When President Barack Obama campaigns during the coming months for re-election, odds are he will not be reviving one of his 2008 health reform pledges, namely that savings from e-health would help pay for universal coverage of all Americans. One of those extensions of the truth so often deemed necessary during a campaign, technological investments may be necessary and justified on many grounds, but short-term cost savings from such a massive shift are little more than wishful thinking.
In this country, the federal government recently earned accolades from many quarters for diffusing what was expected to be highly contentious and drawn-out discussions over funding transfers to provincial counterparts. Fixed annual increases, at a certain point tied to economic growth, arguably provide the certainty that provinces need to both plan and reform while dealing with the daunting realities of aging populations and limited finances. This approach is consistent with a classic approach to political federalism: jurisdictionally respectful within the contours of the Canada Health Act. Short of outright privatization, the underlying message is that experimentation is welcome with as much freedom from federal intrusion as legally and politically feasible.
As the world goes digital, however, a quagmire emerges. The logics of interoperability and efficiency lead many to wonder whether more national systems are not, at some point, necessary. There are also complementary risks of smaller and less wealthy provinces affording less in the way of technological refurbishment, thereby exasperating service quality and access divides between various parts of the country.
It bears noting that the Conservatives faced a similar dilemma prior to taking office in 2006, with their support while in Opposition for the creation of a national ID card. During the aftermath of 9/11, most countries pursued variants of national ID systems, including Anglo-Saxon cousins the United Kingdom and Australia. The abandonment of such schemes in these aforementioned jurisdictions, partly due to contentious politics but more so due to administrative cost and complexity, would reframe Stephen Harper’s thinking once in power.
Despite recognition that centralization has its limits both politically and operationally, the fact remains that much like the U.S., a great many studies have demonstrated that Canada is an e-health laggard. It seems intuitive that a federal government would not be indifferent to the long-term repercussions of such a worrisome standing, but the question remains what can be done.
One response could be to bolster the resources of the Canada Health Infoway to spur greater investment in e-health adoption (for obvious reasons, the preferred course of this body itself). Nonetheless, while the Infoway has done much good in fostering the initial layers of infrastructure over e-health’s inaugural decade, it is without governance responsibilities for design and delivery. In an era where e-health is advancing rapidly around the world, the Infoway’s role as a research arm and observatory is important but also insufficient.
Canada should look closely at Australia. Differing constitutional and partisan arrangements notwithstanding, the federal and state governments have worked closely in recent years, leading to a 2010 national e-health partnership. Subsequently, to quote the federal government, “as part of the 2010/11 federal budget, the Government announced a $466.7 million (Australian) investment over two years for a national Personally Controlled Electronic Health Record (PCEHR) system for all Australians who choose to register online, from 2012-13.” The PCEHR is notably underpinned by a strategy enjoining federal and state health ministers in a common purpose and within a collaborative governance strategy of the sort that is glaringly absent at present in Canada.
In keeping with Canada’s constitution, the perils of excessive centralization (especially in all matters involving IT), and the present stance of the Harper government, it is reasonable to also look to provinces for innovative suggestions to resolving this quagmire and moving forward in a more concerted, national effort. Looking to the Council of the Federation, for example, as more than a lobbying arm for more dollars, would be a start.
In addition, the crucial local dimensions to delivery and decision making cannot be overlooked. And while municipalities are for the most part outside of direct health care delivery mechanisms, they too are central players in many aspects of fostering healthy lifestyles and communities.
Any truly national e-health architecture must therefore encompass these many layers and their growing interdependence. In short, with matters of macro funding seemingly settled, it is time for the real work to begin – and time for new political mechanisms to traverse old boundaries.
Jeffrey Roy is Professor of Public Administration at Dalhousie University (roy@dal.ca).
