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La situation délibérative dans le débat public

 | 
Bernard Castagna
, 
Sylvain Gallais
, 
Pascal Ricaud
, 
et al.

Les acquis de l'observation

Citizen Participation in Canada and the United States: the case of health care reform

Peter Κ. Kresl

Texte intégral

  • 1 Michael Doyle, « Kant, liberal legacies and foreign policy, » Philosophy and Public Affairs, Vol. 1 (...)
  • 2 Francis Fukuyama, The End of History and the Last Man, London : Penguin Books, 1992.

1Since the end of World War Two, successive governments of the United States have argued that the US version of democracy was the most efficacious for the rest of the world. President after president has sought to transplant the US model of democracy in foreign soils in the belief that if this could be done conflict would be ended and the peoples of the host countries would live more satisfying lives. Perhaps they intuitively comprehended the argument made by Michael Doyle that democracies do not engage in war with each other.1 After all, where in societies of rational individuals set in democratic institutions could the desire to engage in war emerge? Or perhaps they prematurely understood Fukujama’s similar argument that with democracies everywhere and the Soviet system defeated the lack of basis for conflict would bring the “end of history.”2 Or perhaps it was simple naïveté and innocence with regard to the rest of the world. For whatever reason it is clear that US governments acted with a missionary zeal with regard to the implantation of the American model of democracy abroad. Whether it was Europe in the late 1940s, the 1950s and the 1960s or in the Third World following the wars of national liberation, the US did what it could to sell American democracy.

2One can, of course, question whether: 1) democracy could in fact be transplanted in societies that were traditional in their character, with political systems that were based on kinship, theocracy, tribe, authoritarianism, and so forth, or 2) the US model of democracy was superior to French, Canadian, British, Icelandic or other models of democracy. These questions are certainly important ones to ask but in the space available here we will be able to examine only one aspect of this more general question. Specifically we will examine how the Canadian and American political systems dealt with the desire to undertake a policy review and to propose reforms of the same policy question. The Canadian political system will provide the contrast in part because of the many apparent similarities between values and aspirations of the two societies, and in part because in spite of this Canadians and Americans have created such different political systems.

  • 3 Seymour Martin Lipset, Continental Divide, New York : Routledge, 1991, and Veloz and Adams, Sex in (...)

3When viewed from afar Canada and the US do seem to be two societies cut from the same cloth. Predominantly English speaking, with market economies and democratic political systems that differ in quality rather than in quantity, a high land/man ratio, weak initial institutional structures, histories of being immigrant rather than emigrant societies, encounters with Indians who were the initial owners of the land, and histories of conquest of the continental space from the Atlantic to the Pacific, the two societies would appear to be inseparable. However, there is a cottage industry that is devoted to determining and articulating the differences in values, aspirations and structures of these two peoples. Seymour Martin Lipset has done the classic work in this field but many others have contributed to our understanding that Canada and the US are two distinct and separate societies.3

  • 4 George Hoberg. Keith G. Banting and Richard Simeon, « The Scope for Domestic Choice : Policy Autono (...)

4A few words on the characteristics of the two models of democracy would be appropriate at this point. Scholars have made much of the differences between the two models of democracy found in North America, those of the US and of Canada. The US liberated itself in a war of secession and established a system of democracy that was unique at that time; Canada gained its sovereignty through an evolutionary process that lasted over a century, and adhered to a system of democracy that was little different that that of England. It is generally agreed that the two distinct systems suit the distinct values and aspirations of the two peoples. As three Canadian political scientists have summarized it: “The United States has constitutional checks and balances, and Canada, a parliamentary system; there are weak U.S. parties and highly disciplined parties in Canada; the United States has a centralized federation, and Canada, a decentralized one.”4 In this paper I would like to examine how these two models of democracy, the American and the Canadian, responded to the same challenge. This will provide an interesting story in itself but it will also enable us to gain a comparative understanding of how participatory democracy works in both countries. Two questions emerge: 1) Is there anything we can learn about participatory democracy from this comparison? And 2) how connected are both systems to their respective citizenry and electorate?

