OTTAWA - The fate of medicare is on the line as Canada's premiers meet next week in Victoria.
The two-day gathering, which starts Monday, comes at a time of potential peril to the country's health-care system.
Spending has been running rampant in recent years, cutbacks are on the way, long-promised national reforms are nowhere to be seen and an aging and growing population is putting even more strain on the system.
The premiers are looking for a solution to their problems and some are hoping Prime Minister Stephen Harper's Conservative government eventually comes to the table with cash to assist in reforms and initiatives such as home care and seniors care.
But so far, Harper is cautiously standing back - giving provinces a long-term funding plan that falls short of what many premiers had wanted, urging them to get their spending under control and stressing the importance of keeping the future system financially sustainable.
That new approach from Ottawa - a stark contrast to previous Liberal federal governments that sought to ensure national standards are in place for medicare - has left premiers scrambling with different reactions.
Western premiers don't necessarily mind Harper's hands-off strategy, while some other premiers have voiced concerns that medicare could be headed toward a patchwork-quilt system that lacks equity between regions. In short, for now at least, a national solution to the looming crisis appears out of sight.
Still, several premiers interviewed this week by Postmedia News indicated a determination to seek innovative solutions to the enormous task that lies before them.
"There are some big issues in health care that we have to address and I think it's going to take some political courage to do that," said British Columbia Premier Christy Clark, who will host the meeting.
She said provinces should not shirk from the challenge of reforming the system now that Harper's government has left the task in their hands.
"We will eventually bankrupt the system if we keep going the way we are. And so we have to find ways to try and make the system sustainable."
Ontario Premier Dalton McGuinty said his province has spent recent years working hard to improve the system through innovation - thereby lowering surgical wait times and ensuring more patients have a family doctor.
But he said Harper needs to be at table to work with provinces collectively on a plan forward.
"As my dad used to say: 'Nobody is as smart as all of us. And nobody is as strong as all of us.' So I think we have missed an opportunity to come together and tackle this challenge together."
Most premiers are annoyed at how the federal government has undercut a process they thought would lead to health-care talks. In December, federal Finance Minister Jim Flaherty unilaterally unveiled a non-negotiable funding plan that runs to 2024, but which falls short of what provinces had hoped for.
Federal health-care transfers will continue to increase by six per cent until 2016-17. After that, increases will only be tied to economic growth including inflation -_currently roughly four per cent - and never fall below three per cent.
This week in Ottawa, parliamentary budget officer Kevin Page released a report concluding the plan will place a huge financial burden on the provinces. He expects cash transfers to the provinces to grow at 3.9 per cent annually, on average, from 2017-18 to 2024-25 - compared to provincial-territorial health bills, which he forecasts will grow by 5.1 per cent a year.
Moreover, if the funding plan stays in effect beyond 2024, the implications are stark: The federal share of medicare spending would gradually fall from its current level of 20.4 per cent - eventually hitting 13.8 per cent in about 40 years, and then 11.9 per cent two decades after that.
In provincial capitals, the premiers are now confronting many challenges. Among them:
o Avoiding slash-and-burn approaches as health spending is reined in.
o Finally moving the system away from its institutional focus on reactive hospital-based acute care, to one where publicly insured medical treatment is delivered closer to home (in private clinics or, indeed, at home).
o Getting a grip on the "cost-drivers" of the system, most notably, prescription drugs - which can be cheaper if provinces join together to buy in bulk.
o Figuring out which medical procedures - from knee surgeries to caesarean sections - are actually worth the cost to the system and whether there should be fewer of them.
o Doing a better job of informing Canadians (particularly young people who are increasingly overweight and obese) about the importance of lifestyle - diet, exercise, smoking - to their own odds of living a long, healthy life.
o Preparing for the demographic wave that is fast approaching: The population is getting older. These are citizens who will increasingly need health care, and after decades of paying taxes they will expect results. Provinces must grapple with the costs, and confront ethical questions surrounding end-of-life care.
Alberta Premier Alison Redford says provinces must find innovations and understand that health care "does not begin the day a person walks into a health-care facility but very often the underlying causes are issues that deal with social policy, poverty, domestic violence."
Saskatchewan Premier Brad Wall says the country needs a more "fulsome and informed debate" about how medicare dollars are being spent.
"We need to be focused on better patient care and better value for taxpayers," Wall says of the provinces.
"Continued economic growth is also vital to long-term funding of health care, lest the system become even more unsustainable. And, since working Canadians are healthier Canadians, the two issues are inextricably linked."
Quebec Premier Jean Charest says it's important for the federal government - which transfers billions of dollars in equalization payments to provinces in addition to health transfers - to get the entire package right.
"At the end of the day, we want the overall transfers to be equitable and fair. And we would not want to be in a situation where there's an increase in one area and a decrease in another where the net outcome is negative."
New Brunswick Premier David Alward believes a crisis is looming - particularly with the aging population needing care - and that some hard questions need to be asked about why the country isn't getting better results for its health-care money.
"We need to have a real, honest, open discussion of the future of health care in our province and country," he said.
"We do have a good health-care system, we have great people in that system. But it does need innovation, it does need accountability as well. Not being prepared to have that discussion, I think we all, as political leaders, do a disservice to the people we represent."
Welcome to the Great Health-Care Debate of 2012.
Canadians have seen this before. They witnessed their cherished medicare system falling apart in the 1990s - as hospitals closed, medical staff were laid off and patients lined up for hours at hospital emergency wards.
The shock to the national psyche led to a royal commission headed by former Saskatchewan premier Roy Romanow.
His 2002 report proposed significant hikes in federal funding for provincially delivered medicare systems. Just as important as the extra cash, he stressed, was the need for major reforms in areas such as pharmacare, primary care and home care.
Then-prime minister Paul Martin promised a "fix for a generation" and summoned premiers to Ottawa for a high-stakes summit in September 2004.
After locking themselves up in the old train station near Parliament Hill, the leaders cracked a deal and held a news conference in the middle of the night.
Provinces were guaranteed a 10-year deal with $41 billion in extra health-care funding with a guarantee that federal transfers would rise by six per cent annually. In return, provinces were expected to initiate reforms.
With the exception of shorter wait times for some medical procedures, however, the much-heralded accord fell flat.
In 2011, it's expected the country's health tab, which includes government spending and how much Canadians pay out of their own pocketbooks, will have reached $200.5 billion - up from $107 billion just a decade ago.
That's $5,811 per citizen on health care last year. Or seen another way, it represents 11.6 per cent of GDP.
The public/private split on health care spending hasn't changed in recent years.
The public portion (governments, primarily the provinces,) is still 70 per cent - $140.9 billion. Meanwhile, the private portion of the tab (households and private insurance companies) Is 30 per cent - $59.5 billion.
All the while, it has been the provinces and territories that are at the heart of the health-care system.
For four years in the mid 1990s provincial and territorial health spending slowed to a virtual halt. Then the taps were opened. In 1995, provinces and territories spent $49 billion on health care. In 2011, the tab is expected to have reached $130.3 billion.
Policy expert Don Drummond, a former senior Finance Department official, is among those who have delivered a blunt message in recent months.
"For the amount of money spent, the system should surely be delivering better results," he wrote in a report for the C.D. Howe Institute.
"Things will only get worse as health care eats up every other public service like an insatiable Pac-Man. I do not believe the public will allow governments to levy ever-increasing taxes to avoid that scenario. So the system must be reformed."