say regarding the provision of healthcare, which is somewhat topical right now. So, prior to the various pieces of provincial and federal legislation governing public health insurance, that emerged from about 1947 in the province of Saskatchewan up to about 1972 in Newfoundland, prior to this, there was no healthcare system to speak of any more than we can really talk about having a system of hairdressing, or a system of commercial baking, both of which are private endeavours loosely regulated by the provinces, much as healthcare was in the first half of the 20th century. And only when provinces began to have some real skin in the game by virtue of having to pay for services, did they really begin putting their heads to thinking about how to properly organise these services.

Now, the debate is the extent to which the Canada Health Act in practice determines what the healthcare systems of each province actually look like.

[Split screen: Katherine Fierlbeck and slide. Text on slide: Canada Health Act; 5 Criteria & 2 Conditions: Public Administration; Comprehensiveness; Universality; Portability; Accessability; Recognition; Information. 2 Conditions – mandatory penalties: No extra billing (Section 18); No user fees (Section 19) / Loi Canadienne sur la santé; Administration publique; Intégralité; Universalité; Portabilité; Accessibilité; Reconnaissance; Information. 2 Dispositions – pénalités obligatoires; Pas de surfacturation (article 18); Aucuns frais modérateurs (article 19)]

Katherine Fierlbeck: So, the five famous conditions of the Canada Health Act are actually fairly broad. Nor do they preclude private healthcare per se. Yes, they must have a public insurance system in order to receive federal funding, but this doesn't necessarily rule out some form of private insurance or direct private delivery. People under the Canada Health Act must have access to all medically necessary services insured by the province on uniformed terms and conditions. So, you can't offer these services to women but not men, or to tall people but not short people. But once you ensure this, the question at issue is whether the provinces can offer these, or whether the provinces can allow these services to be offered privately as well. Now, of course, many provinces do. So, I guess the question is whether those provinces that do are Canada Health Act compliant or not. And of course, each province has the authority to determine for itself what it considers to be medically necessary.

Beyond that, the particular nature of each province's healthcare system is largely determined by provincial legislation. Now, a common and somewhat irritating practice of many journalists is to assume that the restrictions that characterize Ontario's healthcare system are true for the rest of Canada. This is patently not the case. Ontario, for various reasons, has the most restrictive healthcare system when it comes to access to private services, which is set out in the commitment to the future of Medicare Act of 2004, which essentially bans any physician from opting out of the public system, except for those who are grandfathered, which is something that most, if not all, provinces actually do allow.

[Split screen: Katherine Fierlbeck and slide. Text on slide as above, plus: Interpretation letters (Sec. 22 – discretionary penalties]

Katherine Fierlbeck: Now, the interpretation letters appended to the Canada Health Act. Currently there are three of them, although Duclos has just announced that he's going to be tabling a fourth. The interpretation letters are really worth reading in some detail as they do provide a much clearer sense of the federal intent of Canada Health Act.

[Split screen: Katherine Fierlbeck and slide as above, and as described.]

Katherine Fierlbeck: One interesting issue right now are the block fees where a clinic charges say an annual membership fee before you can access publicly insured services. They're not allowed to do that according to the Epp and Marleau interpretation letters. Another issue is public coverage of all medically necessary diagnostic tests. So, since 2020, failing to cover these costs publicly, even if they're provided in private facilities, is considered a violation of the Canada Health Act according to the Petitpas Taylor interpretation letter. Yet both of these practices still happen in various provinces. Much of the force of the Canada Health Act rests in section 18 and 19 against extra billing and user fees. So, when provinces tolerate these practises, Ottawa is mandated by legislation to levy penalties. However, when provinces transgress other measures outlined in the interpretation letters, Ottawa is not statutorily obliged to levy fines. This is completely discretionary and depends on the desire of the government of the day to follow through.

But to understand why private healthcare takes the form it does in each province, and it does very considerably, you really have to take a hard look at the full panoply of legislation provinces have at their disposal to control the level of private healthcare within their domains.

[Split screen: Katherine Fierlbeck and slide, as described.]

Katherine Fierlbeck: So, this toolbox, if you will, includes whether physicians can opt out of the public system if they want. Again, those in Ontario cannot, unless they're grandfathered. Many provinces do require those who do opt out of the public system to limit their fees to the public fee schedule, which immediately lowers the potential profitability of any independent private practitioners. But again, not all provinces do this. Can patients claim reimbursement for publicly insured services provided by private practitioners? If you look at the legislation I think in provinces like Newfoundland and Manitoba, there's some interesting provisions there. Not all provinces prohibit the sale of private insurance of publicly insured services, and some like Quebec sort of allow some but not others. Not all provinces prohibit doctors from working both in the public and the private system at the same time, the so-called dual practice. Some provinces prohibit co-mingling, where clinics can hire doctors to work in both the private and the public stream, but others don't.

So, the bottom line here is that it is provincial legislation in the first instance, and not the Canada Health Act, which determines a province's toleration for private healthcare activity, which is why you get so much finger pointing with each level arguing that the other's legislative framework for healthcare regulation is out of date.

[Split screen: Katherine Fierlbeck and slide, as described.]

Katherine Fierlbeck: Now, the third question is my favourite. And this is a question, why can't we all just get along? And here's where columnists and letters to the editors say, well, look, in the end, the taxpayers pay the bills anyway. And when we go to the emergency department, we don't care whether it's provided by the federal or the provincial government. So why don't the governments just stop bickering and do what's right for Canadians? And the problem here is that it's not that governments are shortsighted and focused on petty local concerns. Arguably there's some of that, but rather that it's actually rational to play this kind of political poker. Fiscal capacity, of course, is a large part of the problem. Healthcare is an increasingly expensive program, and Ottawa, as you know, has more relative fiscal capacity than the provinces. The more financial allocation provinces and territories can squeeze out of Ottawa, the more they see themselves as being able to provide an appropriate level of services to the respect of electorates. So, in a sense, they're just doing their job.

And the problem here is really that all the respective jurisdictions have an institutional memory of how the federal provincial relationship works and has worked in the past. So this particular federal provincial dynamic isn't really that old. It's younger than I am. And when Medicare was set up, the offer of half price healthcare was too enticing for provinces to ignore. But in the intervening years, the less obvious costs of this kind of relationship quickly became apparent.

[Split screen: Katherine Fierlbeck and slide, as described.]