5The issue I would like to raise for this comparative study is that of reform of the national systems of health care. In all societies health systems are undergoing a great deal of stress. Populations are ageing while individuals experience the vast majority of their medical expenses following age 60, technological advances and new drugs have caused health care costs to soar, many states have reduced their financial support of health care institutions and programs, demography is creating a “fiscal time bomb” with increasing fiscal demands being accompanied by shrinking work forces/tax payers, and the health care profession is becoming less attractive to the members of the labor force. So many nations have begun to reexamine their health care systems and have sought to introduce reforms or at least to spend less on them.

  • 5 Encylopedia Canadiana, Toronto : Grolier of Canada, 1977, Vol. 5, p. 284.
  • 6 Seymour Martin Lipset, p. 138.

6The two North American health care systems are quite different in their structure. The US system is largely a private sector activity with individuals making their own arrangements either through participation in plans offered by health insurance companies or through plans offered by their employers as part of their compensation. In the 1960s President Lyndon Johnson introduced, as components of his Great Society initiative, Medicare and Medicaid, with the former giving some health care coverage to retirees and the latter welfare recipients. About one-third of poor Americans and 15 million children remain without health care coverage. Military veterans have access to the health care of the Department of Veterans Affairs. The Canadian system was inspired by the health care project undertaken by the socialist provincial premier of Saskatchewan, Tommy Douglas, in the mid-1950s. A few years later it was decided that the federal government would assist provinces in establishing their own programs throughout Canada. Five provinces began their participation in 1958, four more joined in 1959, the two territories did in 1960, and Quebec joined in 1961. The plans were comprehensive and included in-patient services and drugs, but not mental and tuberculosis treatment. In 1965 the national Medical Care Act was adopted in 1968 and covered “all medically required services rendered by physicians, without dollar limit or exclusions.”5 Coverage was universal and there were no co-payments, user fees, deductibles or other charges. Federal government financial participation was set at half of the provincial costs. By 1972 all provinces and territories had joined. In Canada, health care is a provincial responsibility and while the federal government may assist the provinces financially, program design is essentially up to the individual province. In the 1968 act, provincial government retained control over matters such as whether coverage would be voluntary or compulsory, the way in which the provincial contribution would be raised, and whether additional services could be included in the provincial plan. Upon participation of all provinces and territories, 99 per cent of the population was included in the plan’s coverage. In 1988, a year before the Canada-US Free Trade Agreement was signed, Seymour Martin Lipset reported that 95 per cent of Canadians preferred the Canadian system to the American, as did 61 per cent of Americans.6 In Canada, national health care is not a program any serious politician would contest, whereas in the United States any increase in government participation is considered to be “socialist” and is virtually a political death warrant. It is interesting to note that in the US the citizens regularly express a preference for a more comprehensive and universal health care system, even with a more prominent role for government, but they are bested in the political system by tightly focused and well-funded representatives of the private sector health insurance industry.

7We should note, briefly, that the two systems are different in some important ways in terms of the resulting health care statistics. The point of presenting the following data is simply to indicate that while Canada spends less of its GDP on health care, its health results do not suffer as a consequence. In the table below, two key indicators of health are given, life expectancy and infant mortality, and Canada compares favorably with the US. It has become commonplace to suggest that since this is achieved with a lower expenditure per capita and as a percentage of GDP the Canadian system does what it does more efficiently. Commissioner Romanow was informed by physicians in Boston that the administrative cost per capita in the US was S 1,050 while in Canada it was only $ 350. This is due to the multiplicity of payment agencies, private and public, with which the US physician must contend. Having a single payer, the federal or state/provincial government is a major element in the relative efficience of the Canadian health care system. The caveat with regard to the performance figures must, of course, be noted that health indicators are subject to influence by demographic and life style factors.

