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The health care reform law enacted last year calls for cutting more than $400 billion from Medicare over the next decade, primarily by slowing the rate of growth in payments to health care providers and phasing out unjustified subsidies to private Medicare Advantage plans that insure roughly a quarter of all enrollees. Republican leaders, who denounced those cuts in 2010, have since embraced Representative Paul Ryan's proposal, which adopts virtually all of the same reductions. Even these will be difficult to achieve without driving out providers, according to the government's nonpartisan budget analysts.

Since January 2010 the growth in Medicare spending has actually slowed to an annual rate of about 4 percent, less than half the annual rate for the previous decade

The only way to make Medicare sustainable is to have it grow at the same rate as the economy that provides the tax base to support it. In recent years, Medicare spending has been growing faster than gross domestic product, by roughly 1.7 to 2 percentage points.

Policy experts of varied political stripes have proposed a host of ways to eliminate excess spending without harming beneficiaries or the medical system. Some would charge higher Medicare premiums for those able to afford them, or raise the age of eligibility, or increase cost-sharing by beneficiaries to deter unnecessary use of medical care. All such proposals have strengths and weaknesses that need to be carefully analyzed.

A more radical proposal, championed primarily by Republicans, is to stop providing Medicare payments for specified benefits no matter the cost and instead give beneficiaries a set amount of money to buy private insurance policies that might not provide the same benefits. These so-called premium-support or voucher plans come in many flavors - some good, some bad - and would need to be carefully vetted. The most extreme version, proposed by Representative Ryan, would save the federal government a lot of money mainly by shifting big costs to beneficiaries and driving up costs for the rest of the health care system.

Medicare's system for paying health care providers is a big part of its spending problem. The traditional Medicare program pays doctors separate fees for each of 7,000 different services, such as a diagnostic test, office visit or surgical procedure. This encourages excess use of medical tests and procedures

The solution, most experts agree, is to have Medicare pay doctors and other health care providers fixed sums to manage a patient's care and then let the doctors decide which services are truly necessary. Close monitoring would be needed to ensure that doctors don't deny medically important services to improve their bottom lines.

Medicare's coverage has some glaring gaps that need fixing. There is no provision for long-term care in nursing homes or at home, forcing many middle-class people to impoverish themselves to qualify for Medicaid. And patients can be socked with very high or very low rates of cost-sharing depending on whether care is delivered in a hospital, nursing home, by a doctor or at home. This crazy-quilt pattern confuses patients about the costs they will have to pay and almost certainly complicates and drives up the costs of administering the program.

House calls are starting to make a comeback amid a rapidly greying population, although they're still rare. The idea: A doctor or nurse-practitioner, sometimes bringing along a social worker, makes regular visits to frail or homebound patients whose needs are too complex for a typical 15-minute office visit - and who have a hard time even getting to a physician's office. "It helps you avoid the emergency situations," said Naomi Rasmussen, whose 83-year-old father in Portland, Oregon, is part of Medicare's Independence at Home study.

On Thursday, Medicare released its long-awaited analysis of the study's first year and said the project saved an average of $3,070 per participating beneficiary; Conway said all but five practices generated savings. Medicare will divide $11.7 million in incentive payments among the nine practices that met enough of the quality requirements for that financial bonus, including Portland's Housecall Providers. "We need to shift costs to this kind of intervention," said Dr. Pamela Miner of Housecall Providers.

It took extra primary care visits, but "he went from bouncing in and out of the hospital to one hospitalization in an entire year," said Housecall Providers nurse Mary Sayre. But this kind of care is hard to find, in part because of reimbursement. Medicare did pay for more than 2.6 million house call visits in 2013. But add in the travel time, and doctors can see - and get paid for - many more patients in a day in the office than they can see on the road. Enter Medicare's Independent at Home demonstration project, now in its third year of testing how well a house call approach really works and how to pay for it. About 8,400 frail seniors with multiple chronic conditions - Medicare's most expensive type of patient - are receiving customized home-based primary care from 17 programs around the country. The incentive for doctors: They could share in any government savings if they also meet enough quality-care goals.