Katherine Fierlbeck: So, for the provinces, the lesson, to a large extent, was what's easily given is easily taken away. From established programs, financing in the late seventies, to the belt tightening of the 1990s under Martin, to the reduced escalator imposed under Harper, provinces have learned that they have to be careful what they agree to in the first instance, because if they enter into a cost shared program, Ottawa could well walk away at any moment leaving them holding the bag. And if their electorates are used to a certain level of services, then they won't be able to pull back without some form of political punishment. And that's precisely why it's so difficult now to establish a new shared cost program like dental care or PharmaCare. Now, the provinces are going, Nope, we've learned, we've been down this road before and we've learned, and we just don't trust you. And even if we did trust you, we don't know if we could trust your successor.

[Split screen: Katherine Fierlbeck and slide, as described.]

Katherine Fierlbeck: Then there's the issue of size and capacity. Small provinces are wary about agreeing to anything that requires a level of fiscal or policy capacity that they don't enjoy. Mandated long-term care standards might be one example. How is it possible to agree to a certain level of standards that a province isn't sure it can afford? And larger provinces often have the opposite concern, that they actually do have the capacity to do things well, so why would they want to be part of a pan-Canadian process that hobbles their ability to do their own thing in a way that they find both appropriate and effective?

[Split screen: Katherine Fierlbeck and slide, as described.

Katherine Fierlbeck: Now, at the same time, the frustrations of Ottawa are equally apparent as health transfers simply go into general operating revenues. Increased federal transfers mean more capacity to do all sorts of things, including giving out tax breaks, which then actually limit the ability of a province to raise funds for the same healthcare it says that it has trouble funding. So, the federal skepticism that vastly increased health funding will be used for the wrong purposes is probably well founded. And even bilateral funding, as currently set up, has such a weak accountability framework that it's doubtful that a bilateral strategy is all that much better than a traditional multilateral one when it comes to accountability.

[Split screen: Katherine Fierlbeck and slide. Text on slide: Thank you; k.fierlbeck@dal.ca

Katherine Fierlbeck: So, the federal, provincial, territorial dynamics in healthcare are incredibly complicated, and it's difficult enough to understand the lay of the land, let alone figuring out how to navigate problem solving, moving through it. I know I've raised probably more questions than I've addressed, so I'm more than happy to dig down into the weeds on any of these topics in the question section. Thank you.

[Charles Breton, Dr. Chaim Bell, and Katherine Fierlbeck appear in video chat panels.]

Charles Breton: Hello. Sorry. I wasn't supposed to come back, but while Katherine was speaking, the alarm went on in Jo's building and she had to evacuate. So now I'm back <laugh>. Thank you, Katherine. That was very interesting, and we'll get back to a lot of what you've talked about in the discussion that will follow. But now to hear more about on the ground, how do these dynamics play out to some extent? We'll turn to Chaim and his own personal experience as a doctor in the healthcare system.

So, Chaim, over to you, please.

[Dr. Chaim Bell appears full screen.]

Dr. Chaim Bell: Thanks very much, Charles, and thanks very much, Katherine. And hopefully Jo is okay, and we can maybe regroup with her after the alarm is over. So, I think partly when we developed this program, we wanted to have a little bit of foundational knowledge, which Katherine so adeptly provided. I'm just going to give a little bit of my background so you understand a little bit of my perspective on things, and I think a lot more of the fun and opportunity will come when we respond to the questions that should be coming from you.

So, just a quick thing: I'm a physician. I'm a general internal medicine physician, sort of a hospital-based physician who looks after hospitalized patients at Sinai Health. I've been on the front lines of both SARS in 2003, and most recently on the front lines as well as a leadership role during the pandemic. So, that's the type of medicine that I provide. I've also, from a leadership perspective our hospital and our department, we're one of the ones that provided both inpatient care as well as intensive care unit care for pandemic patients, just to give you a little bit of a taste.

From my perspective on things, I have a bit of a lens and experience with the healthcare system, both from an international perspective, more in an academic realm through the VA in the United States, of Veterans Affairs, which is really quite a large almost universal healthcare system in the United States, arguably the largest, depending on how you categorize certain things; and with fellowship training programs as well, I've been involved with training programs in other countries, including in Israel.

At the federal level, I'm the Chair of the Council for Canadian Academies. We have a health data - it's a report that we're bringing forward on health data sharing, and expert panel to try and improve that within Canada. And that's supposed to move forward through a policy response. I was also one of the first members of the Pan-Canadian Oncology Drug Review, which was devised to try and standardize and apply a Pan-Canadian approach to oncology drug funding approvals across the country. I've been on many panels and committees associated with the Canadian Institute of Health Research, the CIHR. And I've also been involved with FNIB consultations looking at health data from a federal perspective.

From a provincial perspective, my focus has really been in Ontario, but also in some other provinces including Alberta and British Columbia looking at drug funding and grant panels. In Ontario, I've looked at panels associated with drug funding on a provincial basis, as well as health technology funding on that provincial basis. As well, I was involved in the Ontario government as a consultant to the Health Quality Branch, and as well, with negotiations with the Ontario Medical Association and coverage of rare drugs. Finally, at the local level, I've spoken a bit about my clinical responsibilities, but I'm also the Chief of Medicine at Sinai Health, we have a lot of interaction with the University of Toronto.

So, it's a long way of saying that what I bring to the table here and what we're trying to apply is, as Katherine said, it's a morass of overlapping frameworks and overlapping legal applications on how we're delivering healthcare. And we can reflect on a whole host of them: on how it works in the regular world; how it's worked during a pandemic perspective; and how we think it might work in the future. And then talk about some of the challenges, which, as Charles pointed out, I think has really been laid bare during the pandemic. But, in a sense, it's nothing that we hadn't identified or anticipated. It just accelerated and catalyzed a lot of what we were about to see.

So anyway, it's just a way of bringing that forward. And I look forward to trying to respond to many of your questions, and hopefully Katherine can do a better job than me at that.

[Charles Breton, Dr. Chaim Bell, and Katherine Fierlbeck appear in video chat panels.]

Charles Breton: Thank you, Chaim. So on this, let's deal with the pandemic right away and jump in it. And maybe perhaps at two different levels.

[Charles Breton appears full screen.]