Table 1 – Comparative Health Statistics, Canada and the United States

Health Indicator

Canada

United States

Life expectancy at birth, years (2001)

79.5

77.3

Infant mortality rate (2001)

5.0

6.8

Health expenditures/GDP (1999)

9.3

12.9

Public health expenditures/GDP (1999)

6.6

5.7

Medical doctors per 1,000 population (1990)

2.1

2.4

Hospital beds per 1,000 population (1990)

6.3

4,9

Percent of population with health insurance of some sort

100

84

Share of total health expenditures paid by the public sector (1998)

72

46

Per capita total health expenditures $US (2000)

2,550

4,740

Sources:
Statistical Abstract of the United States: 2002,
Washington: US Census Bureau, 2002, and Building on Values, Ottawa: Commission on the Future of Health Care in Canada, 2002.

8The reform efforts were undertaken in the two countries in different circumstances. In the United States, President Clinton introduced a health care reform initiative shortly following his inauguration in 1993. This was done apparently not out of any real conviction that health care was in need of reform, but rather because it was good politics. In an election in 1991 Pennsylvania’s former governor, Richard Thornberg, lost the Senate race to the underdog Harrison Wolford. Wolford’s major campaign promise was that he would work for health care reform. Since it worked for Wolford in a large industrial state, Clinton thought it would bring him benefits in the congressional elections two years hence. In Canada the experience was rather different. Prime Minister Jean Chrétien was entering what he had agreed would be his last term and he was looking, in 1992, to build his “legacy” as one of Canada’s longest serving federal leaders. Health care has been a touchstone for Canadian identity for the past half century and reforming it would fit well with both his desire and the aspirations of the Canadian electorate. So for different reasons and in different democratic systems each leader introduced a process that was to lead to reform of health care.

  • 7 The following material is based on :
    www.pbs.org/newshour...ay96/background/health_debate_page1_html

9The US approach to this (attempted) policy initiative was somewhat removed from participatory democracy.7 To be sure President Clinton had to protect himself from the Gingrich Republicans who were prone to see any increased role in health care for the state as socialized health care and a “great offensive of the Left”. Others suggested that cost had to be minimized lest a reform be seen as just another Democratic “big government” approach. These criticisms have great currency in the US political scene. Clinton decided in January 1993, just after being elected the previous November, to establish The President’s Task Force on National Health Reform, with his wife, Hilary Rodham Clinton as head and an old friend Ira Magaziner as the head of daily operations. Placing his wife at the head of the Task Force gave clear indication of the importance the President attached to the initiative, but as advisors stated “The person who’s in charge shouldn’t sleep with the President, because if you sleep with the President, nobody is going to tell you the truth.” The Task Force was given a time schedule of 100 days for its work.

10Initial public support was in excess of 60 per cent in polls taken at the time. However, things began to fall apart politically from the outset. The 100 day time limit required that the budget and the health reform be passed in one bill, on an up-or-down vote. Senator Byrd of the Senate Appropriations Committee and a senior spokesman for the integrity of the Senate argued that Clinton’s approach amounted to a “prostitution of the process” since it would involve rushing to a vote “a very complex, very expensive, very little understood piece of legislation.” In spite of the tight, small group that is involved in the process of developing the health care initiative leaks of information begin in April 1993. Will the project be financed by a new value-added tax? Will $ 150 billion in new taxes be required? Hillary Clinton accused the Health Insurance Association of America of “price-gouging”, and “unconscionable profiteering.” The leader of the Republicans in the Senate, Senator Robert Dole, instructed members of his party that they were not to meet with the First Lady. The Washington Post and New York Times published the discussion of the first of four private meetings, and the Task Force canceled the remaining three, feeling that they had been betrayed.

