The Politics of Money, a new podcast from the Institute of Fiscal Studies and Democracy, explores how public finance, politics, and institutions shape the world we live in.
Hosted by IFSD's Sahir Khan and Kevin Page, Canadaโs first Parliamentary Budget Officer, our podcast blends deep subject-matter expertise with accessible conversation.
A trusted place where listeners can follow the money โ and learn the real stories behind Canadaโs big policy choices.
Thank you for joining us on The
Yeah.
Politics of Money, the official podcast of
the IFSD.
And as usual, I am joined by my fellow
bald people.
we have ~ our chief economist,
Dr. Mostafa Askari ~ and
live from Thunder Bay, Ontario is Kevin
Page,
our CEO. My name is Sahir Khan.
This is a first of a series of kind of
pre-budget podcasts.
The budget is gonna be tabled sometime
this fall,
and a number of issues are obviously front
and center,
and we certainly know about defense,
security, the economy, trade. But there's
a there's an issue that just never quite
goes away in Canadian politics,
and that's health care. And we have the
Canada Health Transfer due for
~ renewal in 27-28.
And some of the bilateral agreements are
are up for renewal next year.
And so all of a sudden, you know,
the premiers and other important
stakeholders are raising issues around
healthcare
and how it fits in the whole fiscal
situation and really this kind
of budget squeeze that Canada's now kind
of dealing with.
So want to kind of get the conversation
started,
Kevin. healthcare major structural ~
spending pressure.
Also really important for the economy,
wellbeing of Canadians. How does
healthcare fit into the hinge moment,
the agenda, the priorities? ~ Might not be
front burner in the news every day,
but never too far from the hearts of
Canadians.
Yeah, I think that's very well said,
Sahir. I think ~
that when we saw the the platform from the
liberals in ~ the spring of 2025,
Yeah, I think that's very well said,
Sahir. I think ~ that when we saw the the
platform from the liberals
that like healthcare wasn't front and
center in terms of the hinge moment.
in the spring of 2025, that like
healthcare wasn't front and center in
terms
Hinge moment being a moment where ~
decisions we're making now are gonna have
of the hinge moment. The hinge moment
being a moment where ~ decisions we're
making
a long-term impact. We are we find
ourselves,
according to the Prime Minister,
now are gonna have a long term impact.
and and you know, I think we would all
agree,
We are we find ourselves, according to the
Prime Minister,
in a world that is changing, a world order
that's changing,
and and you know, I think we would all
agree,
a world that is changing, a world order
that's changing,
~ significant wars.
~ in in Europe, in the Middle East,
~ significant wars ~ in in Europe.
the potential for conflict in
other places, including the South China
Sea.
in the Middle East, the potential for
conflict in other places,
~ We find ourselves in trade arrangements
that are,
including the South China Sea.
~ we find ourselves in trade arrangements
you know, agreements that are no longer
being honored.
With these higher defense, you know,
sense that Canada, you know, we're in a
moment right now with with these higher
demands ~ on Canada and just some weak
productivity issues that we need
defense, ~ on Canada and ~ you know,
to make some big decisions. So but I think
healthcare was presented
and just some weak productivity issues
that we need to make some big decisions.
by Prime Minister Carney
So
but I think healthcare was presented by
Prime Minister Carney
you know, in the in the budget of 2026 as
something
that can contribute, but something that
played a more supporting role.
you know, in the in the budget thousand
twenty six as something that can
contribute,
I think that where some of my colleagues,
something that played a more supporting
role.
I think that we're the I think where some
of my colleagues,
our colleagues, people like Jim Stanford,
I was you know I was at the premier's
meeting with ~
our colleagues, people like
I think they see it as like a big
industry,
you know on the tw twenty third or twenty
second of July. I think they
a 400 billion dollar industry
see it as like a big industry,
that that contributes significantly to
growth,
a four hundred billion dollar industry
that that contributes significantly
to productivity, to research, and is you
know export resilient.
to to productivity, to
if you look at you know the size of the
labor force,
so yeah, if you look at you know the size
of the labor force,
it's you know, again, you look at
innovation dollars,
it's you know, again, you look at
innovation dollars,
it's you know, all these like it's a big
sector of our economy.
it's you know, all
I think the
So that
premiers certainly see it as a unity issue
and so yeah,
Yeah, they see it as a tra you know an
important issue.
