How is the federal government responsible for health care?
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Listen to Agent Pale Horse, the second season of White Hot Hate, available now. This is a CBC Podcast. I'm Dr. Brian Goldman. This is White Coat Blackguard. We're changing things up this holiday weekend. As you probably know, we're in the midst of a hotly contested federal election campaign. Much of the campaign's focus is on our rapidly changing relationship with our neighbours of the south. Here on White Coat, we think healthcare should be top of mind.

This week's episode of our sister podcast, The Dose, asked what roles the federal government plays in our healthcare system. Our guest was Amelie Canal-Vallée. She's a professor at McGill's School of Population and Global Health and Canada Research Chair in Policies and Health Inequalities.

She started talking about the Trump administration neutering the FDA, medical research and the Centers for Disease Control and how that will inevitably impact our health care system and the well-being of Canadians. With a little over a week before the federal election, we think this is a conversation you might want to hear. Before we begin our conversation, can you give us a hi, my name is, tell us what you do and where you do it.

Hi, my name is Amélie Kenel-Vallée and I'm the chair of the Department of Equity, Ethics and Policy in the Faculty of Medicine at McGill University. Most listeners know that it's a provincial and not a federal health card that they've got in their wallets. What's the most important thing people should know about the role the federal government plays in their health care?

Well, I think I would use the metaphor that the federal government is both a watchdog and a cheerleader for health care. So the federal government, dating as far back as our Constitution, 1867, the powers between the federal and the provincial governments were laid out where the federal government had the power to spend money.

on healthcare and education, but for largely linguistic and religious reasons, the provinces maintain the rights or the responsibility to deliver on healthcare and on education.

So the federal government has the capacity to spend on health care, but that means that it also has the potential to use both a carrot and a stick with that spending. So the federal government uses the Canada Health Act as a guide for the provinces on what they should be spending.

And that guide is actually serving as also a bit of a stick. So it's a carrot because there's money attached to it, the Canada Health Transfers.

But there's also a stick in the sense that there are some rules with the Canada Health Act that the provinces must abide by in order to receive that funding, that full funding that they're entitled to. I was an adult when the Canada Health Act was, in fact, I was a practicing physician when the Canada Health Act was enacted 41 years ago. And I remember that the big hot button issue at the time was user fees.

You know, could doctors surcharge patients if they thought they deserve they should be paid more and that hospitals could could surcharge patients for hospital services. So that was the main that was the main thing that the Canada Health Act was trying to deal with at the time. Am I right?

Absolutely. So the Canada Health Act has five principles, public administration, comprehensiveness, universality, portability and accessibility. And under these principles, there is the important principle of funding medically necessary care. And in the Canada Health Act, that was stipulated as being physicians and hospital services funded.

So, in a way, you can think of this interplay between the federal government and the provincial governments as a bit of a potluck dinner. So the federal government invites everyone to the table, pays for part of the food on the condition that everyone brings a main dish, so that's physicians and hospital services, and they set the table. But each province decides what dish to bring beyond that.

So sometimes some food groups may be missing. Sometimes whole food groups or whole courses may be missing. And that's part of the reason why we see variations across the provinces in what is being covered and not covered.

And that focus on physicians and hospitals means that there has not been a corresponding focus on nurses, nurse practitioners, pharmacists may be playing an evolving role as they are in many provinces, physiotherapists, occupational therapists as well.

Absolutely. And we can, you know, when we talk about this election, you in Ontario had recently had another important election. And the contrast between the discussions on health care is pretty stark here.

So while in Ontario there was a lot of discussion about primary care and accessibility to primary care, I think that's top of mind for many Canadians. This is not something that's being discussed at all in this election at the federal level. And that has to do with the responsibilities, the division of power between the federal government and the provinces.

And and that's something that's really important for Canadians to understand. In a way, one of the reasons I think we don't hear a lot about health care in this election. Well, first of all, there is the, you know, saga of tariffs that we are this this reality show that we're all unwitting participants in that is eating up a lot of the oxygen in the room here.