11A powerful lobby of business groups and insurance companies formed to defeat the health reform measure, arguing that it would force small businessmen into bankruptcy and that the Clinton reform is being directed by the Left. However, one of the most prominent supporters of a national health care system was General Motors. Their look to the future convinced them that rising health costs were going to have a powerful negative impact on their industrial competitiveness. At a meeting of the National Governors’ Association in August 1993 the head of the National Federation of Independent Business attacked the Clinton initiative just before the President was to speak and he was forced to re-write his speech to take into account this attack. In September, the Health Insurance Association of America began to run a series of highly effective television ads featuring a couple, Harry and Louise, who are frightened of the impact the reform will have on them – “They choose, we loose” was the one – liner that was familiar to all American voters. Attempts to restructure the initiative to accommodate the arguments of the Right had no success as Newt Gingrich, head of the Republicans of the House, determined that there would be no Republican support for any Clinton designed approach to reforming health care. That Fall the Clinton approach to health care reform failed.

12The US process was essentially closed to both the public and the major stakeholders in the health care system. While the design of the reform contained many laudable elements, such as universal coverage, governmental participation to assure affordability, and so forth, the failure to open to design stage to these other groups meant that no one other than the design team knew what it contained until it was made public, no important constituencies identified with it so as to assure their assistance in making it public policy, no experts could press for modifications that would make it more acceptable to either the public, stakeholders or congress. Given the visceral distain of the Republicans in both houses of congress to President Clinton, without strong public and stakeholders enthusiasm the reform proposal was doomed to failure.

  • 8 Robert J. Jackson, Doreen Jackson and Nicolas Baxter-Moore, Politics in Canada, Scarborough, Ontari (...)
  • 9 The source for all references to the work of the Commission is : www.healthcarecommission.ca/

13North of the border the process was quite different. The Canadian approach to important questions of public policy is often to establish a royal commission that is charged with studying all aspects of the policy issue, gaining an understanding of the wishes of the populace, seeking a wide range of professional and expert opinion, and then presenting a report to the government which includes its findings and recommendations. A royal commission is established by the prime minister through an Order-in-Council. While the commission submits a report to the prime minister who is not obligated to accept its advice, their proposals “are generally incorporated into government action as incremental policy change.”8 This was done in 1985 with regard to the state of the Canadian economy under the chairmanship of Donald Macdonald — The Royal Commission on the Economic Union and Development Prospects for Canada. The work of this commission was instrumental in the establishment of the Canada-US Free Trade Agreement in 1989. The Royal Commission on the Future of Health Care was formed on April 3, 2001 with, in obvious homage to the pioneering Tommy Douglas, the former Saskatchewan New Democratic (social democrat) premier Roy Romanow as chairman.9

  • 10 Much of this discussion on Royal Commissions is based on : Neil Bradford, « Writing Public Philosop (...)
  • 11 Bradford, « Writing Public Philosophy..., » p. 138.

14Royal commissions can be viewed from two contrasting perspectives. On the one hand, they can be seen as stalling mechanisms during times of policy controversy, as expensive procedures for rationalizing decisions that have already been taken, or as entities that issue recommendations that will never be adopted.10 But when one examines the commissions that have been established, it becomes clear that they have had dramatic and lasting impacts. The Aird Commission on Broadcasting (1929), the Royal Commission on Bilingualism and Biculturalism (1963), and the Royal Commission on National Development in the Arts, Letters and Sciences (Massy-Levesque Commission, 1951) have all altered public policy in fundamental ways. With regard to economic matters, the Royal Commission on Dominion-Provincial Relations (Rowell-Sirois Commission, 1937), Royal Commission on Canada’s Economic Prospects (Gordon Commission, 1957), and the Royal Commission on Canada’s Economic Union and Development Prospects (Macdonald Commission, 1985) have been pivotal reports that have both reflected and altered the thinking of their time. Bradford finds that the royal commissions have been necessary responses to “innovative deficiencies in other representational institutions and policy development mechanisms in federal politics.”11

15Commissioner Romanow began by articulating the following as a set of basic understandings about Canadians and their health care system:

  • the “Medicare house need remodeling but hot demolishing,”

  • “Medicare has become one of the defining feature of Canada’s national identity,”

  • Canadians are worried about the fiscal sustainability of the system,

  • Canadians want the federal and provincial levels of government to cooperate better, and

  • Canadians need to clearly express the values they want to see reflected in their health care policies and programs.