Charles Breton: And I'll start with you, Katherine. From your experience and seeing how provinces and the federal government interact on healthcare, you talked about the funding aspect and the fiscal aspect, talking about how it wasn't always this way, but it's been this way for a while, how they fight over a few of those things. Would you say that quantitatively the relationship between the provinces and the federal government were much different during Covid? There was much more relationship, much more discussion. But would you also say, did you see a qualitatively different relationship that may perhaps can continue,

[Charles Breton, Dr. Chaim Bell, and Katherine Fierlbeck appear in video chat panels.]

Charles Breton: or are we back to our old ways already in terms of how the provincial and federal government talk to each other on this file?

Katherine Fierlbeck: Okay, so two questions there. First, there was a qualitatively different kind of relationship,

[Katherine Fierlbeck appears full screen.]

Katherine Fierlbeck: whether it can continue along those lines? No, I doubt it. And there was a large degree of pulling together. And I think what we learned from previous pandemics, both SARS but more importantly H1N1, was that the messaging had to be consistent. And I think there was a lot of attention played to that, arguably to a fault, that there was very little room for debate over scientific data allowed. But again, there was an important convergence in the official line, which helped.

One thing that was rather interesting during Covid was the fact that there were some little spats between provinces themselves, and of course, as you know, Nova Scotia and New Brunswick, I guess all the Atlantic provinces closed their borders, and there was a certain amount of disagreement regarding when they should be opened, so it had some provinces opening their borders, but the other province refused to open theirs in the same way, so that caused a little bit of friction.

I think that having a federal system was, in a way, helpful during Covid, insofar as the Covid response could be more cleanly tailored to a certain geographic area. And again, as an inhabitant of Nova Scotia I was quite aware that we enjoyed a lot of normal activity where Quebec and Ontario were locked down for much longer periods. Had it been a national response, I think we would've suffered needlessly because of that. I think being able to tailor Covid responses to geographical areas was quite helpful. And again, a lot of us are doing forensic analysis of how provinces responded to the pandemic, looking forward to, God help us, the next one coming down the pipeline. And it is absolutely fascinating to see how each response was very tailored to a province in terms of the protocol for testing and what have you.

So, it will be interesting in the next year or so to be able to analyse these responses, to see how well they worked. And provinces can look to each other to see whether there's something that they could have done better. Again, Nova Scotia did a lot of pop-up testing, a lot of rapid testing, more so than other provinces. Was this useful, was this helpful? Is this something that other provinces ought to do? So, getting back to this, almost old cliche of federalism, really an incubator for new practices, I think that Covid sort of borne that out.

At the same time there was a lot of discussion about the difficulty in data communication. We had, of course, the whole issue in SARS Mark One about the provinces' inability to send data to Ottawa on a timely manner, which caused the World Health Organization to shut down Toronto as a global travel destination. And we thought we'd learned from that, but of course, we hadn't. And that's a much deeper issue that still hasn't been resolved. You know, hopefully provinces will be able to negotiate something with Ottawa before the next pandemic comes rolling along. But that's still a practice that has to be sorted out.

[Charles Breton, Dr. Chaim Bell, and Katherine Fierlbeck appear in video chat panels.]

Charles Breton: And so, Chaim, on this, again, I think at the level of discourse between the leaders I think I would agree with Katherine that we're back to old ways, but one would hope that behind the scenes there were lessons learned during Covid that are still being applied. So I'm curious to know if that's the case. And especially you talked about your involvement on the data side. One would hope, again, like Katherine said, that perhaps we did not learn lessons from the SARS crisis on that side, one would hope that now we have, so I'm curious on your side, do you feel like some of the good things that Covid brought in terms of how we interact with each other, and our provinces and the federal government interact with each other, is still with us? Or are we back to how we were working before?

[Charles Breton, Dr. Chaim Bell, and Katherine Fierlbeck appear in video chat panels.]

Dr. Chaim Bell: It's interesting you brought up the original SARS in 2003 because the classic Naylor report,

[Dr. Chaim Bell appears full screen.]

Dr. Chaim Bell: David Naylor who was the Dean of the University of Toronto Medical School at the time, called for a few important changes to come about. One of which interestingly was the Public Health Agency of Canada, which played a role in this pandemic, which wasn't present really in 2003. So, we did have an important federal change to the constituents and leaders at the time where we didn't have before. We didn't have the Theresa Tam to the same extent last time with that same platform. It was different, but it wasn't to that same extent.

So, there were some important changes. I mean, partly, they're only as good as the personal relationships between the people. And some of it had to do with, if you looked at many of the leaders in the provinces, or the Chief Medical Officers of Health, there was a lot of change that happened even during the three years that was ongoing. So that just from that sort of organizational framework.

The other aspect from an organizational framework is that public health is different than the delivery of healthcare in Canada, and we have to also recognize that there are different laws, that Katherine can probably speak about much more eloquently than me, really dealing with public health and the public health specific requirements. And it's a different setting. Most of us are much more familiar with healthcare delivery or receiving healthcare in a hospital, in a clinic. And that's often what the discourse is, and we're not as familiar with public health. And public health, it's one of these things that you might say, if you've seen one public health system in Canada, you've seen one public health system in Canada. They're different depending on the provinces. And I think here we can pretty reliably say that form follows function, so what we saw in Quebec with the way they organise healthcare and public health is far different than the way we would see it in Ontario, but mostly the rest of Canada as well.

Quebec has, in my opinion, much more of a progressive approach to it, using regional approaches that are melded. Alberta has gone through different iterations of this, as an example. But as an example, in Ontario you had, I think it was 34 different public health areas who weren't necessarily, and I don't know why I'm going in and out of focus, but I'm not trying - nothing's happening here. <Laugh> something like 34 public health areas where each of the Chief Public Health Officers for those small regions didn't report directly to the Chief Medical Officer of Health who was supposed to be the Chief Public Health Officer for the province. So, in a sense, they weren't accountable to them.

So, when you have that type of organizational framework, even if there's a good relationship between the province and the federal government, it doesn't trickle down the same way as where you have different health regions able to respond differently. That's just an example from Ontario. Just sort of copy and paste this across the provinces, and you'll see that even if we're sort of all rowing in the same direction, it's not going to last for long. And I think that's been the resounding feeling, is that the organizational framework is inconsistent across the provinces.

[Charles Breton, Dr. Chaim Bell, and Katherine Fierlbeck appear in video chat panels.]

