Federal Health Minister Jane Philpott did not have a seat at the table for Monday's discussion among provincial and territorial ministers. Her meeting with the other ministers of health is Tuesday.
But Philpott, a genial doctor, made herself available to the reporters gathered at the King Edward Hotel in downtown Toronto all the same, inviting those loitering around the lobby to a room on the mezzanine level.
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In relaying Philpott's comments to the provincial ministers, a reporter would later describe the federal minister as having been "extremely frank." She certainly seemed primed for a debate.
And it is a debate — about the funding of health care, the state of the system and the federal role — that she has now primed.
'Make sure that investments in health go to health'
Philpott started, innocently enough, with an explanation that "the conversations that I'm about to have with the provincial and territorial health ministers have to be about making sure that Canadians have the health and the health care that they need."
But then, a turn.
"That we make sure," she continued, "that investments in health go to health."
The health minister would deliver variations on this statement another five times in the course of her 11-minute appearance.
It is, of course, a statement so self-evident that one is invited to be curious about why it needs saying.
The focus of dispute between the provinces and the federal government is the Canada Health Transfer, the mechanism the federal government uses to transfer funds to the provinces to assist in paying for health-care services.
Currently, the transfer is scheduled to increase by three per cent each year, less than the six per cent it had been increasing by in recent years. The provinces would like to see the six per cent escalator maintained. The federal government has so far expressed no interest in doing so.
But the Canada Health Transfer is not tied to any specific programs in the provinces.
"I don't know where that money's going," Philpott eventually explained. "We give the money to the Canada Health Transfer and it actually goes to the general revenue streams of the provinces."
Eric Hoskins, Ontario's health minister, would later express discomfort with the implication that provinces weren't committed to investing additional funds in health care, noting that the current federal transfer to his province could not be said to account for the entire increase in the province's health budget.
Quebec Health Minister Gaetan Barrette said, "I can tell you that the federal funds are all spent in health care."
But Philpott had ventured that it would be unrealistic to expect Ottawa to cover a six per cent increase if provincial budgets were not increasing by the same amount.
In the meantime, Philpott has so far offered a certain sum for home care and palliative care, and today she said that she'd like to hear ideas for funding the treatment of mental illness.
'Middle-of-the-road' health care?
But two sentences after her initial insistence that funding for health care be used to fund health care, Philpott would hit on another interesting idea
"We know," she said, "our health-care system is not doing as well as it could."
Though this might have been a relatively benign observation, she would expand on the problem a few moments later.
"There are countries in this world … that are getting far better value for money than we are," she said. "We're paying some of the highest costs in the world for health care and we've got a middle-of-the-road health-care system."
This, understandably, compelled several of the provincial ministers, those who are responsible for the actual delivery of health care, to defend the system (even while admitting imperfections).
"I've worked and practised in dozens of countries around the world and so I can proudly, as a physician, say it's not perfect, but this is one of the best health-care systems you're going to find," said Ontario's Hoskins, suggesting Philpott's "middle-of-the-road" comment did a disservice to the system.
How much funding is enough?
Underneath all this is the debate about how much federal funding is enough.
The federal government points to recent provincial budgets to note that spending on health has only increased by two to three per cent. The provinces note projections for future years that suggest annual increases of four or five per cent will be necessary.
There is also a call for the Trudeau government to cover 25 per cent of the total cost. And there are warnings that if the federal government doesn't increase its share, the system will suffer.
The failure to commit to a higher escalator is, Hoskins said on Monday, a "huge blow to our governments and a huge blow to your ability to invest in a sustainable health-care system."
The Liberals seem interested in targeted funds. What about that?
Barrette stepped forward to say that what's been offered for now on home care (Philpott is offering a $1.5 billion over the next four years, divided among the provinces), would cover a tiny fraction of what it would cost Quebec to fully fund that area.
But Alberta Health Minister Sarah Hoffman then stepped up to note that the Liberal platform and her party's platform lined up on several areas of interest and that she is open to discussions.
Perhaps that is a small glimmer of potential for when the federal and provincial ministers are in the same room on Tuesday.