And I think the Premier certainly see it
as a unity
it's it's not gonna go away.
So Mostafa, where does it where does
healthcare kind of fit in in terms
of the the overall fiscal situation for
the federal government?
~ it's the delivery is clearly a a
provincial responsibility,
but the federal government makes important
contribution,
has through tax points and through current
expenditures.
~ the pressure
Particularly with demographics,
never goes away, or or at least not for
the foreseeable future.
So how how how do we get through some of
these challenges and and how does
it fit into the fiscal structure that we
we have?
Well, right now, it's the second largest
item in the government program spending.
I mean, probably in the in the next couple
of years,
the defense is going to take that over.
You know, health becomes the probably the
third largest.
But it is a l a large item in the
government ~ program spending.
It grows every year based on the based on
the escalator that we have right now,
it is 5% until 2027- '28. And after that,
if there is no change in the agreement,
it goes back to the average of the nominal
GDP growth over the previous three years,
which is which is going to be around three
and a half to four percent.
So that that's that's part of the budget.
It grows significantly and by 2030 -'31,
is gonna get close to eighty eighty,
eighty-five to ninety billion dollars.
Now overall, in in fact actually the the
federal government
~ transfers about hundred and fifteen
billion dollars to provinces
in different ways.
And one of them is social transfers,
one of them is health transfers,
CHT. These are the biggest items in there,
and then equalization. These are those
three actually is about $100 billion a
year.
So and that that money goes to provinces,
they can use it in any way they wish,
because there is no targeted funding here.
Although they call CHT they call it
social,
but provinces can can can use that money
in any way or shape they would like
to see it and they fit in their budget.
So it is it is a big item and any change
in that,
~ whether there is a change in escalator
or a change in the base
or any other change, obviously it has a
huge impact on the government budget
and the bottom line.
Look, Kevin as Mostafa said, you know,
large amount of Federal Government
spending are transfers,
and we've seen that accountability for
results often suffer with transfers,
in that you've got one order of government
kind of raising money
and another order of government spending
it.
Not a lot of levers kind of in between to
kind of hold that spending
to certain targets with respect to
results.
In this renegotiation or the next round of
renewal,
do you s do you expect any discussion
around results or
Yeah.
or changing models or different approaches
that could get better outcomes
for Canadians?
so that's a it's a great question.
I think there is room for improvement.
I think ~ I think there is room for
improvement.
I think we see through these bilateral
accords ~ where ~ where monies
I think we see through these bilateral
accords ~ where ~ where monies
are being provided ~ you know for a range
of issues and you know,
are being provided ~ you know for a range
of issues and you know,
including mental health and long term care
and you know and digital related issues.
including mental health and long term care
When they do these bilateral accords,
digital related issues that there are some
speci you when they
there are ~ outcome performance
indicators.
do these bilateral accords, there are ~
outcome performance
So I think that is positive.
think that is po positive. ~
And I think it's ~ we've also
seen advancements. And Dr. Askari was
actually,
And I think it's we've also seen
advancements.
I think, part of those when he was at
Canada Health Canada.
And Dr. Askari was actually, I think,
We saw ~ significant progress with the ~
the Canadian Institute
part of those when he was at Canada Health
Canada,
we saw ~ significant progress with the ~
the Canadian Institute
of Health Information. I think now,
you know, all Canadians can go to these
sorts of sites and see
of Health Information. I think now,
you know, all Canadians can go to these
sorts of sites and see
how we're doing province by province on
these sorts of big issues,
how we're doing province by province on s
~ these sorts of big issues,
~ health outcomes, access issues,
~ health outcomes, access issues,
spending related issues. So we have I
think we're in a much better position
spending related issues. So we have
now than we were.
I think we're in a much better position
now than we were.
I mean Mostafa and I were at you know
Department of Finance
in 1980. So I think like you know,
I mean you know when Mostafa and I were at
you know Department
it's you know, given the tightness of the
fiscal situation,
of Finance in nineteen eighty.
So I think like you know it's you know
given the tightness of the fiscal
situation,
I think and the need to kind of spend
money wisely in this area,
I think and and the need to kind of spend
money wisely in this area,
I think we'll probably there'll be a push
probably to do,
I think we'll probably there'll be a push
probably to do you know a little
you know, a little bit more on the
bilateral court side where
we see stronger performance indicators.
bit more on the bilateral court ~ but
yeah,
I think, you know, again, the more we talk
about outcomes,
the more I think politicians connect with
Canadians.
I think we know, again, the more we talk
about outcomes,
the
Now even ~ a a push towards
bilateral approach it still doesn't help
provinces deal with
the demographic pressures which now are
are falling on them.
The federal government has, I guess,
to some extent insulated itself from some
of the demographic pressures,
fiscally made itself sustainable through a
series of cuts and over the years.
~ How do the provinces improve their their
fiscal sustainability while managing
these pressures?
If the federal government still going to
kind of largely hold the line
on the transfers and focus on kind of
smaller bilateral issues?
Well, first of all, the government is not
holding the line.
I mean, there they it is actually growing
over time.
There is definitely demographic pressures,
but those pressures actually over time
they're going to decline because although
the aging continues, but the rate of aging
is going to decline after 2030-31.
once the baby boomers exit the population,
and then that you're gonna see the a
little bit of ~ less pressure
on those those sort of expenses.
There is no doubt that the the aging is a
big driver of the healthcare cost.
And in fact, one of the things that have
been always discussed in the past,
and the government's never agreed to this,
is that
the allocation of Canada Health Transfers
should be based on
the aging ~ demographics of the different
provinces.
Because right now we are doing an equal
per capita allocation.
And while that is equal but is not
equitable because the provinces like
Newfoundland
that have huge aging ~ issues,
the cost per person, health cost per
person in those provinces are much higher
than
the cost per person in Ontario and Alberta
or BC.
So Kevin, how how does this negotiation
kind of play out when spending continues
to rise faster, healthcare spending,
than than provincial government's fiscal
capacity?
How do you square the circle with the asks
that are coming from
the provinces with the fiscal kind of
limits that that
the federal government currently has?
Yeah, I think there's definitely a feeling
that ~ the fiscal situation
Yeah, I think there's definitely a feeling
that ~ the fiscal situation has changed.
has changed ~ since COVID that you know
we're I think ~ Canada,
~ since COVID that, you know, we're I
think ~ Canada,
other countries are experiencing what much
higher debt because of,
other countries are experiencing much
higher debt because of,
you know, COVID and other factors.
you know, COVID and other factors.
And I think the military as well is a huge
fiscal pressure.
And and I think the military as well is a
huge fiscal pressure.
~ I mean, if you look at these sort of
budgetary deficits in different sizes
~ I mean if you look at these sort of
budgetary deficits in different sides of
the
of the in different countries,
in Canada.
in different countries, in Canada,
You know, our deficit, you know,
you know, our deficit, you know,
total government deficit probably in the
two percentage points of GDP,
total government deficit probably in the
two percentage points of GDP,
which is definitely higher than
prior to COVID. So everybody's a little
bit squeezed,
Definitely higher than it was prior to
COVID.
So everybody's a little bit squeezed,
you know, in that sense. So I think the
idea of getting,
you know, in that sense. So I think the
idea of getting,
you know, if we think of GDP as as a you
know as an indicator of the tax base,
you know, if we think of GDP as as a you
know,
as an indicator of the know, I think it's
personal,
it's reasonable for the federal government
to think about we're gonna grow
it's reasonable for the federal government
to think about we're going
the Canada Health Transfers with you know,
to grow the Canada Health Transfers with ~
you know,
in line with GDP.
in line with GDP, which is, as Mostafa
said,
Which is, as Mostafa said, a three year
moving average right now in
a three year moving average right now in
the agreement,
the current in the current agreement that
will
agreement, the agreement
will fall into place naturally at the end
of in 2028-29.
that will like will fall into place
naturally at the end of in 2028-29.
