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These services, which are delivered by private companies or non-profit organizations but funded primarily by government requisitions on a per client basis, have been targeted by pay equity programs over the past three years because wage rates are barely above minimum wage.

The coalition is made up of 650 individuals and 83 organizations that educates and advocates for the adoption and the implementation of adequate legislation in order to achieve pay equity - equal pay for work of equal value - for all workers in both the public and private sectors.

DANIELLE MARTIN (WOMEN'S COLLEGE HOSPITAL): Well, I think it's probably not divided properly and I also think that we need to be very mindful of the ways in which advertising and marketing, whether it's direct to patients or consumers as we often consume from the American media on our television screens, or whether it's direct to physicians. So, you know, in fact, even in the U.S. under the Affordable Care Act, physicians are now required to declare any amount of money that they take from the pharmaceutical industry. We have no such sunshine law here in Canada. Don't Canadian patients want to know if your doctor has had their vacation or their last meal or their speakers' fees paid by the company that makes the drug they have just prescribed for you? WENDY MESLEY (HOST): Well, we saw in those ads they'll say: Ask your doctor. Is there a lot of pressure and is that contributing to the number of pills on the market? SAMIR SINHA (GERIATRICIAN, MOUNT SINAI/UNIVERSITY HEALTH NETWORK):

WENDY MESLEY (HOST): What are you seeing, David? DAVID HENRY (PROFESSOR, DALLA LANA SCHOOL OF PUBLIC HEALTH, UNIVERSITY OF TORONTO): I think this is right and it's a surprise to somebody from outside of Canada to find that in a country with a good comprehensive care system, there is not drug coverage. So patients with chronic disease, for instance diabetics, ironically in the city where insulin was discovered, are relying on free handouts from their physicians to provide what is really an essential medication; it's keeping them alive. WENDY MESLEY (HOST): Who do you think is falling through the cracks? What are you seeing?

CARA TANNENBAUM (GERIATRIC PHYSICIAN, PHARMACY CHAIR, UNIVERSITÉ DE MONTRÉAL): The vulnerable population in my mind are older adults with multiple medical conditions who are taking 5, 10, 15 medications at the same time and have to pay the deductible on that. And that adds up for a lot of them who don't have a lot of money to begin with, so they start making choices about will I take my drugs until the end of the month? Will I take every single medication that I have to? Do I really need those three medications for my high blood pressure, or can I let one go? And that could have effects on their health. WENDY MESLEY (HOST): Well, you mentioned diabetes, David. We heard earlier on "The National" this week from a woman in B.C. She has diabetes. That's a life-threatening disease if it's not looked after. This is what she said.

SASHA JANICH (PHON.) (DIABETES PATIENT): Roughly about 600 to 800 bucks a month. I don't get any help until I spend at last 3500 a year and then they'll kick in, you know, whatever portion they decide to cover. WENDY MESLEY (HOST): So, David, that's really common? People on diabetes aren't fully covered?

DAVID HENRY (PROFESSOR, DALLA LANA SCHOOL OF PUBLIC HEALTH, UNIVERSITY OF TORONTO): Well, they're covered to a degree in B.C., but it's what we call the co- payment level that they have to make even under an insurance program. In Ontario, they don't have any insurance at all. They're going to pay the full market price if they don't have insurance through their employer, and they may lose that if they're out of work. WENDY MESLEY (HOST): What are you seeing? What's not covered? Give me an example. DANIELLE MARTIN (WOMEN'S COLLEGE HOSPITAL):

Well, actually, one thing that I think is surprising to a lot of people is the variability in coverage among public drug plans in Canada. So something that's covered, even if you're covered under a public drug plan, for example if you have cancer and you have to take chemotherapy outside of the hospital, in many Canadian provinces that's taken care of. In Ontario, for example, it's not. And I think that many Canadians are surprised to discover, imagine the, you know, enormous stress of a cancer diagnosis, that on top of that you're going to have to pay out of pocket at least to very… sometimes to very, very high levels, in fact. WENDY MESLEY (HOST): Samir? SAMIR SINHA (GERIATRICIAN, MOUNT SINAI/UNIVERSITY HEALTH NETWORK): And even just the other day, I just was debating with a pharmacy about the cost of some vitamin D. I have a person who's under house, he's on social assistance, and they said: We'll give you a free blister pack, you know, so he can sort his meds. We'll give you this. And we were actually, you know, working out a pricing system so this guy could even afford something so that he wouldn't break bones and actually have a fracture down the road. So it's amazing how some of the basic things we think are important aren't even covered. WENDY MESLEY (HOST):