Her father, stroke survivor Teodor Mal, is prone to frequent infections and unable to tell his wife or daughter whenever he starts to feel ill. Visits to multiple doctors left him so agitated that a good exam was difficult, and just getting him and his wheelchair there took several hours and a special van. Then Mal began getting his primary care from Portland-based Housecall Providers Inc. When family members see any worrisome changes in his behaviour or appearance, providers can make a quick visit to see if another urinary tract infection or case of pneumonia is beginning, in time to give at-home antibiotics a chance.

The Affordable Care Act created the Medicare study, and legislation is pending in Congress to extend the project another two years. The program is "bringing the house calls of yesteryear into the 21st century," said Sen. Edward J. Markey, D-Mass. He said Thursday's pilot results are promising enough to make the project permanent so that many more Medicare patients eventually could seek this kind of care.

However, until now no federal government has had the nerve to take on serial offender Quebec. Quebec has been allowing its doctors and clinics to charge extra user fees since 1979. The province's current health minister, Gaetan Barrette, freely acknowledges this. In some cases, these fees were truly exorbitant. The Montreal Gazette reported last year that some colonoscopy clinics were charging patients an extra $600 for medications - on top of the publicly paid medicare fee. Many Quebecers were outraged. The provincial Liberal government's somewhat peculiar response was to pass a bill codifying the practice of extra-billing but giving itself the authority to regulate it. In March 2015, the then-Conservative government in Ottawa formally notified Quebec that it would be looking into the issue. This March, Liberal Philpott sat down with Barrette to discuss the practice. On Sept. 6, she sent her provincial counterpart a letter threatening cutbacks to Quebec's health transfer. A few days later, Barrette announced that extra billing will end as of next January.

It is hard to gauge the importance of Philpott's threat. User fees have become widely unpopular in Quebec. That alone may have been enough to drive the provincial government to disavow them. Still, it was bracing to see a federal health minister publicly standing up for the principles of medicare. It is not an everyday occurrence. It is particularly interesting that she targeted a province that is notoriously touchy about what it sees as federal interference. Perhaps she will do more. Certainly, more needs to be done. The latest annual report on the Canada Health Act filed with Parliament notes that private MRI clinics in British Columbia, Alberta, Quebec, New Brunswick and Nova Scotia are charging user fees to patients. It says some hospitals are avoiding the ban on charging for drugs by routing the sick through outpatient clinics - which do charge. It also notes that the portability requirement of medicare, which allows Canadians to receive care outside their home provinces, is routinely ignored.

Quebec routinely refuses to fully reimburse other provinces that provide health services to Quebec residents. Yet it has never been penalized by Ottawa for this. Nor have an unspecified number of other provinces that, at one time or another, did the same. Except for Prince Edward Island, the report says, no province appropriately reimburses residents who obtain medical care outside Canada. Such patients aren't necessarily entitled to the full cost of their out-of-country care. But they are entitled to be reimbursed for the amount it would have cost them to be treated in their home province. To work as a national program, Canadian medicare needs two things. First, the federal government must put up enough money to give it a real financial role in the system. The 2002 Romanow royal commission suggested that Ottawa provide at least 25 per cent of medicare funding. That figure still makes sense. Second, Ottawa has to use its financial clout to enforce those few national standards that do exist. A former Liberal health minister, Diane Marleau, tried to do this back in the 1990s. She was sandbagged by Jean Chrétien, the prime minister of the day. Let's hope Philpott has better luck.

It was bracing to see a federal health minister stand up for medicare principles, writes Thomas Walkom.

Of the 49 million Medicare beneficiaries, one-fourth already receive comprehensive care through H.M.O.s and other private plans run by companies like UnitedHealth, WellPoint and Humana. The number could rise significantly under Mr. Romney’s proposals.

The type of competition Mr. Romney wants to see in Medicare is strikingly similar to the competition that is supposed to drive down commercial insurance prices under Mr. Obama’s health care law. Under the law, people under 65 could choose among competing health plans offered through an insurance exchange in each state, and the government would subsidize premiums for lower- and middle-income people.

Much of the rhetoric thrown around today in scuffles between governments and physicians might ring a bell for students of medical history. More than 50 years ago, doctors were also accused of being too stubborn to accept changes to pay structure, and a provincial government was also charged with putting fiscal concerns before patient needs. Of course, if that old saying holds any merit — “Those who cannot remember the past are condemned to repeat it” — perhaps a refresher is in order. There seems, after all, to be a little bit of history repeating itself.

