Ottawa gives Quebec special treatment in this area of health-care funding

Many Canadians may be unaware that health care is a provincial responsibility, with the federal government mostly playing a financial role through cash transfers. Those transfers come with conditions outlined in the Canada Health Act (CHA), a federal law, along with occasional federal clarifications as to how the Act will be interpreted regarding particular policy approaches across the country. Provinces that don’t comply with this federal diktat run the risk of reductions in cash transfers from Ottawa.

But that risk seems to vary a little depending on who’s doing the violating. A review of federal rule enforcement since 2014/15 finds Quebec has apparently been living under a slightly different set of rules than the other provinces.

Under the CHA, provincial governments must annually provide reports to the federal government outlining the amounts of “extra billing” and “user charges” charged to patients in the province. More recently, Ottawa has updated and standardized the format for this reporting.

These standardized “financial statements” are publicly available in the Canada Health Act Annual Reports starting in 2018/19, showing nine of Canada’s provinces dutifully submitted their information each year. That is, everyone except Quebec. Rather than providing information in the new standardized format, Quebec’s provincial government instead sent (and continues to send) letters to Health Canada stating it does not allow user charges, that health care is the exclusive jurisdiction of the provinces, and that accountability for the province’s health-care system is to the National Assembly and the people of Quebec.

There does not appear to have been any consequence for Quebec deciding the new reporting rules don’t apply to them. Which brings us to the more obvious special case for Quebec—two years of seemingly exclusive access to refunds for their penalties.

Prior to 2018, and aside from a three-year period following the Act’s introduction that allowed provinces time to align to the new regime, cash transfer reductions were not reimbursable to provinces found to be in violation—monies penalized were monies lost.

But in both 2016/17 and 2017/18, Health Canada reported transfer deductions for both British Columbia and Quebec, but also a full reimbursement of the penalties for Quebec only. According to Health Canada, the 2016/17 reimbursement occurred because the provincial government had already taken steps to eliminate the fees in question. The second reimbursement was listed as “ex gratia” payment, which as defined by the federal government means a “benevolent payment made by the Crown used only where there is no other statutory, regulatory or policy vehicle to make such a payment.” Health Canada went on to explain that the second refund “reflects Health Canada’s priority, which is not to take deductions but to seek the elimination of patient charges and to ensure access to needed medical care… This Quebec example, where a province faced a deduction after taking corrective action, proved to be the inspiration for the Minister’s new Reimbursement Policy.”

In other words, Quebec was penalized for CHA violations in two years and then paid back because Health Canada deemed it to have fallen back in line. Only after the second reimbursement was a program and process created for the other nine provinces to get their penalty monies back in the event a penalty was levied against them, under which B.C. was then able to get some of its penalty back.

This is not to say Quebec always receives special treatment. The province has been penalized in recent years (along with the other provinces) for allowing patients to pay for diagnostic imaging (e.g. MRI and CT scans), and is working with Health Canada to be refunded those penalties through the new reimbursement process. But it remains clear that Quebec doesn’t always play by the same rules as the other provinces.

It would seem, at least over the past decade of federal-provincial health-care relations, that there are sometimes two sets of federal rules in play for the provinces. One for Quebec and one for the rest of Canada. If Ottawa wants to be involved in health care and set rules for the provinces, it should at least impose them consistently.