Ever since the March provincial election, Quebec watchers have been wondering how the reconfigured landscape of the province would impact on the national scene.

They are about to get an answer, and it stands to put Quebec’s renewed drive for more autonomy on a collision course with Canada’s most popular social program.

A challenge to the Canada Health Act is probably the last thing Prime Minister Stephen Harper needs in the lead-up to the next federal election. Yet that is exactly what will be coming his way.

The latest Quebec hot potato should land on his prime ministerial lap as early as the fall, when a commission recommends alternatives to the public financing of the province’s health system.

The appointment last month of former Liberal minister Claude Castonguay to lead such a review was initially overshadowed by the furor over Jean Charest’s tax-cutting budget, but it will resonate for much longer. Castonguay has yet to officially get down to work, but, in Quebec, his findings are widely seen as a foregone conclusion.

As the minister who shepherded the introduction of medicare in the province in 1970, Castonguay is considered the father of the Quebec public health-care system. In contrast with most medicare pioneers, though, he feels he gave birth to an insatiable monster, designed to gobble up untold amounts of public resources even as it delivers uneven outputs.
He advocates introducing user fees for medical services and a full-fledged two-tier health-care system. He sees the Canada Health Act, and the public monopoly on health care it imposes on the provinces, as remnants of a paternalistic federal era. Now, his views are set to become government policy.

The Castonguay commission is the most significant result to date of Quebec’s ongoing realignment and a token of the influence of the Action Démocratique party on the province’s directions. The idea of operating a two-tier system outside the framework of the Canada Health Act is lifted straight out of Mario Dumont’s platform.

It would be unwise to dismiss the Liberal decision to borrow one of the ADQ’s most controversial ideas as one of the last gasps of an embattled premier, obsessed with fending off a right-wing competitor. Philippe Couillard, on whose watch as health minister the review is being undertaken, is considered the front-runner to succeed Charest.

The Liberal repositioning may leave the PQ as the only defender of the status quo. But the sovereigntist party is hardly a good fit to champion a federal role in health care.

Pauline Marois has so far kept her peace on this issue. She may be keeping her powder dry for the next campaign, but she’s vowed to modernize the social-democrat creed of her party. Some of her closest advisers are known to be open to overhauling medicare.

Without going as far as Castonguay, the PQ may not be adverse to a basic rethinking of the system.

The probable emergence of a Quebec challenge to the Canada Health Act is not good news for the prime minister. It could find support in his home base of Alberta, but suspicions that his government is soft on medicare could wreak havoc for his party in other parts of the country, not the least in Ontario.

Under Harper’s leadership, his party has put a tight lid on the medicare debate.
Now, Quebec is marshalling forces to pry that lid open. It is hard to think of a bigger Pandora’s box for the ruling Conservatives.

Chantal Hébert is a national affairs columnist for the Toronto Star.