The origin of conflict between provincial governments and physicians can be summed up in one word: medicare. It therefore dates back to midnight of July 1, 1962, when the Saskatchewan Medical Care Insurance Act passed into law, introducing the first universal, government-run, single-payer health system to North America. All of one minute later, most of Saskatchewan’s doctors went on strike.

tually, to be precise, the fighting between the government and doctors in Saskatchewan began a couple of years earlier, during the 1960 provincial election. Premier Tommy Douglas had made universal health care the main peg of his re-election campaign. The College of Physicians and Surgeons of Saskatchewan fiercely opposed the idea, contending that government interference in medicine would do far more harm than good.

A public battle ensued, pitting doctors against politicians. Debates were held, pamphlets were circulated, pledges were signed. Did the whole affair stay civil and free of propaganda? Well, you could say that. But only if you enjoy being wrong.

Let’s start with some of the literature circulated by opponents of medicare. One pamphlet, Political Medicine is Bad Medicine, was chockablock with scary warnings and seasoned with a liberal sprinkling of words in all-caps for emphasis. Red Tape! Skyrocketing costs! Inferior care! The premier’s plan “proposes a PERMANENT INFLEXIBLE GOVERNMENT SCHEME at a high cost” that would subject medicine “to POLITICAL considerations bearing no relation to your NEEDS.”

Then there was the infamous flyer — later used by Premier Douglas to shame his opponents, according to Saturday Night magazine — that suggested many doctors would flee the province if the medicare bill passed. “They’ll have to fill up the profession with the garbage of Europe,” read one excerpt, a quote from an anonymous doctor taken from the Toronto Telegram. “Some of the European doctors who come out here are so bad we wonder if they ever practised medicine.”

Later, some in the anti-medicare camp acknowledged that mistakes were made, passion had trumped reason, and the medical profession had suffered for engaging in political mudslinging. “Many doctors concede privately that they went too far, that the campaign lost them prestige in their communities,” reported Saturday Night magazine.

Of course, the premier was no stranger to rhetoric himself. In fact, according to some political commenters of the time, he was a master of the form. He accused the province’s physicians of using “abominable” and “despicable” tactics and pedalling “scurrilous trash.”

In the end, Douglas and his party, the Co-operative Commonwealth Federation, won the election and pushed ahead with their health system plan. The doctors and government set aside their differences and all lived happily ever after. Yeah, right.

Medicare was coming to Saskatchewan — that battle was over — but physicians still weren’t cooperating with the government. They focused their efforts on changing sections of the proposed medicare act, specifically those that granted the government almost unlimited power to control the practice of medicine.

There was no provision for negotiation. The doctors would simply have to do what the government told them to do, and be paid what the government said they would be paid,” Dr. Marc Baltzan (1929–2005), a Saskatoon nephrologist and former president of the Canadian Medical Association, wrote in a 1984 article in Canadian Family Physician entitled, “Doctor/Government Fee Negotiations in Canada.”

After the act became law, unchanged, the province’s physicians closed their offices, though they still provided emergency services in hospitals. The standoff lasted 23 days, ending only after both sides compromised and signed the Saskatoon Agreement. The deal amended the act to ensure doctors would maintain their independence and could, if they wanted, opt out of medicare and bill patients directly.

The deal was brokered by Lord Stephen Taylor, a British doctor and politician who helped implement the National Health Service in the United Kingdom. Later, reflecting on his Saskatchewan adventure, Taylor wrote that much of the animosity between the two parties arose because they did not understand each other at all. The government did not anticipate how much their plan would threaten the autonomy of a proud profession. Physicians “could not believe that the government was composed of honest and responsible people.”

Taylor, a man of both medicine and government, chose to take a dispassionate view of the conflict. “I see honest men on both sides, well motivated but mystified by the actions of their opponents.”

Decades later, debate over another act — the Canada Health Act, federal legislation adopted in 1984 — again showed just how differently government and physicians can view a change to how doctors are paid. This time, the government was putting an end to extra billing by physicians. But according to Baltzan, as mentioned in his Canada Family Physician article cited above, this was merely a “political euphemism” for banning a patient’s right to be reimbursed by the government when billed directly by a doctor.