Charles Breton: And in a way, and I guess, Katherine, that's a question for you to some extent, is one of the issues here that there isn't any kind of institutional framework for people to have those discussions? So, for instance, knowing that there are 13 different healthcare systems in Canada and 13 different public health systems, there isn't a clear way or institution where people can learn what works and what doesn't. Or, yes, everyone can come with innovations and see what works and what doesn't, but we don't communicate across those different healthcare systems to really learn from one another. And perhaps that's a role for the federal government to play.

Katherine Fierlbeck: Well, I'm not quite so sure about that. It really depends what area of healthcare you're talking about, because there are discrete FPT groups looking at particular aspects of the healthcare system.

[Katherine Fierlbeck appears full screen.]

Katherine Fierlbeck: And I think a lot of discussion goes on there. And also when a province wants to find out about how another province does something, it will make an effort to do so. So when Nova Scotia wanted to centralize and amalgamate its health authorities, it went to Alberta and had a long discussion there. So, where there is a will, there is a way.

And it's not just a matter of learning about best practices even when there's a sense of what other provinces do, often there's not a will to take up these new practices. There's always the perpetual argument that provincial health authorities are not big risk takers. And even knowing about a different way of doing things doesn't mean that they're willing to implement it. So, there can be better communication. I think if you look at the European Union, as a political whole, there's a lot more institutionalization of these little groups, of these agencies, who are actually funded by the central authorities.

So, in the European Union, Brussels as the federal leader, is mandated by the by the constitutional treaty, the TFEU, to assist any member state on any healthcare undertaking if they want. So the federal government actually has to get involved when the regional entities want to, and it would be very useful to have something like that in Canada, because we do have the Council of the Federation, but often when there is a desire of provinces to work together, they don't have the capacity, they don't have the policy capacity, they don't have the infrastructure to really sit down and work things through in any depth. So we could do things better, but there is some communication.

[Charles Breton, Dr. Chaim Bell, and Katherine Fierlbeck appear in video chat panels.]

Charles Breton: Is there? Okay, that's good to know. So in terms of healthcare governance, again, we talked about Covid and we've looked back, so let's just look ahead in a way, and perhaps Covid highlighted some of those upcoming challenges. So when it comes to healthcare governance and healthcare delivery, what are, in your mind, both of you, really the main challenges that we're facing? We know about population aging. We know that also one problem for the federation is that population aging is not exactly the same, is not a problem to the same extent across the country. Much more important in Atlantic Canada than it is in Alberta, for instance. That is a younger province. Labour shortages, like those are the two that come up most of the time. Are these really the main challenges that we face ahead? Is there anything else that the federation needs to really look into? Perhaps, again, information sharing? It was something that Covid 19 highlighted as perhaps one place where the country, as a country, could do better?

So, in your mind, what are those main challenges ahead and how can we respond to them as a federation, not as 13 different entities trying to deal with those massive challenges ahead?

Dr. Chaim Bell: Maybe I'll start first, Katherine?

[Dr. Chaim Bell appears full screen.]

Dr. Chaim Bell: So, health human resources are probably one, two, and three on what's presenting now. These go back for many, many years to cuts to medical school, but it's not just medical school, right? This is nursing, an aging workforce in nursing. There have been a lot of gains in certain areas where we've been shifting from hospital-based care to home-based care, and we haven't had that same shift in the workforce for those people.

Where I see the issues are often in connections with that health human resource file. I'll give you an example. And this is probably pertinent to the federal government more than anything is we have targets, I think, depending on which numbers you believe, somewhere between 400,000 and 500,000 new immigrants are supposed to come to Canada every year for the next five years. In Ontario alone, we've got about a million and a half people without a family doctor. That's just sort of basic, if we're looking at the organizational framework. Assuming that a third to a half of those people come to Ontario, how is that going to interdigitate with a healthcare system that's already failing? Where you've got more people now, not saying anything about the health of immigrants. And in fact, we know from data that, as a whole, immigrants to Canada are usually healthier and better educated, of course, but that still means that they still require a family doctor. They still will require health resources. And if we're looking at it from that perspective, the idea of saying, how can we - there's a reason why we're looking for increasing our population with immigration, but how does that impact health?

I think if you use that lens to anything within the purview of federal governments, that's one of the things that we really need to think of is, we are already a stressed system, how is this going to stress us more? And how can we help? You know, the corollary is, who's holding the clipboard that says many of those immigrants that we should bring in are people that we should bring in who are in the health field, directed to nurses and such. And in order to do those things, you almost need somebody in charge that's identifying. I'm not sure, and I could be very wrong, but it hasn't been clearly communicated, at least to me, of those 400,00 or 500,000, how many of them are going to be nurses, or doctors, or technicians that are going to be helping us?

That, to me, would be that whole idea about rowing in the same direction, where you're able to have a concerted approach to things. Where that you would have the - and before we were talking about federal health and provincial health authorities. Here, it's not even that they're different entities and different disciplines, but really, they're really interrelated. And I think if we get it right, wow, that would be amazing. But when we don't get it right, that just adds to our problems. Katherine.

[Charles Breton, Dr. Chaim Bell, and Katherine Fierlbeck appear in video chat panels.]

Katherine Fierlbeck: Yes, I'd echo that. Absolutely. Health human resources is the biggest issue right now.

[Katherine Fierlbeck appears full screen.]

Katherine Fierlbeck: And part of the problem in terms of federalism is that each region has different capacities, so you're not talking about equivalent players. So, there has been a lot of discussion about national licensure, which can be helpful in allowing medical professionals to move more easily across borders, but once you have some jurisdictions having much more fiscal capacity to attract them, that is not going to be a particularly attractive proposition to some of the provinces.

Just the other day, Alberta announced that, for want of a better word, it was quite happy to poach healthcare workers from some of the provinces. We have a major issue in the Maritimes at keeping paramedics here because their scale of reimbursement is so much higher in other provinces. So, it's all well and good to say, well, we have to have greater mobility, and that the federal government can facilitate this mobility. But really, who are the winners here and who are the losers here? And some of the small provinces with the smaller economies are going, it doesn't look good.

And again, I can use the European Union as a parallel here. So, over a dozen years ago the laws would change to allow medical professionals to work anywhere within the EU. And I remember being in Brussels and talking to a Romanian healthcare official. And I asked her what effect that had on her. She just shook her head and said, well, we lost one third of our healthcare workers because we just can't afford to pay them. And I thought, hmm, that could be Nova Scotia. So, what is a solution to one jurisdiction is a major problem for another jurisdiction.