16The process of gathering information prior to writing the final report was quite different from that of the US. In its interim report of February 3, 2002 the Commission indicated that in its first ten months it had:

  • undertaken an extensive research program,

  • obtained input from provincial leaders, aboriginal organizations, and experts,

  • reviewed systems in other countries,

  • received over 300 formal submissions,

  • initiated a public education program, and

  • commenced a series of 12 “deliberative dialogue” sessions across Canada.

17The keystone of this process was a “Four-Phase national Dialogue,” Phase I: Public Education (January-February 2002), Phase II: Public Consultations and Expert/Stakeholder Roundtables (March-June 2002), Phase III: Regional Synthesis/Analysis (June-September 2002), and Phase IV: Validation (Fall 2002).

18Phase I featured a series of televised panel discussions on the following topics:

  • Canadian Values: What do Canadians want from their health care system?

  • Sustainability: How to make health care sustainable?

  • Constructive Collaboration: Who should do what in Canada’s health system?

  • Continuous Improvement: How can we make the system work?

  • Organizing principles: Role of the Canada health Act

  • Rural Health: How should we define access?

  • Lessons from Abroad: How have other countries responded to the challenge?

19Phase II began with a series of 21 Citizens’ Dialogue Sessions in 18 Canadian cities in the ten provinces plus Iqaluit (Nunavit), Whitehorse (The Northwest Territories) and Yellowknife (The Yukon). Newspaper ads and the Commission’s website were used to encourage citizen participation and presentation. Access by citizens in rural areas was to be facilitated by teleconferencing, where possible. One day of open hearings would be followed by closed workshops with presentations and discussion by experts and stakeholders, and a summary of all proceedings would be posted on the Commission’s website. In addition to these local discussions, a series of twelve televised Policy Dialogues would be broadcast on the Canadian Public Access Channel (CPAC) to all parts of the nation. The Dialogues were held at universities located in all provinces, with the exception of Prince Edward Island. The Dialogues were moderated discussions by “leading health care experts” on the following topics:

  • Home care in Canada

  • Access to Healthcare in Canada

  • The Canada Health Act

  • Consumer Choice in Canada’s Healthcare System,

  • Pharmacare in Canada (two dialogues),

  • Medically Necessary: What is it, and who decides?,

  • Sustainability of Canadas’s Healthcare System,

  • Health Human Resources in Canada’s Healthcare System

  • Medically Necessary: What is it, and who decides?,

  • Globalization and Canada’s Healthcare System, and

  • Homecare in Canada

20Each Dialogue accommodated participation by the audience in addition to the experts.

21A second element in Phase II was “Partnered Policy Debates,” in which the Commission would meet with one or more health policy advocacy groups for discussions, with a report to be posted on the Commission’s website, on the following topics:

  • Waitlist/Timely Access to Care: What should be done?

  • Health Human Resources: How can we maintain and grow capacity?

  • The Canada Health Act: Beacon or lightening rod?

  • Financing Health Care: How to raise revenues?

  • Globalization : Threat or opportunity ?

  • Medically Necessary: Who should decide what Medicare pays for?

  • Home Care: Is a national strategy needed and affordable?

  • Pharmacare: Is a national strategy needed and affordable?

  • Consumer Choice: Can it exist within a public system?

  • Aboriginal Peoples Health: How can we do better?

22Finally, Phase II made available in paper and on the Commission’s website a “consultation workbook” which citizens were urged to use to register their opinions on an array of health care policy questions. Online responses were received from 16,463 Canadians while 1,083 submitted the paper form. The Commission noted that “the collection of thousands of quantifiable inputs from people by a governmental agency is unprecedented.”

23Since we are interested in the process of citizen participation in public policy debate and formation, rather than in the specific policy recommendations, we will not review the findings from the initiatives of Phase II.