In his lament over the passing of the “deceitful bill,” Baltzan suggested that it was important to revisit the original fight over medicare in Saskatchewan because “it shows that there is nothing new under the sun: it contains all the elements of physician–government confrontation that have been replayed again and again during the Canada Health Act debate.”

Now, more than 30 years later, it might not be a stretch to say there is still nothing new under the sun regarding negotiations between doctors and government. When things go bad, as they have in Ontario, both sides sometimes resort to a little time-tested rhetoric. Then again, though some of the messages sound familiar, other elements of physician–government showdowns have changed since 1962. For one, doctors back then didn’t have Twitter accounts.

Fighting to improve Social Security and to expand Medicare to all is to benefit people of all ages. After all, what child or grandchild complains about the size of a grandparent’s Social Security check, and what grandparent wants to short change a child or grandchild? And expanding Medicare helps everyone.

the Boomer generation, once all at retirement age, will be a colossal force in defense of Social Security and Medicare, and that they will also be demanding an expansion of those programs, making them both more generous and also broader in reach.

That means we Americans, old and young, need to organize and fight like hell now to defend both programs, and to demand that they be expanded.

Germany, France, Belgium, Netherlands, Denmark and the Scandinavian countries — national pension systems provide people with benefits that replace 60 percent or more of final working income, allowing them to retire without taking a hit in their living standard (lower-income workers actually get even more in retirement and may actually see their living standards rise when they retire).

Compare this to the US, where the replacement rate is only about 37% of working income in retirement.

European countries all have excellent national health programs that make health care essentially free.

The US stands almost alone in the developed world in not having a national health program of one kind or another. Not incidentally, it also has the most expensive health care in the world, gobbling up almost 18 percent of GDP. No country approaches that level of resources spent on health care for its citizens.

Clearly, Obamacare (the so-called Affordable Care Act), is not the answer, as it costs a fortune and still leaves some 30 million without access to affordable health care.

Dr. Robert Zarr, the head of Physicians for a National Health Program (PNHP) points out in an interview on PRN.fm’s “This Can’t Be Happening” program [1], the US could easily move to a national health program like what all these above countries have by simply lowering the age for being eligible for Medicare — currently at 65.

Why don’t we do this, creating what is essentially a Canadian-model health plan (it’s actually called Medicare in Canada, and has been working since the early 1970s, and has been backed by conservative national and provincial governments consistently through most of the intervening years because Canadian’s love it)?

35 buyouts of hospitals or chains of facilities in the last two and a half years by private equity firms

Among the secrets to HCA’s success: It figured out how to get more revenue from private insurance companies, patients and Medicare by billing much more aggressively for its services than ever before; it found ways to reduce emergency room overcrowding and expenses; and it experimented with new ways to reduce the cost of its medical staff

HCA decided not to treat patients who came in with nonurgent conditions, like a cold or the flu or even a sprained wrist, unless those patients paid in advance.

In one measure of adequate staffing — the prevalence of bedsores in patients bedridden for long periods of time — HCA clearly struggled. Some of its hospitals fended off lawsuits over the problem in recent years, and were admonished by regulators over staffing issues more than once.

inadequate staffing in important areas like critical care

Many doctors interviewed at various HCA facilities said they had felt increased pressure to focus on profits under the private equity ownership. “Their profits are going through the roof, but, unfortunately, it’s occurring at the expense of patients,” said Dr. Abraham Awwad, a kidney specialist in St. Petersburg, Fla., whose complaints over the safety of the dialysis programs at two HCA-owned hospitals prompted state investigations.

One facility was fined $8,000 in 2008 and $14,000 last year for delaying the start of dialysis in patients, not administering physician-prescribed drugs and not documenting whether ordered tests had been performed.

Claiming he provided poor care, the other hospital did not renew Dr. Awwad’s privileges. Dr. Awwad is suing to have them reinstated.

“If you were a for-profit hospital with investors and shareholders,” said Paul Levy, a former nonprofit hospital executive in Boston unaffiliated with HCA, “there would be a natural tendency to be more aggressive and to seek more revenues.” Executives at profit-making hospitals are “judged in greater measure by profitability” than the administrators of nonprofit hospitals, he said.

some of HCA’s tactics are now under scrutiny by the Justice Department. Last week, HCA disclosed that the United States attorney’s office in Miami has requested information about cardiac procedures at 10 of its hospitals in Florida and elsewhere.

