The Liberals warn that Stephen Harper is out to gut medicare. This isn’t entirely accurate. The Conservative Prime Minister’s approach to Canada’s universal health-care system is more nuanced. His aim is not to destroy medicare directly but to stand aside and let others do what they will.

The others in question are the provinces. Provincial governments pay the bulk of public health-care costs. All are looking for ways to cut spending. Some, most notably Alberta and Quebec, have long resented Ottawa playing a role in an area that constitutionally lies within their jurisdiction.

As the Canadian Medical Association Journal reported last month, at least five provinces (including Ontario) are turning a blind eye to private clinics that break the law.

Some defy the federal Canada Health Act by charging patients for medically necessary services. Others ignore provincial laws aimed at maintaining the integrity of medicare — such as those that prevent physicians from operating both inside and outside the public system.

Harper’s federal government has been even more remiss.

Medicare exists as a national program for only two reasons. The first is money. As long as Ottawa gives cash to the provinces, it can require each recipient to operate a provincial medicare program that adheres to the Canada Health Act.

The second is enforcement. The Canada Health Act permits (and in one case requires) Ottawa to withhold money from provinces that break the rules.

Most of the time, Ottawa prefers not to confront recalcitrant provinces. Still, between 1984 and 2006, the federal government levied penalties averaging about $400,000 a year.

Since Harper came to power, however, federal medicare penalties have shrunk to about $84,000 annually.

This, presumably, is what Harper was referring to when, in last week’s televised English-language debate, he talked of giving the provinces’ free rein in medicare.

“We’re not going to wave the finger at the provinces because they’re trying to experiment with different delivery systems,” he said after New Democratic Party Leader Jack Layton accused him of ignoring private clinics that openly charge patients extra fees.

For Harper, medicare has long been a tricky issue. An avowed decentralist and free marketeer, he used to explicitly favour two-tier medicine.

In 2001, he famously called on Alberta to withdraw from national medicare. In 2003, he suggested the Canada Health Act be scrapped and replaced with 10 different federal-provincial health contracts.

Harper’s ambivalence to medicare cost his Conservatives the 2004 election — an election that, until the health issue was raised, was his to win. That’s why, a year later, he pledged fealty to the Canada Health Act. It was, he explained in a speech to B.C.’s right-wing Fraser Institute, a political necessity.

But by this time, Harper also understood the weaknesses of that act. All parties talk of increasing health grants to the provinces by 6 per cent annually. But if these grants are made in the form of taxing authority rather than cash (as Quebec Conservative Maxime Bernier has suggested), there can be no control.

Ottawa may withhold cash from provinces that break medicare rules. But it can never unilaterally take back taxing authority it has given away.

Loading... Loading... Loading... Loading... Loading... Loading...

More to the point, medicare requires a federal government willing to enforce the Canada Health Act. If, in the name of allowing provincial experimentation, it chooses not to do so, the system simply atrophies.

As Harper told his Fraser Institute friends six years ago, those who think the Canada Health Act necessarily prevents two-tier medicine are simply wrong. With the right government in control federally, it can be a most flexible instrument.

Read more about: