Yes, it started within each province, but the Federal Govt passed laws in 1981 defining what each province had to offer. If you don't adhere to the rules, say bye-bye to federal funds.

It would be fairer to say that the Canadian system is national with provincial implementation within that framework.

Yes, that’s a great point, but it’s important to understand how the status quo system came about. There’s a path dependency. It didn’t start as a top-down system, it happened from the bottom-up, and the Federal government only supplemented funds once the political will for the healthcare system was broad enough that literally every province was bought into it.

None of that is the case in the US yet. There have been attempts (by the Rs) to provide block grants to States which have received pushback by the Ds.

Also even today, the Canadian Federal government does not supply the majority of the funds for each Province’s insurance system, it’s still a minority relative to the Provinces. It’s an extraordinarily stable system because the power over whether the system continues to function is largely decentralized.

The federal transfer payments for healthcare are significant. I cant find exact numbers (no doubt they are out there), but I vaguely recall hearing it’s close to 50%.

But yes, each province developed their own program and the federal government agreed to throw in funds as long as certain requirements were met.

Not that different from federal highways funds in the US actually. That’s how the federal government maintains minimums for drinking age, DUIs, speed limits, etc.

As of 2020, Federal transfer payments for healthcare amount to 22%: https://www.cmaj.ca/content/192/45/E1408

That shouldn't come as a surprise considering that just under 80% of all government spending in Canada is driven by the Provinces, and healthcare spending is the single biggest line item for most countries: https://www.oecd-ilibrary.org/docserver/reg_glance-2016-en.p... (Table 3.1: https://i.imgur.com/GDtBaVT.png)

There you go. Didn’t know the share had dropped so much!

Somehow I’ve never heard that through all of this debate over the last decade.

Maybe another potentially surprising fact: Canada’s Federal income tax is more or less identical to the US’s; and in fact the US imposes a slightly higher tax on ultra high earners than Canada. This works in Canada because Provinces levy high taxes as well, and 80% of government spending in Canada happens at the Provincial level. In other words, if Americans want to make the US more like Canada, there’s a really easy way to make the US more like Canada: the States.