HCA’s cardiac business is extremely lucrative, and the Justice Department has requested reviews that HCA conducted that indicate some of the heart procedures at some of its hospitals might not have been necessary and resulted in unjustified reimbursements from Medicare and other insurers.

Small and nonprofit hospitals are closing or being gobbled up by medical conglomerates, many of which operate for a profit and therefore try to increase revenue and reduce costs even as they improve patient care. The trend toward consolidation is likely to accelerate under the Obama administration’s health care law as hospitals grapple with what are expected to be lower reimbursements from the federal and state governments and private insurers.

Columbia/HCA became the target of a widespread fraud investigation in the late 1990s, which led to one of the largest Medicare settlements ever.

HCA wanted to attract more patients to its emergency rooms, and it did. Annual visits climbed 20 percent from 2007 to 2011. But while emergency departments are often a critical source of patient admissions, they are frequently money-losers because many patients do not have insurance. HCA found a solution: it figured out how to be paid more for the patients it was seeing.

Nearly overnight, HCA’s patients appeared to be much, much sicker.

No one has accused HCA of up-coding, or billing for more expensive services that were not needed — one of the complaints made against it a decade ago.

The acting head of Medicare is Marilyn B. Tavenner, a former HCA executive who left there in 2005 to become the secretary of Health and Human Resources in Virginia.

Several former emergency department doctors at Lawnwood Regional Medical Center in Fort Pierce, Fla., said they frequently had felt compelled to override the screening system in order to treat patients.

When the doctors failed to meet the hospital’s goals for how many patients should be considered emergencies, “they really started putting pressure on.”

Regulators in several states have taken HCA hospitals to task over screening out patients too aggressively, including situations where the screening missed serious conditions.

“Staffing is critical,” said Courtney H. Lyder, the dean at the UCLA School of Nursing and an expert on wound care. “When you see high levels of wounds, you usually see a high level of dysfunctional staff,” he said.

HCA owned eight of the 15 worst hospitals for bedsores among 545 profit-making hospitals nationwide, each with more than 1,000 patient discharges, tracked by the Sunlight Foundation using Medicare data from October 2008 to June 2010.

an examination of lawsuits shows bedsore problems have been persistent at several HCA facilities

The hospital was cited twice by Florida regulators, in 2008 and 2010, for having inadequate numbers of nurses on its staff to oversee wound care for patients.

further state Medicaid cuts and alterations to Medicare funding that are on the table for the Congressional “super committee”

Click here to read the report.

The most obvious way to fix the problem would be to bring prescription drugs under Medicare. To do so would also make economic sense: in a recent Canadian Medical Association Journal study I coauthored, we found that implementing universal public drug coverage would save the private sector a whopping $8.2 billion annually. It seems counterintuitive to think that covering more people would cost us less. However, if we bargained more effectively and purchased medications in bulk, the prices we pay for those drugs we already buy publicly would go down. If access to health care in Canada is truly based on need, not ability to pay, there is no justifiable reason to exclude prescription medications from our public plans. As we head into election season, let's demand some big ideas from our politicians that will really improve the health of Canadians. A basic income and universal pharmacare would be a good start. If we did those two things, there would be a real, measurable impact on the health of our communities. After all, that's what government is for. Dr. Danielle Martin is a family physician and vice-president of medical affairs at Women's College Hospital in Toronto. A renowned advocate for Medicare, Martin will be speaking about "Creating a Healthy Canada: An Agenda for Today ... and Tomorrow" on Wednesday at City Hall.

Until now, many Canadians may have shrugged their shoulders about pharmacare because their drug costs were already paid - about two-thirds have been covered by private family benefits, and many others can count on government subsidies for seniors or welfare recipients. But in an era of precarious employment, where young people can't count on jobs for life or hope for family benefits, anyone can fall through the cracks. Are politicians now willing to make the moral and economic case for pharmacare after decades of evasions? Are Canadians finally ready to heed that message, after decades of denial?