Well, we saw that the drug costs have almost doubled in the last 11, 12 years. Is part of the problem… there's only so much, it seems, money to go around for prescription drugs. Is part of the problem that there's too many… some drugs are too easily available while people who really need them are not getting them? And there's marketing playing into that. We see a lot of ads in the last ten years. Check this out. VOICE OF UNIDENTIFIED WOMAN (ANNOUNCER): (Advertisement) We know a place where tossing and turning have given way to sleeping, where sleepless nights yield to restful sleep. And Lunesta can help you get there.

UNIDENTIFIED MAN #1: (Advertisement) Anyone with high cholesterol may be at increased risk of heart attack. I stopped kidding myself. VOICE OF UNIDENTIFIED MAN #2 (ANNOUNCER): (Advertisement) Talk to your doctor about your risk. VOICE OF UNIDENTIFIED WOMAN (ANNOUNCER): (Advertisement) Ask your doctor if Lunesta is right for you.

WENDY MESLEY (HOST): It's funny, you know, we hear our health plan discussed in the United States and now you talk about our socialized medicine and it's sort of until you have a health problem, you assume everything is covered. But who falls through the cracks that you see, Samir? SAMIR SINHA (GERIATRICIAN, MOUNT SINAI/UNIVERSITY HEALTH NETWORK): Yeah, I mean, I treat a lot of older patients and those who are 65 and older generally are covered by a provincial drug plan. But, you know, I'm seeing more and more, especially after the recent recession, we have people who are closer to that age who lose their jobs and if they lose their jobs and they were relying on private drug coverage plans, they are not covered. And then they find themselves they can't afford their medications, they get sicker and they literally have to wait and be sick until they can actually get their medications.

Well, it's a huge amount of pressure, I think, you know, for… you know, if you're a doctor that relies on information or supports from pharmaceutical representatives, for example, then there is that pressure that you're put under, there is that influence that you have. But also, we know that if your patient asks you specifically and says, you know, what about this medication, you may say, well, it's easier to prescribe you that medication if that's what you really want. But there's actually five things you can do to improve your sleep and actually avoid being on that medication, but we don't get asked for that. WENDY MESLEY (HOST): But I want to be like the lady with the wings.

SAMIR SINHA (GERIATRICIAN, MOUNT SINAI/UNIVERSITY HEALTH NETWORK): And that's what I hear: Why can't I be like that? But I think it's important to think about the other options. WENDY MESLEY (HOST): David, what do you think? DAVID HENRY (PROFESSOR, DALLA LANA SCHOOL OF PUBLIC HEALTH, UNIVERSITY OF TORONTO): I would like to focus a little bit on the prices that are being paid. We talked about usage and whether drug use is appropriate. There's also the price that is paid. Canada is paying too much. And if we can just return for a second or two to the idea of a national program, there's a huge advantage in being the sole purchaser on behalf of 35 million people, as it would be with a national program in Canada. And we know from experience you can reduce drug prices by 30, 40 percent. That's billions of dollars a year. WENDY MESLEY (HOST):

That's a political debate that you have launched and I hope that it gets taken up by the politicians. Who is buying these drugs? We have seen that there are more people having trouble getting drugs, more people using drugs. Who is it? DANIELLE MARTIN (WOMEN'S COLLEGE HOSPITAL): That are taking prescription drugs in Canada? WENDY MESLEY (HOST): Yeah. DANIELLE MARTIN (WOMEN'S COLLEGE HOSPITAL):

Well, you know, interestingly over the last decade, we have seen an increase in prescription drug use in every single age category. So the answer is we all are. We're all taking more drugs than our equivalent people did a decade ago and I think… WENDY MESLEY (HOST): Teenagers? DANIELLE MARTIN (WOMEN'S COLLEGE HOSPITAL): Absolutely, teenagers and the elderly and everybody in between. And so the question really becomes: Are we any healthier as a result? You know, in some cases we're talking about truly life-saving treatment that are medical breakthroughs and, of course, we all want to see every Canadian have unfettered access to those important treatments. In other cases we may actually be talking about overdiagnosis, overprescription and as you say, Cara, sort of chemical coping of all different kinds. And I think that's what we need to kind of get at and try to tease out. WENDY MESLEY (HOST):