And another issue, of course, is not just licensure, but you have to understand that for a lot of professions such as pharmacists and nurse practitioners who are playing a much greater role now, if you look at their scopes of practice, they vary tremendously across all provinces. So there's not a good sense of what a nurse practitioner should be allowed to do across the country. It's very specific to a particular province.

And as part of the health human resources, I'd say one thing that we should have a national discussion about, not in terms of imposing solutions, but in terms of discussing best practices and models, is primary healthcare provision. You know, how do we set up primary healthcare homes? How do we reimburse them? Of course some provinces rely more on fee for service, and then we have alternative payment plans. We have a move toward primary care networks or collaborative care clinics in all provinces in different ways. But again, what we mean by collaborative care clinics varies tremendously. It can be the government giving resources to physicians, the GPs to hire cognate healthcare professionals. You can have co-leadership models where you have other healthcare professionals working alongside of GPs in a clinic. Or you can have a turnkey model in which the province hires on a salary basis, both physicians and other healthcare professionals. And it's very harem scarem now, every province is experimenting with this, and there's not a good sense of what works and what doesn't. And I think it'd be very useful to have Ottawa facilitate a national conversation in what works and what doesn't in terms of primary healthcare design.

[Charles Breton, Dr. Chaim Bell, and Katherine Fierlbeck appear in video chat panels.]

Charles Breton: That's very interesting. And, Katherine, I think that the point that you made about how a solution that might be appealing to Alberta or Ontario might not appeal to Nova Scotia or PEI, for instance, and that's something that's important to keep in mind here. And again, maybe that's somewhere where federalism, in a way complicates things.

So, I get two more questions and then we'll turn to questions from the other people that are with us, there are a lot of those questions coming in. So again, this might highlight where a place where federalism is more a hindrance than anything,

[Charles Breton appears full screen.]

Charles Breton: but maybe we can try to talk about federalism in a positive way and see why, in your view, in terms of whether it's governance or delivery, places a role that in a way that where federalism actually is something that's useful, that is helpful. We've talked about policy learning, so maybe that's one. Are there any other aspects of, again the governance of healthcare, or the delivery of healthcare where we can see where federalism actually acts as an enabler, as something that makes things maybe more efficient or easier, or maybe there isn't, but <laugh>, I put the question to you. I don't know who wants to take on that first, it's a difficult question.

[Charles Breton, Dr. Chaim Bell, and Katherine Fierlbeck appear in video chat panels.]

Dr. Chaim Bell: Katherine, do you want to start?

Katherine Fierlbeck: Sure. So, policy learning is a major aspect of, at least in theory, of what works.

[Katherine Fierlbeck appears full screen.]

 Katherine Fierlbeck: And it's not just learning what works well, but what to avoid as well, I think we have to keep in mind. But another aspect of federalism is, again, both theoretically and I think in practice, is that it is more responsive to the particular values of a particular population. You know, do we want more private healthcare? Do we want to make sure that we don't have a certain level of private healthcare? In Covid, we saw this, I think, quite substantially, and that certain provinces were very intolerant of too much lockdown, too many lockdown measures. And in other provinces, the sensibility of the population was that provinces were lifting restrictions too quickly. So just in terms of ease of governance, healthcare governance is never an easy file, but the more defined a population you have, I think the easier it is for a government to respond to the particular needs, but also the sensibilities of a population, which as you know, in Canada are very, very different.

[Charles Breton, Dr. Chaim Bell, and Katherine Fierlbeck appear in video chat panels.]

Charles Breton: Chaim, anything to add on this point?

Dr. Chaim Bell: You saying what works with the federalism? You know, some of the things I think work there, you could debate how well they work,

[Dr. Chaim Bell appears full screen.]

Dr. Chaim Bell: but within it drug and health technology or device assessment is done at a federal level in the healthcare sphere. That's one of the big issues. And you wouldn't want those approvals to be done on the provincial basis. It's hard enough in a small country like Canada to have the expertise for that. That would be something, I would say, in healthcare that would be something important. Vaccines are along those same lines. It's just like a drug. And we can talk about how, just at least during the recent pandemic, how that helped us out from a Canadian, a federal perspective, as compared to normally purchasing through individual drug manufacturers would've really affected our purchasing power and the speed of which we would have access to things.

So, definitely, in those situations, it certainly helps the smaller provinces more, where they might not have the same level of expertise or purchasing power. And there have been some very good recent efforts, particularly in the drug sphere, where there's a concerted effort to try and purchase prescription medications from a federal perspective. They've looked at it, they've had a few test cases that have gone quite well. So, the CDEC file and CADTH, those are the two - CDEC is within CADTH - they've taken on a larger role in this sphere. Health Canada, of course, from the licensing aspect, I think. And that was certainly brought to the forefront during the pandemic more than - you wouldn't know that the committee existed, much less all the people on the committee who determine whether the vaccines are coming or not. And here, you know who the consultant is, how quickly they're reviewing things, it really was sort of an inside baseball of the processes. But I think those would be the ones I would look at. There've been a lot of national commissions, but they haven't been tied to accountability frameworks. And I think that's sometimes the challenge with federal versus provincial.

[Charles Breton, Dr. Chaim Bell, and Katherine Fierlbeck appear in video chat panels.]

Katherine Fierlbeck: If I can just follow up on that. I agree completely on that drug evaluation through bodies like CADTH, which is technically federal in the best possible sense of a joint collaborative activity between Ottawa and the provinces, I think that really is a success story.

[Katherine Fierlbeck appears full screen.]

 Katherine Fierlbeck: But also, what are the drawbacks of a federal system, in terms of pharmaceuticals, is that drug companies tend to play provinces off against each other, right? They are able to get one province to cover a particularly expensive drug, and then the campaign starts: So this province covers this, province cares about their citizens, but your provincial government won't carry our drug, so obviously your government doesn't care about you. And these kinds of very nefarious activities are much more easy in a federal system. And also the pricing of drugs, which we're getting toward, we've addressed that to a certain extent with the Pan-Canadian Pharmaceutical Alliance. But a lot more work can be done there. And then if we could have a national formulary, I think it might help as well. But pharmaceuticals, absolutely important. And both pros and cons of what goes on in federal system.

