Canadian federalism fragments health system governance. Although the Constitution has been interpreted as providing shared jurisdiction over health generally, with respect to health care, the courts have interpreted it as giving direct jurisdiction to the provinces. The federal role in health care is therefore indirect, but nevertheless potentially powerful. For example, the federal government has used its spending powers to establish the Canada Health Act (CHA), which commits funding to provinces on condition they provide first-dollar public coverage of hospital and physician services. However, in recent times, as federal contributions have declined, the CHA has been weakly enforced. Further, the failure to broaden the CHA to include prescription drugs, dentistry, and other important aspects of health care have contributed to Canada’s abysmal record on Aboriginal health and its increasingly poor rankings in international comparisons. Progress requires enforcement of an adequately funded CHA, national pharmacare, and concerted action on Aboriginal health.