24Phase III called for a series of five closed, roundtable sessions of which the aim was that of synthesizing the findings of Phase I and Phase II on a regional basis. Participating would be up to twenty of these who had been involved in the earlier workshop events. A report of these deliberations would be posted on the Commission’s website. Phase IV consisted of a national stakeholder conference on the theme of “Building a Health Care System for the 21st Century,” with the objective of developing a consensus on a set of policy recommendations.

  • 12 Building on Values : The Future of Health Care in Canada, Ottawa : Commission on the Future of Heal (...)
  • 13 Allison Dunfield, « Accept targeted funds, Romanow urges premiers, » The Globe and Mail, February 3(...)

25In November 2002, Commissioner Romanow released the final report of this process, Building on Values: The Future of Health Care in Canada.12 The next step in the Canadian Royal Commission process is for the prime minister to meet with the ten provincial premiers and the leaders of the territories for the purpose of deciding on a policy that is acceptable to all. In the Canadian constitution, the British North America Act, health is a provincial responsibility and the role of the federal government is to work with the provinces to create a reasonably coherent “national” system and to make a financial contribution toward the expenditures of the provincial program. While the original agreement was for the federal/provincial contributions to be done on a 50/50 basis, by 1979-80 the federal share had slipped to 43 per cent and by 2001-2002 it was down to 27.5 per cent. This has resulted in a recurring provincial complaint; but it is also the case that if one does not bring money to the table in such a process one loses one’s clout in the discussion and in the final policy adopted. Thus the Romanow proposal that federal funding for health care be increased by $ 25 billion over the next six years was met with a demand from the premiers for an additional $ 7 billion for 2003-2004 alone.13 The Territories and aboriginal peoples argued that they had not been treated fairly, in part because of the high cost of treating people in small communities and the Prime Minister was forced to meet with them again.

26The final step in the process will be with the Prime Minister presents the proposal for health care reform to the House of Commons for its approval. Given the strength of the Prime Minister’s Liberal Party and the weakness of the opposition, approval will not be in question. But we must note that when the bill is successfully presented to the House, it will have been subjected to extensive analysis and comment by the electorate in citizen participatory meetings and media presentations, it will have been negotiated between the Prime Minister and the Premiers, the aboriginal peoples will have had access to the process, and all “stakeholders” will have had their chance to have their position(s) presented to the Commission. This is, of course, in clear contrast to the process that was utilized by President Clinton.

27What can one conclude from this examination of how the Canadian and American political systems considered reform of health care?

28First, there is the basic understanding that the contrast may just be between a parliamentary and a presidential-congressional system. In the US system access by lobbyists is directly done to the individual representative or senator. Lacking a strong tradition of party loyalty, the individual legislator is a free agent who is susceptible to inducements that could be offered by the industry representative. In the Canadian system, the party caucus reduces the ability of the member of parliament to act as an individual actor.

29Second, Canada is a smaller country and a large country such as the US has difficulty instituting processes that make its political system this open to the citizenry. There is, of course, some validity to this point. The US has come a long way from the fabled New England town meeting of the 19th century that has come to a sort of Norman Rockwell representation of American democracy in action. Urbanization, industrialization, mobility, and 150 years of immigration-based population growth have all eroded this romantic image. It would be sad if large, complex societies have to pay the price of reduced citizen participation.

30Third, in all systems the past exerts a powerful constraint on change as “path dependency” allows only for minor deviations rather than dramatic reconsiderations. In neither the US nor the Canadian health reform proposals was a dramatic break with the past likely to be adopted. The Clinton approach which actually did suggest an increased role for government at the expense of private sector and universal coverage could have been approved only if the process had been such as to engage various constituencies in the reform process; this Clinton failed to do completely. Romanow has proposed a reform that is based on all of the traditional Canadian preferences and recommits the society to comprehensive coverage that is dominated by the public sector.