[Charles Breton, Dr. Chaim Bell, and Katherine Fierlbeck appear in video chat panels.]

Charles Breton: Very, very interesting. It's an area that I did not know very well. So before we go to the questions, one last one for me. So, we've talked about, I think both of you highlighted how human resources is really the challenge of today, right? Even yesterday, perhaps. So it's the one that's closest to us. But I was wondering if there was anything else that wasn't getting as much attention, and that you're concerned about in the healthcare system, something that you foresee as becoming an issue, but perhaps one that we don't talk about as much coming out of Covid. Again, I think labour shortages is really something that Canadians experience on a daily basis now. But perhaps there are other things that might not be as important as labour shortages but that you see, that you're somewhat concerned about in the coming future. So perhaps, Chaim, I'll start with you on this one.

[Dr. Chaim Bell appears full screen.]

Dr. Chaim Bell: Sure. You know, I always go back to I'm not a primary care provider, but I think primary care is the bedrock and the foundation of our healthcare system. And I think the investment in primary care and the connection with primary care is something that really hasn't been moved up on people's radar. I think that it's part and parcel of the health human resources. It definitely goes together. But I think the idea that primary care is organized in multiple different ways in province, between and within the same province, that that's a challenge. So it's inconsistent. I think the fact that so many people don't really have good access to primary care will just compound any of the inequities we have. The people that tend not to have access to primary care are often the people who we know can have adverse outcomes, or worse outcomes for a variety of other reasons, so that they might be vulnerable for other reasons as well. So, I would emphasize that primary care aspect in addition to the health human resources, but I see them as sort of parts of the same manifestation. But I think we want to single out primary care for sure, as something that if you don't have it, you're not going to perform as a healthcare system.

[Charles Breton, Dr. Chaim Bell, and Katherine Fierlbeck appear in video chat panels.]

Charles Breton: <Affirmative>, Katherine?

Dr. Chaim Bell: Katherine?

Katherine Fierlbeck: Yes. You did mention data and the collection of data and the communication of data and the publication of data as being an issue. And that, I would say, runs a close second. The state of national health data in Canada. I mean, CIHI is doing a wonderful job as it is, but the ability to access important data in real time is a national embarrassment. I mean, there's been this ongoing discussion internationally about excess deaths, and the level of excess deaths across various countries and what causes it. And then you look to Canada and data stops like six months ago, and you have no idea what's going on. And you go to conferences, and they have, oh, here's the Australian data, here's the British data, and here's Ontario's data, because you just can't find Canadian data for this, that, or the other.

And there's so many, so many issues involved with data collection.

There's the technical issue that I can't even wrap my head around. And then there's the political side of things where certain provinces just don't like the idea of giving up their control regardless of anything else. And then there are the real limitations imposed by laws that require provinces to be responsible for the protection of privacy for their population. So you can see that they want to be very careful about the kinds of data that they share and so on and so forth. So, data sharing has been a huge mess. And again, there are all these different initiatives on the part of the federal government and also provinces to try to address that. And I'm crossing my fingers that we're going to get somewhere on that one.

[Katherine Fierlbeck appears full screen.]

Katherine Fierlbeck: Another major issue, of course, is the upstream determinants of health. So, I think to a large extent, and we've pumped so much money into public health, which is a great thing, but a lot of it has been focusing on disease surveillance and disease mitigation. And I'm worried in a way that less attention and maybe fewer resources are being put toward concerns of population health. So nutrition; obesity; smoking; alcoholism; opioid use; what have you. I mean, are we going to focus so much on the disease surveillance aspect of public health that we lose sight of these very important and actually these very expensive trends that if left unaddressed are just going to exacerbate the existing tensions that we have in our healthcare system.

Of course, there's more, I mean, long-term care, again, is another one. If you look at countries that do long-term care right, they've made a sizable national investment. The Netherlands, for example, people do pay a hefty amount out of their paycheques every month for their long-term care. And when they retire, they expect to get good long-term care. And of course, because long-term care is so sustainable, they don't have the same kinds of pressures with alternative level of care in their hospitals as we do. So getting long-term care right is another piece in the puzzle. But again, because it is so decentralized, where do you start?

[Charles Breton, Dr. Chaim Bell, and Katherine Fierlbeck appear in video chat panels.]

Dr. Chaim Bell: And I have to say thank you, Katherine, because I'm the chair of looking at it for health data sharing, and you're the one who brought it up, so even better. But yes, I totally concur with that. And even if you look at it, how quickly we got data, it depended on the province. And when we did get data, we were able to overcome some of those challenges temporarily, of course, at least in Ontario and some of the other things where we looked at our Ontario Science table, it was able to change the way that we looked at the data on how quickly, or the length of time between vaccines, and we were also able to prioritize them to high needs areas, high needs neighbourhoods at the neighbourhood level, with some of the quick data that was coming back. And normally, as Katherine said, you're a year and a half out before you've even analysed the data. So, we don't have the same dashboards that other people would have.

And we're always comparing ourselves to the States, and I would say that that's the wrong comparison, <laugh>. And I think that if you take anything away from this, that that's our natural person to compare, right? We're always looking over our shoulder and looking like, you know. But that's the wrong thing. And that will only lull us into complacency, because we might be better in some things than some people in the United States, but if you look at Europe, if you look at something like Australia with a similar type of - they use states - but the provincial federal divide, they're able to get that before us, and they're able to sort those things out that we haven't seemed to sort out yet. So I would encourage if anybody in the public service is looking, the US might be a political comparator for the political parties, but if we want to get better, that's not the comparator that we want to use.

Charles Breton: I was going to ask a question on data sharing before you both mentioned it, because it was a question from the audience. There's one part of that question that I think we can try answering though, I'm not sure we'll have a final answer on it.

[Charles Breton appears full screen.]

Charles Breton: But part of that question that that person was asking is, so it seems to be a big issue. It seems to have big implications for the quality of care and access to care. So, what is needed to improve data sharing in the country? What is it that will solve a problem here in terms of better data sharing across jurisdictions?

[Charles Breton, Dr. Chaim Bell, and Katherine Fierlbeck appear in video chat panels.]

Charles Breton: Do we have an answer? Do we know? <Laugh>

Katherine Fierlbeck: Take it away.

Dr. Chaim Bell: Yes, you know what isn't needed is really the other question.

[Dr. Chaim Bell appears full screen.]

