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Time to finally change the Canada Health Act for the sake of patients

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From the Fraser Institute

By Nadeem Esmail

Back in 1984, the Canada Health Act (CHA) received royal assent and has since reached near iconic status. At the same time, under its purview, the Canadian health-care system has become one of the least accessible—and most expensive—universal health-care systems in the developed world.

Clearly, policymakers should reform the CHA to reflect a more contemporary understanding of how to structure a truly world-class universal health-care system.

Consider for a moment the remarkably poor state of access to health care in Canada today. According to international comparisons of universal health-care systems, we endure some of the lowest access to physicians, medical technologies and hospital beds in the developed world. Wait times for health care in Canada also routinely rank among the longest in the developed world.

None of this is new. Canada’s poor ranking in the availability of services reaches back at least two decades. And wait times for health care have nearly tripled since the early 1990s. Back then, in 1993, Canadians could expect to wait 9.3 weeks for medical treatment after GP referral compared to 30 weeks in 2024.

This is all happening despite Canadians paying for one of the world’s most expensive universal-access health-care systems. And this brings us back to the CHA, which contains the federal government’s requirements for provincial policymaking. To receive their full federal cash transfers for health care from Ottawa, provinces must abide by CHA rules and regulations. And therein lies the rub.

We can find the solutions to our health-care woes in other countries such as Germany, Switzerland, the Netherlands and Australia, which all provide more timely access to quality care. Every one of these countries requires patient cost-sharing for physician and hospital services, and private competition in the delivery of universally accessible services with money following patients to hospitals and surgical clinics. And all these countries allow private purchases of health care, as this reduces the burden on the publicly-funded system and creates a valuable pressure valve for it.

Unfortunately for Canadians, the CHA expressly disallows requiring patients to share the cost of treatment while the CHA’s often vaguely defined terms and conditions have been used by federal governments to discourage a larger role for the private sector in the delivery of health-care services. At the same time, every new federal commitment to fix health care means increased provincial reliance on Ottawa. In 2024-25, federal cash transfers for health care are expected to total $52 billion, which means there’s $52 billion on the line for perceived non-compliance with the CHA. In short, this is why the provinces beholden to a policy approach that’s clearly failing Canadians.

So, what to do?

For starters, Ottawa should learn from its own welfare reforms in the 1990s, which reduced federal transfers and allowed provinces more flexibility with policymaking. The resulting period of provincial policy innovation reduced welfare dependency and government spending on social assistance (i.e. savings for taxpayers). When Ottawa stepped back and allowed the provinces to vary policy to their unique circumstances, Canadians got improved outcomes for fewer dollars.

We need that same approach for health care today, and it begins with the federal government reforming the CHA to expressly allow provinces the ability to explore alternate policy approaches, while maintaining the foundational principles of universality.

Next, the federal government should either hold cash transfers for health care constant (in nominal terms), reduce them or eliminate them entirely with a concordant reduction in federal taxes. By reducing (or eliminating) the pool of cash tied to the strings of the CHA, provinces would have greater freedom to pursue reform policies they consider to be in the best interests of their residents without federal intervention.

After 40 years, it’s high time to remove ambiguity and minimize uncertainty—and the potential for politically motivated interpretations—of the CHA. If federal policymakers want Canadians to finally have access to world-class health care, they should allow the provinces to choose their own set of universal health-care policies. The first step is to fix the 40-year-old legislation that has held the provinces back.

Nadeem Esmail

Senior Fellow, Fraser Institute

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Business

Residents in economically free states reap the rewards

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From the Fraser Institute

By Matthew D. Mitchell

A report published by the Fraser Institute reaffirms just how much more economically free some states are compared with others. These are places where citizens are allowed to make more of their economic choices. Their taxes are lighter, and their regulatory burdens are easier. The benefits for workers, consumers and businesses have been clear for a long time.

There’s another group of states to watch: “movers” that have become much freer in recent decades. These are states that may not be the freest, but they have been cutting taxes and red tape enough to make a big difference.

How do they fare?

recently explored this question using 22 years of data from the same Economic Freedom of North America index. The index uses 10 variables encompassing government spending, taxation and labour regulation to assess the degree of economic freedom in each of the 50 states.

Some states, such as New Hampshire, have long topped the list. It’s been in the top five for three decades. With little room to grow, the Granite State’s level of economic freedom hasn’t budged much lately. Others, such as Alaska, have significantly improved economic freedom over the last two decades. Because it started so low, it remains relatively unfree at 43rd out of 50.

Three states—North Carolina, North Dakota and Idaho—have managed to markedly increase and rank highly on economic freedom.

In 2000, North Carolina was the 19th most economically free state in the union. Though its labour market was relatively unhindered by the state’s government, its top marginal income tax rate was America’s ninth-highest, and it spent more money than most states.