But also it's because it's a catch 22 for the federal government, for the parties that are vying for our votes right now. It's difficult for the federal government to really force the issue into delivering on primary care. Certainly, it's a big issue. Right now, roughly six and a half million Canadians don't have a family doctor or a nurse practitioner. So this being a federal election, what...

can the federal government do about that? Well, that's where the cheerleader role comes in. So, you know, the watchdog watching that the provinces abide by the Canada Health Act and don't impose user fees is really critically important. But the cheerleader role also, I would argue, is as important. And it

It's where the federal government can exert a leadership role in helping the provinces along to really harmonize their practices across Canada, provinces and territories. And harmonization is important because you don't

want to be caught in a situation where you, let's say, move provinces and you lose the funding or the support, the healthcare support that you had in the other one. I remember once I was in Ottawa and I was overhearing in a cafe two gentlemen talking about their diabetes medications and

And one was living in Gatineau and the other one was living in Ottawa. So just the river separating them. And they had such wildly different experiences. One of them was covered by the public system in Quebec and the other one wasn't. And so was put painfully out of pocket. But

The one in Ottawa was much more likely, much more concerned about being able to afford even their medication and was joking about maybe having to skip a day or two. And so that is really concerning when you have a national agenda that you're not able to have Canadians be equally covered, equitably covered across provinces.

And that's a role that the federal government has played in recent years, notably with Pharmacare establishing this universal system with basic coverage at this stage. But it's still something that the federal government is helping, is cheerleading provinces on to do and putting money on the table to do so.

Well, I certainly want to pick up on this to ask what the federal government can do about something that has been a campaign by the Canadian Medical Association. It has proposed a pan-Canadian license to make it easier for physicians and other regulated providers to move around the country and work where they're most needed. What can the federal government do to address that?

The federal government has much more power at their disposal, that is, they are able to set regulations as well. And so this is an important factor. I think the movement of health professionals across provinces is really key to ensuring that they go where they're most needed.

But there will be some considerations regarding remuneration. So I think the federal government will have to keep a watchful eye to make sure that there aren't imbalances between the provinces as far as that's concerned. I think one thing that we learned, or at least that I was surprised about with the discussion on terrorists,

is how little interprovincial trade exists. And I'm kind of taking a bit of a sidebar here, I'm talking about trade, but I think it's just as pertinent to this movement here of health professionals, because that's part of what's happening as well is we have this great nation,

10 provinces, 3 territories. And we think of ourselves as Canadian, even Quebecers now are singing the national anthem more and more and buying Canadian flags. But we are sometimes unaware of the regulations, the barriers that exist to trade and also to movement of health professionals across provinces. So I think this is a role that the Canadian government plays

should be playing more and more. And there are different party views on what the role of the Canadian government should be in terms of this big Canada approach or light government, let the provinces and territories do what they will approach. You know, Emily, this oversight role is...

We could spend our whole time just talking about reducing the barriers that keep people

health professionals from moving from one province or territory to another. In British Columbia, family physicians are being paid a lot more money. And that's part of a strategy by the province to try to attract and retain more primary care providers in British Columbia. And it's working.

So wouldn't the federal government want to play a role in helping prevent the flight of primary care providers from underserviced provinces to, to better service or better paid, uh, you know, provinces. Um,

And try to regulate the movement. You know, people have talked about a pan-Canadian license as if that's a panacea, and it's not because it would lead to some provinces ending up with fewer primary care providers, or it could, and other provinces ending up with more.

That is exactly the concern that I was wording, that I was voicing, that you need a systemic view about this and not just the kind of free market perspective that health care providers should be able to move anywhere, everywhere, because state of the federation as we have it now, it requires

Certainly, I think that it would drive some folks away from some provinces to where they get paid the best or where they have the best practice conditions, etc.

So there would be a lot of appetite for that, I would say, because we are working with a limited workforce. That's part of the challenge that we are facing in Canada. And I think the other point that I would like to raise, well, so you raised the question of whether the federal government should enact some regulations on that count.

I think that it would not be a popular decision because neither provinces nor health professionals would welcome that. So I don't think we're going to hear about that in the election campaign. We'll be right back.

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You're listening to White Coat Blackheart. This week, an extra special episode with our sister podcast, The Dose, on the federal election and how a new government can strengthen and protect health care in these troubling times. I'm speaking with Amelie Canel-Vallée, a professor at McGill's School of Population and Global Health and Canada Research Chair in Policies and Health Inequalities. Let's get back to our conversation.

Several political parties have called for the provinces to make it easier and faster for health care providers from other countries to work in Canada. I'm assuming that there's a role, certainly through immigration policy, that there's a role that the federal government could play in that, a direct role.