There is no better time than a federal election year to demand an answer to the question posed by various royal commissions, think-tanks, health economists and medical experts. Now, the provinces are also joining the debate. Ontario Health Minister Eric Hoskins will try to put pharmacare back on the national agenda next week by convening a meeting in Toronto of his provincial counterparts in search of common ground. Despite early hopes that the federal government would join the debate - Health Minister Rona Ambrose had previously expressed interest in the potential cost-savings - Ottawa hasn't yet agreed to attend. A family practitioner before entering politics, Hoskins has been a pharmacare advocate since his medical school days. He has his work cut out for him.

Canada is alone among western countries with universal health care in not offering an integrated pharmacare program. We are now truly outliers. Pharmacare, like medicare, is based on the principle that no one should be denied access to life-saving treatment for lack of money. Studies consistently show that patients who pay their own way - or face a significant co-payment - are deterred from following through on prescriptions, risking their health and adding to overall costs.

Beyond humanitarian considerations, however, there is also a compelling efficiency argument for pharmacare. Like medicare, it benefits from the single-payer system when operated by government, avoiding the duplication and distortions that competing private insurers must factor in for marketing and administration costs.

A 2013 report from the centre-right C.D. Howe Institute argues that pharmaceutical companies increasingly use "confidential price rebates" in negotiated contracts as part of their global pricing strategies: "If insurers - public or private - do not or cannot do this, they will be left paying inflated 'list' prices," the report concludes. As drugs play a growing role in controlling lifelong conditions, chronic illnesses or rare cancers, the costs will only go up. With greater purchasing power, and integrated decision-making by physicians, the overall cost to the economy can be lower than it would otherwise have been.

The moral and medical arguments have always been there. The economic rationale is harder than ever to ignore. The time is right for a national debate, with the provinces - who pay the bills - leading the way.

Medicare emanated from provincial action in Saskatchewan. Pension reform is now being driven by Ontario. Action against global warming is also being driven by the provinces. There is an opportunity, in this election year, for the federal parties to show leadership. If they don't, Ontario won't be able to justify waiting much longer. Martin Regg Cohn's Ontario politics column appears Tuesday, Thursday and Sunday. mcohn@thestar.ca, Twitter: @reggcohn

The hospital appears to have taken advantage of Medicare rule changes that authorized bonus payments for treating patients with major complications.

national data shows about 5 or 6 percent of Medicare patients have acute heart failure as a primary diagnosis

the chain, based in Ontario, is the target of a federal investigation for suspected Medicare fraud involving "upcoding"

That probe, by the U.S. Department of Health and Human Services, was requested by two lawmakers in response to the chain's high rate of blood infections known as septicemia

several former Prime doctors and coders have contended that Prime's founder and board chairman, Dr. Prem Reddy, urged aggressive coding of routine medical conditions to obtain enhanced Medicare payments

Earlier this month Prime sued Kaiser and the Service Employees International Union, accusing them of conspiring to drive Prime from the Southern California health care market in violation of antitrust laws.

Sandy Barber, a coding supervisor who worked at Prime's Desert Valley Hospital in Victorville in San Bernardino County, testified in a 2005 employment lawsuit that Reddy convened meetings where he "ordered" coders to engage in illegal upcoding to boost reimbursements from Medicare.

It's a 126-bed facility that Prime obtained in 2004 after the prior owners, a physicians group, went bankrupt.

California Watch, the state's largest investigative reporting team, is part of the independent, nonprofit Center for Investigative Reporting.

medicare costs in general aren’t spinning out of control

governments cut back health-care spending growth severely during the recession of the early 1990s, then — because of public pressure — reversed themselves later on

No government is likely to attack medicare head on. They’ve learned that this is political suicide.

My guess is that governments will be looking at ways to privatize even more — from hospitals to specialty clinics — all within the medicare umbrella.

In theory, this could work out. Or, as in Britain today, it could undermine the very nature of the public health-care system. The devil will be in the details.