But then can we like how can we work with
provinces to adjust our system,
But then can we like how can we work with
provinces to adjust our system,
you know, in the context of a Canada
Health Act,
you know, in the context of a Canada
Health Act,
adjust the system on primary care,
adjust the system on primary care,
long-term care, other aspects of the care
system,
long term care, other aspects of the care
system,
so that we're actually growing spending ~
and achieving I think better outcomes.
so that we're actually growing spending ~
and
achieving prior, I think, better outcomes,
you know, but moving like spending in in
line with GDP,
you know, in but moving like spending in
in line with GDP,
in line with our tax base. So we're not
building up more debt
in line with our tax base. So we're not
building up more debt
for future generations. So I think that's
gonna be I think just the the productivity
for future generations. So I think that's
gonna be
I think just the the productivity of the
healthcare know we have good outcomes.
of the healthcare industry. We you know we
have good outcomes Canadians
are very healthy and tend to be healthy
when we look at you know OECD indicators,
The Canadians Canadians are very healthy
and tend to be healthy when we look
at you know OECD indicators. But our
system definitely lags
but our system definitely lags ~ on
access.
~
on access,
On the quality of care.
Yeah, no the the you you're right,
Kevin. It it is a big important thing and
there are issues with
the with the service. In fact,
when you have a market based ~ health
system,
the the sort of the
The arbiter of the of the supply of demand
is price.
When you have a when you have public
sector,
you don't have that arbiter, the
equilibrium sort of the ~ force to do
that.
So in fact, ~ wait times replaces the
price for that
for that exactly for that mechanism that
brings the supply and demand together.
Maybe not completely, but at least it it
sort of helps.
Despite some of the issues, problems with
the system,
I mean you go around and if you have major
issues,
they take care of you really well at the
hospitals.
Yep.
And that's one of the reasons that we have
a
We have a a healthier population than the
than the Americans.
Yeah. Despite the fact that we spend a lot
less.
If you look at ~ the spending that goes on
in that sector,
these like it's a big sector of our
economy.
If you look at ~ the spending that goes on
in that sector,
like on the inputs and those sorts of
things,
it's it is I think it underscores,
like on the inputs and those sorts of
things,
it's it nailed
it, but it it mean
it's
a really important part of the sector that
you want to get right.
It's just it it's a really important part
And you know, we look at some of our
spending measures.
the quality of care. And you know,
~ we're we're a big spending country.
we look at some of our spending measures.
We spend well above the OECD average,
we're we're a big spending country.
We spend we tend to we're well above the
OECD average,
not as much as the Americans, but you
know,
certainly above the OECD.
not as much as the Americans, but
the economy. And we are healthy.
Like you look at United States spends
significantly more than us,
Like you look at United States spends
significantly more than us,
probably four or five percentage points of
GDP more.
probably four or five percentage points
more,
Their health health outcomes are not as
good as Canadians on average,
their health comes and er health outcomes
are are are not on average ha
and they don't
live as long as we do.
on average health,
there's a there's an ~ an implicit
trade-off between price as
the rationing vehicle versus
wait times. Absolutely. And and that's why
I thought,
wow, we we don't have that discussion out
there,
right? I think there's a price access
I think there's a price access trade off,
but there's
So there's some quality of care issues
that we've gotta we've gotta work on as
well.
workarounds with various doctors.
So there's some quality of care issues
that we've got to we've got to work
Even though there are some really good
stories.
on as well. Even though there are some
really good stories,
Like there's there's some there's some
stories out there that get picked
like there's there's some there's some
stories out there that get picked
up in the polling. People want improvement
in the quality of care as well as access.
up in the polling. People want improvement
in the quality
you
know, certainly above the OECD.
So yeah, can we do more? Can we actually
provide better quality
So yeah, can we do more?
care and you know and increase spending in
line with GDP?
Can we actually provide better quality
care and you know and increase spending
I think that's gonna be that'll be one big
aspect of of the healthcare discussion,
in line with GDP? I think that's gonna be
that'll be one big aspect
of of the healthcare discussion,
I think, with with between the the
different levels of government
I think, with with between the the
different levels of
and the health community.
I think Kevin is right. It's not yes,
the money as long if it grows with the
with the GDP on average,
that is fair enough.
What you need also in addition to that,
some restructuring of the health system in
Canada.
Canada Health Act was done. It's it's it's
a great act,
it governs the whole system.
But it may need to be to be modified,
may need to be looked at again and see
whether there are changes in that that
can be made to make it easier for
provinces to deal with some of
the pressures that they they face right
now.
And if it's done through the Canada Health
Act,
it will be
systematic across the the the nation.
So all the changes that the that the
provinces can make will be the same across
the country. And that does not create this
differences that,
you know, Alberta is doing it differently
with than Quebec and Quebec
is doing it differently than than than
Ontario.