We are seeing increasing barriers to attracting talent and retaining talent, international talent in universities. And much of what we do in health care has a lot of also high, you know, a lot of our physicians, top physicians practice in university hospitals, but also beyond that. These are

skilled professionals that would be coming to our country. And the barriers to migration to Canada are extremely high right now. We are known to be a country where it's very difficult to get visas.

And so this is definitely something that the federal government would be able to do, partnering with the provinces. For the purposes of this conversation, Amelie, we're not talking about what governments should do. We're talking about what they could do. Here's another area in which the federal government could play a direct role. And I want to talk for a moment about the fact that Canada is seeing the highest number of cases of measles in many, many years.

What can the federal government do to address that? So what we're facing right now is with, and I'm going to bring back the situation in the U.S. into the conversation again, the layoffs that are happening in the public service in the U.S. are actually also affecting our own capacity to protect ourselves from a public health standpoint,

as well as from a pharmaceutical standpoint. And so what I'm referring to more specifically is the cuts to the CDC, the Centers for Disease Control in the U.S., and the cuts to the FDA, the Federal Drug Agency.

So that is of top of mind in the public health community right now, because there was a lot of collaboration between the systems, between the FDA. So Health Canada relied a lot on FDA decisions and also on the CDC availability. There were labs that were collaborating. And the fact that these agencies are now being developed

cut severely facing severe layoffs is having also impacts on our capacity to monitor for surveillance because diseases and pathogens, bugs, they don't stop at national borders. So it was the right thing to do to have those systems be collaborative and have some level of integration. And

So right now, the federal government must really be mindful that our public health is at risk. Public health is squarely within the purview, it's the responsibility of the federal government.

And it must continue efforts to ensure that our population health is protected, that we increase efforts to vaccinate populations that haven't been vaccinated. And that will mean reaching out to those populations and understanding and hearing them and hearing their concerns about vaccination, pushing back against this wave of COVID

anti-vax sentiment. So there's a lot to do for the federal government. So the efforts need to be renewed. And in fact, the layoffs in the states are putting increasing pressure on our public health systems in Canada and the cheerleading role here and the watchdog role for the federal government will be really, really critical in years to come.

I think it's also fair to say that emerging infectious disease threats from other countries that would include measles would include bird flu. You know, the next we're all wondering what the next pandemic is going to look like. You know, COVID in the last five years that the federal government plays a direct role because this is a security issue and the security of the country matters.

is the purview of the federal government. And so we have the national laboratories, we have level four laboratories for studying, for collecting samples and studying emerging threats, infectious disease threats. And we have FluWatch, we have Sentinel programs across the country that are administered by the federal government through the Public Health Agency of Canada. Mm-hmm.

Absolutely. So the Public Health Agency of Canada, Health Canada, the Canadian Institutes of Health Research, they are all providing critical information on pandemic preparedness.

on climate health linkages. This is the new reality that we are facing and the efforts must not abate in terms of understanding this new reality and acting upon it. Now, as I said, that we're losing capacity, that the U.S. is losing capacity in this regard where we were collaborating with them and interacting with them. There will need to be renewed efforts and I would think also renewed investments.

It's going to cost more money, although I think it's fair to say that the Public Health Agency of Canada, I think in many ways, punches above its weight in terms of its international influence in collecting and sharing data, disease surveillance. This is a related subject that you've already alluded to. We've kind of mentioned tariffs a few times. How might U.S. tariffs affect drug prices in Canada and the Canadian pharmaceutical industry?

Well, there was a recent study from researchers at U of T. Then this was published in the JAMA. It suggests that the U.S. tariffs on pharmaceuticals will likely drive up costs in here as well and cost shortages. So they will drive up costs over there, of course, because they are relying, the U.S. is relying on critical Canadian-made drugs. And this includes antibiotics, antidepressants, HIV treatment drugs.

So while there will be a big effect on the American market, it could also have significant ricochet effects here in Canada because if these drugs are deemed too expensive for these other markets, then demand will, you know, peter out. And so that means layoffs here as well or slowdowns in production unless we find other markets.

And if Canada imposes counter tariffs on these U.S. pharmaceuticals, then it will increase costs here, too, for these other pharmaceuticals that we are relying on from the U.S.,

So then there will be a role for the Canadian government to think about the regulation of price of drug products in Canada. So in Canada, we are fortunate to have the regulation of drug products and there's a federal agency to patented medicine prices review board. That's a mouthful. They look at those prices and they make sure that we get good value for our money.

