Following hard negotiations at the government conference centre in Ottawa in September, representatives of the federal and provincial governments hammered out a new deal for health care. This new deal promises $18 billion in its first six years and $41 billion over ten, promising to create more home care, shorter treatment waiting times and a national drug strategy. An additional feature of the accord is an escalator clause, which is due to take effect in 2006-07. This escalator clause aims to boost transfer payments to the provinces by six percent annually to keep pace with the increasing costs of health care.

By increasing his funding offer by nearly 50 percent, the prime minister extracted from the provincial leaders the acceptance of evidence-based benchmarks to be set by March 31, 2007. These benchmarks are ostensibly designed to determine reasonable waiting times for heart care, cancer treatment, joint replacements, sight restoration and diagnostic imaging procedures.

Critics contend that, while the federal government has finally closed the “Romanow gap” caused by Martin in his days as finance minister, it has done so with virtually none of the provincial accountability Romanow’s 2002 report stated was essential. As well, enforcement of national standards is still weak. NDP Leader Jack Layton endorsed the accord but complained that it doesn’t address a Liberal promise to end private, for-profit health care. At least a third of all health care expenditures, including dental work, eye care and most home care and pharmaceuticals, lie outside the public plan. And fee-for-service remains the most prevalent form of payment to doctors. Beyond these criticisms, Medicare is still mainly about coping with disease, rather than preventing it by improving water and housing (especially in the north and on reserves), by reducing toxins in the environment, or by paying much more attention to nutrition, diet and exercise.

The CD collective makes particular note of a section of the agreement under the heading “Asymmetrical federalism that respects Quebec’s jurisdiction.” This pact, obviously accepted by the provinces as well as by the federal government, allows Québec to go its own way in both reducing waiting times and reporting its progress to its citizens. So, while continuing to refuse to recognize multi-national sovereignty in principle, this pact illustrates that all levels of government accept it as a matter of political reality. The $700 million side deal between Ottawa and the three Aboriginal national communities—First Nations, Métis and Inuit—similarly represents nation-to-nation governance within the context of a more cooperative and flexible federal state.

In short, to obtain agreement on this health accord, all levels of government have been forced to respect the sovereignty of the Québec nation and of Aboriginal nations—something that may well be as important a result as the content of the health provisions themselves.

Of course, as Pierre Dostie reminds us in his Québec Communiqué column this issue, Québec already benefits from a number of asymmetries and, as he notes, the self-determination of a nation can never be fully accommodated by simple asymmetries of this sort. These side agreements merely express the existing multi-national reality of Canada, a theme discussed at length in this magazine over the past few years in the context of our ongoing series on Canadian sovereignty.

This article appeared in the November/December 2004 issue of Canadian Dimension .