So there are definitely some the
structural changes are needed to make sure
that
the healthcare is more efficient,
the costs can be used actually in the
right places and that will help
So we've seen the Canada Health Act in
some ways as being
This very rigid architecture. And yet
experimentation goes on and it gets
tolerated.
Are you suggesting that maybe we have a
window here to re-architect this thing
and start to say that maybe we
Yeah.
need to create some room for
experimentation?
~ and maybe not change a single payer,
the public payer, but maybe the delivery
itself can start to ~ more
not just tolerate but encourage a type of
experimentation that at least has been
Mm-hmm.
taboo politically to say out loud.
But we know goes on. We have a pretty
large private component
to healthcare in Canada already.
And I think we sometimes maybe don't make
the proper distinction between public
funding and and private delivery.
And
Yeah.
the reality is most of our doctors are
private,
~ as it is. But we've created these
taboos,
and is a suggestion here that maybe we
need to make the experimentation official.
Yeah, yeah, no, absolutely. I think you're
right.
Doctors are private ~ businesses.
~
laboratories are private businesses.
So I mean we still have a private system
in place.
But as long as the the all the governments
all provincial governments somehow commit
to the to the public health ~ in general,
but with some flexibilities that could
could be done through the Canada Health
Act and then allow them to deal with some
of these specific issues
~ through private sector and other ways
that they can they can find.
So Kevin,
we've had the provinces kind of face
fiscal sustainability issues kind of
pre-COVID,
but we had the federal government which
which had room and now we're watching that
room, we watch some of that disappear with
COVID and we're watching some
of the new pressures owing to kind of
geopolitical issues with the United States
and elsewhere take away what remaining
room the federal government has.
So is there any choice other than to start
to rethink the Canada Health Act?
Try to preserve the important principles
of access and portability and those
things,
but maybe start to open
Okay.
up how healthcare is delivered in this
country.
The other interesting issue I find is that
you know,
when I lived in the United States,
my employer paid my healthcare premiums.
Right. And and here we're we're paying it
personally and and a big part
of it through the provincial governments,
I mean through our taxes. But certainly if
you want to make this an a payroll tax,
which is what it is in the United States,
one of the most injurious types of
taxation you could possibly have in an
economy.
~ so as I
Yeah. Yeah.
think as we're thinking about these
different models,
we might wanna quickly take a step back
and realize there's some really good
attributes of the model we have.
But it doesn't preclude us from thinking
about so how do you make it better?
Yeah, right.
So maybe this is a chance using the fiscal
pressures to say,
hey, let's have those discussions.
You there are enough studies to
demonstrate that,
you know, part of why our system is better
or has been more efficient
has been based on the single payer.
Yeah.
Not necessarily on the delivery side.
Yeah. and yet, as you pointed out earlier,
like we are seeing privatized delivery.
~ we see it all the time. Yeah,
right. I wonder if maybe we're having
these discussions not out in
the open because politicians view it as a
taboo,
but maybe we can we can be a lot more
clear about so what are the central tenets
of our system that make it work?
And why don't those be the core to the
Canada Health Act?
and reinforce those things about access ~
that that are probably more important.
Well, I think you Sahir you actually you
did a very good job framing
Well, I think you Sahir, you're actually
you did a very good job framing
the hinge moment that we find ourselves
in.
And maybe in some ways we've been kicking
the can down the road.
the hinge moment that we find ourselves
and maybe in the road ~ on the hinge
moment.
I think when one looks at the you know
what the provinces are trying to
I I think when one looks at the you know
what the provinces are trying
do over the past few years, they're
definitely they're trying to bring costs
down.
to do over the past few years,
And we've seen year over year declines in
overall healthcare spending,
they're definitely they're trying to bring
costs down.
And we've seen year over year declines in
overall health care spending,
public health care spending. So I think
public health care
spending.
Yeah, looking for those ways
So I I think
to adjust primary care, looking for those
ways to build stronger work teams,
Yeah, looking for those ways to adjust
primary care,
looking for those ways to build stronger
work teams,
you know, using technology, using nurses,
you know, using technology, using nurses,
nurse practitioners in different ways.
nurse practitioners in different ways.
These are, these things are, they're
they're all being experimented with right
now.
These are these things are they're they're
all being experimented with right now.