Dr. Chaim Bell: A lot of this is attitude. Everybody says, oh, it's just a privacy thing. If it just weren't for those blank privacy commissioners, this would be fine. That's not the case. A lot of the issues, it really is partly that we don't want it enough, and we're not willing to overcome those things. We're not over, as Katherine said, some of it is cultural, the idea that you're not sharing, what am I getting out of it? Some of it is actually that we're not able to access some of the things in certain provinces. We haven't designed it. It becomes a political minefield to try and identify some of those things. But I think it's going to take a multi-pronged approach, and it has to be done where people can see what the benefits are, right? This isn't an academic exercise and just saying, oh, won't we feel better when we go to the OECD? And then it's not just one province in comparison to all these countries, it's the whole country.

The idea is, I think once people see how the data can inform and improve your care and help you make the right decisions, and that's partly what we're trying to do with what we're putting forward with the Council of Canadian Academies, is to identify - they recently came up with a report on the cost of misinformation, right? All the conspiracy theories and such. What did that cost people and what did that cost us, just in health? And that's part of what we're looking at. It's not just, wouldn't it be good to have this? It's, how does it cost us? How does this hamper us? How does this keep us back from improvement? And that's what we're hoping will be able to change the minds, rather than just sort of saying, we're a pursuit of data, data is a good thing. If some data is good, more data is better. It's, look how you would have been better off had you had this information to make this decision. Or if you had this decision, you wouldn't have made this incorrect decision. And look how much it cost you either in time, money, all sorts of things.

So, I think underscoring the value of the data sharing, making it apparent that everybody benefits from that sharing of data, from benchmarking, and that it doesn't look like a punitive thing. I think that's the other thing. People are often worried that the data can only work against me. Why would I ever want to evaluate this government pilot program? Because if it's good, we'll get more money for it. If it didn't work, then it can only work against me politically. And I think we need to get over that, that it's not a shame and blame idea, and that this is used for improvement and modifications. It doesn't mean it's an all or nothing. It can mean that we need to modify it and improve it and still keep it.

[Charles Breton, Dr. Chaim Bell, and Katherine Fierlbeck appear in video chat panels.]

Charles Breton: So, a related question to that one, and this time I'll go to the political scientist to answer it, and a very current question that describes well the last few months. So, a lot of the healthcare discussion is punting around the responsibility between different jurisdictions. Is there a solution that can be implemented or is there a solution to the finger pointing that goes on this file? And I'll add even from a citizen's point of view, in terms of accountability, that makes it difficult, right? The accountability of who's responsible for this mess that I'm looking at? If I want to punish this government, is it the federal government that I want to vote against? Is it the provincial? Even in terms of accountability, it makes it difficult for citizens to keep the government accountable. So, is there a solution to that finger pointing between jurisdictions on the health file?

Katherine Fierlbeck: Okay. Short answer, no. <Laugh> Longer answer: when you talk about data sharing,

[Katherine Fierlbeck appears full screen.]

Katherine Fierlbeck: data sharing between whom? At one level it is about the sharing of data between the provinces and the federal government, and also between the provinces. But at a much more fundamental level, it is making critical data more accountable to everyone. And interestingly this is the tack that Ottawa is trying to take with the provinces in order to leverage its investment in federal transfers a bit more is to say, well, we want you to be more accountable, not to us, per se, but to your populations. And any health researcher who's tried to get data out of a province knows that it's a very difficult task. And that in some cases, provinces aren't collecting data. I mean, only recently have we really begun to think about race-based data. So that's fairly new. But in other senses like Covid, we were just swimming in data, we're very data rich. But then there's not the capacity to go through the data to crunch the data. So, the data's there in a raw form, but we just don't have the capacity to use it.

And then, even if a government did have the ability to sit down with the data and go through it, to what extent would it be willing to share this information with its own population? And of course provinces differ across the board in how open they are. And it's, to a certain extent, the answer is how do you get provinces to be accountable? Well, populations, electorates have to demand that province's account for what they're doing. So, a province will come up with a new policy proposal. And if you look at what a request and recommendation form that a lot of provinces use, they have an appendix that says, explain how you would evaluate whether this policy works or not. And I would love to be able to access, but there's no way, even probably with a [INAUDIBLE], I don't think that I could get this information.

So, the information, the data is out there, the kinds of data that I want to be able to know whether provinces are - whether the kinds of policies they've enacted are actually useful kinds of policies, we don't know, because the provinces won't share this data with us. I don't care if they share it with Ottawa, I want them to share it with me. And getting that is really like pulling teeth.

And of course, as a former premier said in a podcast, when it comes to election time, transparency and very vague governance issues are just not what governments run on. They're run on how many people are in stretchers in hospitals, and how many people die in an emergency ward, and how long do you have to wait for a paramedic? And these are the kinds of things that people want. So governments won't respond to these vague transparency and governance issues because people don't force it on them, so there's a bit of a paradox. There's a bit of a chicken and egg problem there. So yes, data and access to data is critical, but how you go about squeezing it out of governments is much more difficult.

[Charles Breton, Dr. Chaim Bell, and Katherine Fierlbeck appear in video chat panels.]

Charles Breton: So, we'll stay with you because it's a question that you touched on in your presentation but we'll get back to it. Perhaps head on. It's a two-part question, I'll let you decide if you want to answer the first part, but I think we want an answer to the second one. So, would Canada benefit from a two-tier system like in the UK? And can our federation system even allow for a two-tier system to be established?

[Katherine Fierlbeck appears full screen.]

Katherine Fierlbeck: Okay, just a couple of observations there. First, if you're aware of what's going on in the UK, you would probably not consider it to be a model that you'd want to follow. <Laugh> I recall hearing an emergency room doctor in the UK saying that a good shift is where nobody dies in your waiting room. So, you have to understand that the UK does have a private tier, and it has not been at all useful. It certainly hasn't mitigated the kinds of problems that we're seeing here. In fact, there is evidence from Australia and other jurisdictions that when you introduce a private tier, the only way that a private tier can make a go of it is if people have to wait in a public system, right? So, the business model of a private system is based on making the public system as bad as possible in order to attract new demand. And that's even beyond the staffing issues that we'd have to worry about. So, simply saying, open it up, private care, it's going to solve our problems. There's never been a case where having a private care increases capacity. It just makes things more difficult and adds all sorts of different dimensions.