The report also features a decent "to-do" list of where to begin the renovations, with its mandated five point list: Embrace patient engagement and empowerment; Integrate fragmented health systems and modernize the work force; Invest in technological transformation, namely digital health and personalized medicine; Get better value for money by improving procurement, reimbursement and regulation; Partner with industry as a catalyst for innovation. There's nothing new here, and that's not a knock on the panel. What needs to be done to modernize medicare is no secret; how to do it is the challenge. This is where the insight of Dr. Naylor and his cohorts is most evident and useful. The panel says, essentially, that you will never get meaningful innovation without real commitment, and lambastes governments - and Ottawa in particular - for its lack of engagement. Dr. Naylor and his team stress that Canada's health-care system is rife with innovation and creativity but initiatives worthy of emulation are not being embraced and scaled up by make-no-waves policy-makers.

By clinging to the status quo - the path of least political resistance - governments have created an outdated system that is ill-prepared to deal with fundamental shifts such as patients demanding more engagement and the impending arrival of personalized medicine. In the end, the panel states the problem - and the solution - in the stark language of business: There is no system-level innovation in health care because there is a lack of working capital, an absence of expert management and little incentive for or investment in improvement. In short, there is no business plan, no goals. The panel bemoans, quite rightly, the lack of federal-provincial co-operation, saying it is "chagrinized and puzzled by the inability of Canadian governments to join forces" in the best interests of patients. But it saves its most stinging indictment for the federal government.

In the quick reporting after the report's release late Friday, most attention was focused on the call to merge three existing federal funded groups to create a federal Healthcare Innovation Agency of Canada, with a budget of at least $1-billion annually. But what the Naylor report is proposing is not the old fallback position of simply spending more to do the same. In fact, it deliberately avoids saying anything about federal spending or health transfers. Rather, it calls for a new philosophy, one that involves Ottawa having ideas and taking action beyond cutting cheques; to quote: "... a different model for federal engagement in health care - one that depends on an ethos of partnership, and on a shared commitment to scale existing innovations and make fundamental changes in incentives, culture, accountabilities, and information systems." Stated more colloquially, if the next prime minister - whether his name is Harper, Mulcair or Trudeau - wants medicare to actually meet the needs and expectations of Canadians, he needs to put on his big-boy pants and lead, not lie down, and innovate, not just pontificate.

Except that if the plan for medicare designed by Stephen Harper is actually carried out (and the numerous other threats materialize), there is one very large assumption that will be patently false. Medicare allows everyone (including the 1%) to lop off a big chunk from their retirement needs -- in the U.S., private health insurance costs the average American family $15,000 a year -- and even that covers only a portion of costs.

A U.S. study, "Get Sick, Get Out: The Medical Causes of Home Mortgage Foreclosures," shows just how devastating sickness can be without public health care: "Half of all respondents (49%) indicated that their foreclosure was caused in part by a medical problem…" The study also examined the impact of medical disruptions -- large out-of-pocket health payments, loss of work due to medical issues, and those tapping into home equity to pay medical bills. Sixty-nine per cent of respondents reported at least one of these factors.

Medicare isn't dead yet, you say. But for Canadians looking to retire in 25 to 40 years, given the trends, it well could be. Medicare is under attack on so many fronts it will take incredible determination on the part of those who will need it to ensure it's there when they retire. Yet younger generations -- who face the greatest threat of losing public health care -- don't seem to think about it that much. They should -- and before the fall election.

The big five vultures anticipating the joys of feeding off medicare's carcass include: B.C. medical privateer Brian Day's legal challenge to medicare; the still unsigned Canada-U.S. "trade" deal (Comprehensive Economic and Trade Agreement); the continuing scam of public-private partnerships fleecing health budgets of hundreds of millions of dollars in excess costs in virtually every province; a new domestic services treaty (Trade In Services Agreement); and lastly, Stephen Harper's new, imposed, health "accord" that will decrease federal contributions to the provinces by $36 billion over 10 years.

Underlying both reforms is a quiet resignation to the idea that two-tiered health care is inevitable. This sense of resignation is understandable, coming as it does on the heels of a decade-long void in federal leadership on health care. Throughout the Harper government's time in office, the Canada Health Act went substantially unenforced as private clinics popped up across the country. Even in its reduced role as a cheque-writer, the federal government took steps that undermined national unity on health care, switching the Canada Health Transfer to a strict per capita formula, which takes no account of a province's income level or health-care needs. If Canadians hope to reverse this trend, we cannot simply wage a rearguard battle for the enforcement of the Canada Health Act as it was enacted in 1984. Even if properly enforced, the act protects universal access only for medically necessary hospital and physician services. This is not the blueprint of a 21st-century public health-care system.