31Finally, if the proof is in the pudding, so to speak, we may have the contrast between and utterly failed reform attempt in the US and one that achieves at least some of its objectives in Canada. It can be argued that the crucial factor in the difference in the two outcomes is the degree to which citizens were involved in the policy formulation process. Thus, if one utilizes the criterion that is most highly regarded in the US, efficiency, it is clear from this case study in policy formulation that engaging the citizenry at early and subsequent stages in the process is the tactic that is most likely to result in success. But it is still too early to say this with conviction as the Canadian process is not yet completed.

  • 14 Jane Taber, « From pitch to paper, how the report was delivered », The Globe and Mail, November 29, (...)

32Perhaps the fundamental question arises from a comment by Neil Bradford in his paper on Royal Commissions: “It is clear that Canada’s era defining royal commissions have been by design, largely the domain of elites, whether in research or business communities. It is time to consider how this important mechanism of learning and innovation might contribute to reasoned public policy and better democracy.” This statement is apparently strongly based on the performance of the Macdonald Commission which concluded that Canada should pursue an agreement on free trade with the US; it has also been the inspiration for a variety of neoliberal policy initiatives. To the public the Commission’s work was a bit arcane, removed from immediate daily concerns and did not engage them emotionally. Health care is an issue of a totally different character. Every individual and every household is profoundly affected by changes in this area of public policy. Thus when one asks whether the Romanow Commission’s process of developing a set of recommendations has brought the citizenry closer to the circle of decision-makers in Canada the answer is certainly in the affirmative. One health-policy expert who was a close participant in the process has stated that: “Mr. Romanow was affected more by public consultation than the view expressed by organizations.”14 The final impact ot the report is still to be determined so the comparative roles of elites and the citizenry are not yet known, but how this works out will give us a valuable insight to this case study of citizen participation. In the broader perspective of Canadian politics, we do not yet know whether the Romanow process was specific to the preferences of the Commissioner or to the nature of the issue being decided or to evolution of the public policy process in Canada. The final question is whether any of this is relevant to or transferable to the US and to other countries.

Notes

1 Michael Doyle, « Kant, liberal legacies and foreign policy, » Philosophy and Public Affairs, Vol. 12, 1983, p. 205-235 and 323-353.

2 Francis Fukuyama, The End of History and the Last Man, London : Penguin Books, 1992.

3 Seymour Martin Lipset, Continental Divide, New York : Routledge, 1991, and Veloz and Adams, Sex in the Snow.

4 George Hoberg. Keith G. Banting and Richard Simeon, « The Scope for Domestic Choice : Policy Autonomy in a Globalizing World, » in George Hoberg (ed.), Capacity for Choice, Toronto : University of Toronto Press, 2002, p. 255.

5 Encylopedia Canadiana, Toronto : Grolier of Canada, 1977, Vol. 5, p. 284.

6 Seymour Martin Lipset, p. 138.

7 The following material is based on :
www.pbs.org/newshour...ay96/background/health_debate_page1_html

8 Robert J. Jackson, Doreen Jackson and Nicolas Baxter-Moore, Politics in Canada, Scarborough, Ontario : Prentice-Hall, 1986, p. 374.

9 The source for all references to the work of the Commission is : www.healthcarecommission.ca/

10 Much of this discussion on Royal Commissions is based on : Neil Bradford, « Writing Public Philosophy : Canada’ Royal Commission on Everything, » Journal of Canadian Studies, Volume 34, No. 4, Winter 1999, p. 161.

11 Bradford, « Writing Public Philosophy..., » p. 138.

12 Building on Values : The Future of Health Care in Canada, Ottawa : Commission on the Future of Health Care in Canada, November 2002.

13 Allison Dunfield, « Accept targeted funds, Romanow urges premiers, » The Globe and Mail, February 3st, 2003.

14 Jane Taber, « From pitch to paper, how the report was delivered », The Globe and Mail, November 29, 2002.

Auteur

Professeur d’Économie internationale – Bucknell University

© Presses universitaires François-Rabelais, 2004

Conditions d’utilisation : http://www.openedition.org/6540