Again, with the private tier, the problem as you see in the states, not that I should compare too much with the states, but what you do see in the states with all the private healthcare is overtreatment, right? Is that, if you have a private sector, if you are there for the profit, who's got the most money to squeeze? It's the healthy and the wealthy, right? So you're going to model your healthcare directed at those who have lots of money to play with. You're going to give them their full body scans, you're going to give them unnecessary back surgery because they're willing to pay for it. So, simply opening up a private sector so it's a wild west and anything goes is certainly not going to be an answer.

Now, another response to this question is, well, what do you mean by a two-tier system? And I think that you can arguably say that we have a two-tier system in certain respects already. For example, this very morning when I was getting my groceries, I went to the pharmacy counter and I said, look, I have a prescription and it expired, and oh my God, I don't want to have to go to my GP because it's going to be three months. And is it within your scope of practice to write up this prescription yourself? And they said, sure, I can, it's going to cost you 22 bucks. I said, 22 bucks, fine. So, if that's not two tier, what is? So, and previously, I mean, I do have a GP, hard to access them, but again, with the prescription, I could say, well I just want you to give me this prescription again that I've had for the past 20 years. And they'll say, well, yes you can pick it up the counter but it'll cost you 30 bucks. So again, there are all these little kinds of - and you know, they're all over the place, so if you've got the money, you already can get better access to the things that you need for healthcare.

[Charles Breton, Dr. Chaim Bell, and Katherine Fierlbeck appear in video chat panels.]

Charles Breton: So, this is the last question.

[Charles Breton appears full screen.]

Charles Breton: It touches on what you both identified as one of the main issues currently, which is labour shortages. And it also touches on perhaps what people listening to us can do, because we're talking to the federal public service. So here's a question. How much leeway does Ottawa have with respect to medical labour shortages and easy access to healthcare in Canada? So, what's the role of the federal public service, in a way, to improve access to healthcare and perhaps even help with the medical labour shortages? We've touched on perhaps harmonizing some of the qualifications across jurisdictions. Maybe there's something else. So, Chaim, I'll start with you on this question.

[Dr. Chaim Bell appears full screen.]

Dr. Chaim Bell: That's a great constructive question. What can I do to help? Which is always a great thing to ask. And I think part of it is wherever you are in the federal system, you're often in a touchpoint. It's not health necessarily, but health adjacent as we were saying. And so something like looking at technicians or technologists just to recognize what is needed for the healthcare system right now? Who are the types of people? And if we're still using, I know we're not using exactly the point system, but we're using a value-based, we're using a system for immigrants that looks at preferences. We're preferring certain things over others and so maybe some of the preferred areas or some of the preferences given are to things related to the health field or related to people coming into things.

So, it's required that the field provides that information, they have to be forthcoming with that. But maybe there are creative things that say that we want to make sure that Nova Scotia isn't left out, and that everybody isn't going to certain places. And maybe there's a similar type of thing with return of service where we have this with physicians, where people are trained elsewhere, come back, do their training here for licensure, and then they have return of service in underserviced areas. We've had this, it's happened to a small extent. It's happened for - once physicians come in to practice in rural Newfoundland, rural Saskatchewan, there has been some recent CBC articles even on them, South African doctors that fulfilled these things.

Those are examples, but I think a concerted effort in that area, that's where you actually might have some partnership. Where maybe it's the Atlantic provinces per se, that look at wholesale immigration of people. It's often doctors which people gravitate to, for a town and such. But I would argue that you'll get more bang for your buck if you're looking at nurses or other people, personal support workers, other people in that field, so it might not just be the immigration part, there might be some training involved with that. And so, I think this is what is required, and it's required for really someone to hold the clipboard and be in charge of the process. But I think the idea is that there's opportunity from different sectors of society, housing, other things, to be able to look into these things and contribute, because I would argue that one of the biggest things hampering our progress in the next five to 10 years - people say that the solution is immigration and it very well might be, but hampering that solution is going to be our delivery. Housing obviously, but healthcare. It's only going to cause a rift between - if you are a person who doesn't have access to healthcare now, and there are more people coming in, it's sort of that - there are more people coming into that tight area that it's only going to get worse and make people worse and more resentful of it.

[Charles Breton, Dr. Chaim Bell, and Katherine Fierlbeck appear in video chat panels.]

Charles Breton: Thank you. Katherine, on the role of the federal civil service?

Katherine Fierlbeck: That's a tough one because so much of the funding and delivery and the regulation is done by the provinces.

[Katherine Fierlbeck appears full screen.]

Katherine Fierlbeck: And of course, the federal role to a large extent is in footing the bill for things like training. And just recently a new medical school was announced for Cape Breton, and of course that was only possible with federal funds. So, it's actually a tougher question than you might think.

In terms of just spitballing here it'd be nice to be able to, getting back to the data question, it'd be nice to have a national interactive Health Human Resource atlas, where you have a geographical map and you can point and click and see what the various staffing shortages are in any particular region, at any particular point in time. We do that, a lot of provinces do that already, but nice to have a federal map where you can look at the flows. I mean, we sort of have the data. We've got Scott's Medical Atlas that CIHI uses, or medical database that CIHI - so we do have the data, but it'd be nice to be able to put that data in a much more user-friendly form.

But the one area I think that we could look at is the federal role in integrating Indigenous health governance. You know, there's a lot happening in terms of bringing on stream Indigenous governance in healthcare, and it actually differs substantially from province to province. And I think because of the presence of the federal government both in Indigenous services and its former role in Health Canada, it's probably uniquely placed to play a major role in coordinating the discussion of Indigenous healthcare governance across Canada so that it's not such a patchwork.

[Charles Breton, Dr. Chaim Bel, and Katherine Fierlbeck appear in video chat panels.]

Charles Breton: That's a very interesting point. So, I want to end on this, I want to thank you both. I think this was really interesting, very useful, I hope for people in the audience. I want to highlight to everyone who's here that there will be another event in this series on April 18th,

[Charles Breton appears full screen.]

Charles Breton: which I guess we'll touch on some of what we touched here because it will be on digital federalism and open government policies. So, we touched a lot on data here. So maybe in a broader spectrum of data. So again, thank you all and I hope you have a good day.

Katherine Fierlbeck: Thank you.

[The CSPS logo appears on screen.]

[The Government of Canada Logo appears and fades to black.]