We desperately need universal coverage for a full array of health-care goods and services -- pharmaceuticals, mental-health services, home care and out-of-hospital diagnostics. Canada is unique among Organization for Economic Co-operation and Development countries in the paucity of what it covers on a universal basis despite falling in the top quartile of countries in levels of per capita health spending. Far from being our saviour, the Canada Health Act in its current incarnation is partly to blame -- not because of its restrictions on queue-jumping and private payment, but because it doesn't protect important modern needs, such as access to prescription drugs.

There are limits on what a public health system can provide, of course -- particularly as many provinces now spend nearly half of their budgets on health care. But fairness requires these limits be drawn on a reasoned basis, targeting public coverage at the most effective treatments. Under the current system, surgical removal of a bunion falls under universal coverage, while self-administered but life-saving insulin shots for diabetics do not. A modernized Canada Health Act would hold the provinces accountable for reasonable rationing decisions across the full spectrum of medically necessary care.

Instead of modernizing medicare, Saskatchewan and Quebec are looking to further privatize it. Experience to date suggests allowing two-tiered care will not alleviate wait times in the public system. Alberta has reversed course on its experiment with private-pay MRIs after the province's wait times surged to some of the longest in the country.

The current wisdom is long wait times are better addressed by reducing unnecessary tests. A 2013 study of two hospitals (one in Alberta, one in Ontario) found more than half of lower-back MRIs ordered were unnecessary. Skirmishes over privatization have to be fought, but they should not distract us from the bigger challenge of creating a modern and publicly accountable health system -- one that provides people the care they need, while avoiding unnecessary care.

Achieving that will make National Medicare Week a true cause for celebration. Bryan Thomas is a research associate and Colleen M. Flood is a professor at the University of Ottawa's Centre for Health Law, Policy and Ethics. Flood is also an adviser with EvidenceNetwork.ca.

The intervenor coalition includes Canadian Doctors for Medicare, Friends of BC Medicare, Glyn Townson, who has AIDS, Thomas McGregor, who has muscular dystrophy, and family physicians Dr. Duncan Etches and Dr. Robert Woollard, both professors at the University of British Columbia. A second intervenor group representing four patients also warned that the Charter challenge would lead to an inequitable health system across Canada. “This case is indeed about the future of the public health care system, in its ideal and actual forms,” said the group’s lawyer Marjorie Brown, according to a report in The Globe and Mail. Cambie and its co-plaintiffs, who made their opening argument last week, say the BC law barring extra billing, so-called dual or blended practices and the use of private insurance for publicly covered services violates Sections 7 and 15 of the Canadian Charter of Rights and Freedoms.

A successful Charter challenge in BC would mean an inequitable health system, where those who can pay get priority service, states an intervenor coalition.

Moreover, they claim the prohibitions exacerbate the under-funded public system’s problems, especially waiting lists for various treatments and surgeries. Allowing a “hybrid” system would relieve the strain. The coalition brief, echoing the BC government’s lengthy opening argument, said there’s no evidence that creating a two-tier system would reduce wait times. But there is a risk of hollowing out the public system as resources migrate to the more lucrative private alternative. Those who couldn’t afford private insurance could still find themselves waiting for treatment, thus undermining the principles of universality and equity spelled out in the Canada Health Act, Latimer said in her submission. Latimer also questioned whether the legislation falls within the scope of the Charter, more often invoked to overturn criminal laws, not those with socio-economic objectives.

“This legislation is intended to protect the right to life and security of the person of all British Columbians, including the vulnerable and silent rights-holders whose equal access to quality health care depends upon the challenged protections,” Latimer stated. There’s also a risk of sapping the public system of not only doctors but nurses, lab technicians, administrators and others drawn to the more lucrative private market, the brief said. Dual practices could also foster “cream-skimming,” where private clinics handle simpler but profitable procedures, leaving complex cases to the public system. The British Columbia Anesthesiologists’ Society, intervening to support the challenge, will be making arguments later in the trial, which is due to last at least until February 2017. The federal government is expected to begin making arguments in several months.