So the federal government may have to intervene in this regard if the prices get higher, but the drugs are still essential and we don't have other means of producing them or importing them, then there may have to be an intervention there where the federal government would have to intervene to produce.

prevent the board to exclude drugs that become too expensive as a result of tariffs. It's getting down into weeds, but it's going to be critically important for many Canadians, probably. And I would suggest that these are the weeds that we're going to have to get into. We want to know that whatever political party forms the government is thinking about these issues very deeply. Last question I want to ask you, you know, we're hearing from the United States that

that we might be looking at a relative dismantling of the Food and Drug Administration. And you've already said, and I know this already, that Health Canada has relied on FDA Food and Drug Administration decisions regarding approval or not approving certain pharmaceuticals in its deliberations in Health Canada's decisions to approve or not approve prescription drugs. You know, they're not in lockstep with one another.

But how should the Canadian government, how should any Canadian government respond to a reduction in the level of oversight, regulatory oversight of prescription drugs in the United States?

Well, it's obvious that the layoffs at the FDA, although they were purported to not have effects on delivery, they are being seen now to do so. And so we should expect that this will disrupt the flow of safety information for drugs, medical devices and even food to Canada.

And so we will need to ramp up our beef up, pun intended, our internal capacity to produce that information. But obviously that cannot be done overnight or to find other sources. So will we align with the European Union?

We have historically looked to the FDA for some of this information because they had such massive capacity beyond what we had. You know, we're talking about a population of 40 million versus more than 300 million.

and 30 million, it made sense that they were putting that much more capacity and that we could then rely on some of that information where we feel that it is properly reviewed and trusted information. I think there will be no choice but to consider alternative options, including scientific sovereignty for us. Scientific sovereignty. Can you elaborate on that?

Well, I know the term sovereignty is being branded a lot. You know, we talked about it during COVID for our pharmaceutical capacity, manufacturing capacity. I think what we are facing right now is a very different situation.

world in terms of globalization. The signs are here, they are clear every day and we need to be capable to provide for our own people, for our own information and that will mean, and we do have the capacity, we have amazing folks across the country in universities and schools of public health for instance and

they are able to provide some of that information. But at this stage, we will have to ramp up that capacity. So working with universities to ensure that these programs are capable to deliver on what the workforce needs are in Canada is going to be critically important. It was done. You know, it may seem like

it's a big ask, but it was done in 2004 when we, when the Public Health Agency of Canada was created. It was created in response to a crisis. And before that, we didn't have a system of schools of public health like they did in the States. And so I think this is a similar kind of clarion call to action. We need to be mindful that we need to be able, ideally we collaborate. I'm

I love collaboration. I do interdisciplinary work, but I think that now we need to take the message loud and clear that we also need to be able to provide for ourselves. What you're saying, this is a really interesting note to end our discussion on what is...

happening. It's both a crisis and it's an opportunity because it's an opportunity for, you know, for Canada, you know, you know, we'll, we'll decide whether we want to prize science and knowledge and maintain that expertise, the kind of expertise that that's being systematically dismantled in, in the United States as, as we speak. And,

You know, it's a shame that this is not a health care election issue because it should be. I'm really glad that you've come on the program, Amelie Canel-Vallée, to help Canadians, you know, understand what's at stake and what a federation like Canada can do to try to address the crisis at hand during the coming election. And thank you for bringing up the topic.

Amelie Canel-Vallée is a professor at McGill School of Population and Global Health and Canada Research Chair in Policies and Health Inequalities.

As we said during our conversation, there are lots of things the federal government could do to address health care and health care inequalities in Canada. It could adjust immigration policy to bring in more doctors, nurses and other health care providers. It could negotiate with the provinces to help create a pan-Canadian license for health care professionals. It could beef up its pandemic planning and made in Canada testing of new prescription drugs. These are things a new government could do. Whether it should do them is up to you.

which is why we think you should take a good look at the health care platforms of the political parties. That's next week on White Coat Black Art. That's our show this week. Our White Coat Black Art Dose Mashup was produced by Brandi Weichle with help from Jennifer Warren and Samir Chhabra. Our digital producer is Ruby Buiza. Our senior producer is Colleen Ross. I'm Brian Goldman, and I'm proud to bring you stories from the Canadian side of the gurney. See you next week.

For more CBC Podcasts, go to cbc.ca slash podcasts.