From 2013 to 2022, North Carolina reduced its top marginal income tax rate from 7.75 per cent to 4.99 per cent, reduced government employment and allowed the minimum wage to fall relative to per-capita income. By 2022, it had the second-freest labour market in the country and was ninth in overall economic freedom.

North Dakota took a similar path, reducing its 5.54 per cent top income tax rate to 2.9 per cent, scaling back government employment, and lowering its minimum wage to better reflect local incomes. It went from the 27th most economically free state in the union in 2000 to the 10th freest by 2022.

Idaho saw the most significant improvement. The Gem State has steadily improved spending, taxing and labour market freedom, allowing it to rise from the 28th most economically free state in 2000 to the eighth freest in 2022.

We can contrast these three states with a group that has achieved equal and opposite distinction: California, Delaware, New Jersey and Maryland have managed to decrease economic freedom and end up among the least free overall.

What was the result?

The economies of the three liberating states have enjoyed almost twice as much economic growth. Controlling for inflation, North Carolina, North Dakota and Idaho grew an average of 41 per cent since 2010. The four repressors grew by just 24 per cent.

Among liberators, statewide personal income grew 47 per cent from 2010 to 2022. Among repressors, it grew just 26 per cent.

In fact, when it comes to income growth per person, increases in economic freedom seem to matter even more than a state’s overall, long-term level of freedom. Meanwhile, when it comes to population growth, placing highly over longer periods of time matters more.

The liberators are not unique. There’s now a large body of international evidence documenting the freedom-prosperity connection. At the state level, high and growing levels of economic freedom go hand-in-hand with higher levels of incomeentrepreneurshipin-migration and income mobility. In economically free states, incomes tend to grow faster at the top and bottom of the income ladder.

These states suffer less povertyhomelessness and food insecurity and may even have marginally happier, more philanthropic and more tolerant populations.

In short, liberation works. Repression doesn’t.

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Alberta

Alberta Next Panel calls for less Ottawa—and it could pay off

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From the Fraser Institute

By Tegan Hill

Last Friday, less than a week before Christmas, the Smith government quietly released the final report from its Alberta Next Panel, which assessed Alberta’s role in Canada. Among other things, the panel recommends that the federal government transfer some of its tax revenue to provincial governments so they can assume more control over the delivery of provincial services. Based on Canada’s experience in the 1990s, this plan could deliver real benefits for Albertans and all Canadians.

Federations such as Canada typically work best when governments stick to their constitutional lanes. Indeed, one of the benefits of being a federalist country is that different levels of government assume responsibility for programs they’re best suited to deliver. For example, it’s logical that the federal government handle national defence, while provincial governments are typically best positioned to understand and address the unique health-care and education needs of their citizens.

But there’s currently a mismatch between the share of taxes the provinces collect and the cost of delivering provincial responsibilities (e.g. health care, education, childcare, and social services). As such, Ottawa uses transfers—including the Canada Health Transfer (CHT)—to financially support the provinces in their areas of responsibility. But these funds come with conditions.

Consider health care. To receive CHT payments from Ottawa, provinces must abide by the Canada Health Act, which effectively prevents the provinces from experimenting with new ways of delivering and financing health care—including policies that are successful in other universal health-care countries. Given Canada’s health-care system is one of the developed world’s most expensive universal systems, yet Canadians face some of the longest wait times for physicians and worst access to medical technology (e.g. MRIs) and hospital beds, these restrictions limit badly needed innovation and hurt patients.

To give the provinces more flexibility, the Alberta Next Panel suggests the federal government shift tax points (and transfer GST) to the provinces to better align provincial revenues with provincial responsibilities while eliminating “strings” attached to such federal transfers. In other words, Ottawa would transfer a portion of its tax revenues from the federal income tax and federal sales tax to the provincial government so they have funds to experiment with what works best for their citizens, without conditions on how that money can be used.

According to the Alberta Next Panel poll, at least in Alberta, a majority of citizens support this type of provincial autonomy in delivering provincial programs—and again, it’s paid off before.

In the 1990s, amid a fiscal crisis (greater in scale, but not dissimilar to the one Ottawa faces today), the federal government reduced welfare and social assistance transfers to the provinces while simultaneously removing most of the “strings” attached to these dollars. These reforms allowed the provinces to introduce work incentives, for example, which would have previously triggered a reduction in federal transfers. The change to federal transfers sparked a wave of reforms as the provinces experimented with new ways to improve their welfare programs, and ultimately led to significant innovation that reduced welfare dependency from a high of 3.1 million in 1994 to a low of 1.6 million in 2008, while also reducing government spending on social assistance.

The Smith government’s Alberta Next Panel wants the federal government to transfer some of its tax revenues to the provinces and reduce restrictions on provincial program delivery. As Canada’s experience in the 1990s shows, this could spur real innovation that ultimately improves services for Albertans and all Canadians.

Tegan Hill

Director, Alberta Policy, Fraser Institute
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