Now, Mostafa has much has a much deeper
understanding than I do as
Now, Mostafa has much has a much deeper
understanding than I do as
how do this connects in a public-private
system.
how do this connects in a public private
system.
We're about 70% public, 30% private.
We're about 70% public, 30% private.
How does that really connect in a Canada
Health Act?
How does that really connect in
Do we need to open that up?
a Canada Health Act? Do we need to open
that up?
Or we can we continue to do the kind of
experimentations
Are we can we continue to do the kind of
experimentations here that you question,
here that you question, you talk about.
Because I think that is the hinge moment.
you talk about? know, again back to that,
Again, we're definitely in a place when
you have an economy ten times bigger than
like again, it we're definitely in a place
when you have a,
you know, a b can economy ten times bigger
than you,
you, the biggest military in the world,
the biggest military in the world,
talking about a 51st state we definitely
feel threatened in that sense.
talking about a 51st state, we're
definitely feel threatened in that sense.
And we're gonna have to deal with trade
issues and defense issues.
And we're gonna have to deal with trade
issues and defense issues.
But I think healthcare and the you know,
But I think like healthcare and the,
is we need to see it as, it's definitely a
very important social cohesion issue.
you we need to see it as it's a unit,
it's definitely
a very important social cohesion issue.
And actually when we have good health in
this country
and good healthcare service, we're just a
we're a much stronger competitive economy
And actually when we have good health in
this country and good healthcare service,
we're just a we're a much stronger
competitive economy as well.
as well. So I think like thinking about it
in those terms,
So I think like thinking about it in those
terms,
you know, the kind of experiment
experimentations here that you talked
about,
you know, in the kind of experiment
experimentations here that you talked
about,
I think it brings us to this, you know,
I think it brings us to this, you know,
healthcare needs to be front and center as
part of our hinge moment agenda.
the healthcare needs to be front and
center as as part of a
Yeah, it's it's hard to talk about a
productive economy without individuals
that
are are are healthy, well educated,
well trained, ~ and and looked after.
you know, whether in their families or as
necessary by the state.
I think the discussion is taking us to
this place where,
you know, whether it's this year or next
year,
the next few budgets are going to be
really pivotal for what healthcare starts
to look like going forward. And the forces
acting on Canada and
our economic and fiscal situation are
maybe going to force a discussion that
should
have happened ~ a number of years ago,
but really the politics didn't allow for
it.
Your sense Mostafa are we at that moment?
Well, I think we are, but I think it's not
is not really the job
of the federal budget to deal with this.
I think is the First Ministers have to
really get together and figure
out exactly how they're going to look at
the different changes in
the structure in the structure of the
system beyond the the money.
Money is an issue, but money is not the
whole thing.
Definitely the
changing of the escalator permanently to a
to a higher level
is quite dangerous fiscally for the for
the federal government and that should
to in my view that should not be
considered.
Maybe for a temporary four or five years
that that's okay.
But beyond that, this is going to be the
disastrous for fiscal sustainability
in at the federal level.
So the hinge moment is about Canada's
sovereignty,
its economy and and how we present
ourselves to the world and how we
how we protect ourselves and our identity.
Healthcare clearly is an important part of
this.
And so I think for the next couple of
years,
not just this budget, as Mostafa says,
but on an ongoing basis, we're gonna end
up talking about the role of healthcare.
But also I think healthcare represents
part of that competitive advantage that
Canadians have in this hinge moment.
It contributes us to being a healthy,
well trained, you know, strong population,
able to be a productive workforce.
And so I think hopefully we have more of a
discussion kind of going forward.
For a service oriented economy
the quality of our human capital really
matters if we're going to
be a competitive economy.
So with that,
I also want to invite our listeners and
viewers to maybe suggest some questions
in the comments that you want to see about
some of the pre-budget topics that
the three bald men can cover between now
and October,
November, whenever this budget happens,
because we really are looking for input
you know,
what are your top hot topics? What do you
want us to cover?
And particularly from an angle that kind
of integrates the ideas with economic
and fiscal constraints and considerations.
We'll certainly give our two cents.
Thank you for checking in from your
holidays in Thunder Bay,
Kevin. And ~ we'll look forward to seeing
you back in the office soon.
Safe travels. Miss
Miss you guys. See you next week.
Until next time from The Politics of
Money.