Well, and the largest group of all on prescription drugs right now, Cara, are the seniors. CARA TANNENBAUM (GERIATRIC PHYSICIAN, PHARMACY CHAIR, UNIVERSITÉ DE MONTRÉAL): The seniors, yes, and I'm very passionate about this topic because sometimes I see patients come into my office on 23 different drug classes, and that's when we don't talk about what drugs should we add but what drugs can we take away, and the concept of de-prescribing. And imagine if we could get people who are on unnecessary drugs, because as you get older you get added this drug and a second drug and this specialist gives you this and that specialist gives you that, but then there starts to be interactions between the different drugs that could cause side effects and hospitalization. And maybe it's time to start asking, well, what's the right drug for you at this time, at this age, with these medical conditions? And personalized medicine is something that we have been talking about. It would be nice if we could introduce that conversation into therapy and not just drug therapy, but all therapy. Maybe the drug isn't needed. Maybe physiotherapy is needed or a psychologist or better exercise or nutrition. So I think it's really a bigger question. WENDY MESLEY (HOST): Samir?

SAMIR SINHA (GERIATRICIAN, MOUNT SINAI/UNIVERSITY HEALTH NETWORK): Exactly. I mean, in my clinic the other day I had a patient who was on eight medications when she came with me, and… WENDY MESLEY (HOST): This is a senior? You deal with seniors as well. SAMIR SINHA (GERIATRICIAN, MOUNT SINAI/UNIVERSITY HEALTH NETWORK): Absolutely. And when she left my office, she was thrilled because she was only on two medications, mainly because some of the medications are prescribed to treat the side effects of other medications, for example, or the indications for those medications were no longer valid in her. But we added some vitamins and we just balanced things out appropriately. And she was thrilled because, as Cara was saying before, the co-pays, the other payments that one needs to pay for medications you don't want to take, that's a problem as well. WENDY MESLEY (HOST): We're going to take a short break, but we have one more discussion area which is: What are the next challenges that Canadians might face with prescription drugs? We'll be right back.

(Commercial break) WENDY MESLEY (HOST): Welcome back to our "National Checkup" panel. Danielle Martin, Samir Sinha, Cara Tannenbaum and David Henry are all here to talk about the next frontier. So we're hearing all of this exciting new science marches on and there's all of these new drugs, new treatments. Everyone wants them or everyone who needs them wants them, but they're expensive, right, Danielle? DANIELLE MARTIN (WOMEN'S COLLEGE HOSPITAL): They can be extremely expensive. So, you know, what we call these blockbuster drugs coming onto the market, some of them truly do represent breakthroughs in medical treatment and in some cases they can cost tens or hundreds of thousands of dollars a year. So they really are very expensive. But what I think many people may not realize is that the number of drugs coming out, even the expensive ones that are truly breakthroughs, is still a very small portion of the drugs coming out on the market. Many, many drugs that are being released and are expensive are marginally, if at all, really any better than their predecessor. So just because it's new and fancy and costs a lot doesn't necessarily mean that it's all that much better.

WENDY MESLEY (HOST): So what's going to happen, David? DAVID HENRY (PROFESSOR, DALLA LANA SCHOOL OF PUBLIC HEALTH, UNIVERSITY OF TORONTO): We need to find a plan. These drugs may cost hundreds of thousands of dollars. Nobody can afford that individually. Tens of thousands, rich people can afford them but the average person cannot. So there's really no way we can cope with these unless we've got a plan and, in my view, it has to be a national plan. And the advantage of that are that when you're buying or you're subsidizing on behalf of 35 million people, you're going to get better prices and your insurance pool that covers these costs is much greater. So the country can afford drugs that individuals can't.

WENDY MESLEY (HOST): Samir, what do you see as the new frontier here? SAMIR SINHA (GERIATRICIAN, MOUNT SINAI/UNIVERSITY HEALTH NETWORK): I think the new frontier is going to be more personalized treatments in terms of how do we actually treat cancers, how do we treat certain rare conditions with more personalized treatments. WENDY MESLEY (HOST): Because it's very exciting, right? You have this cancer that's not that common and then you hear that there's a treatment for it and you want it. SAMIR SINHA (GERIATRICIAN, MOUNT SINAI/UNIVERSITY HEALTH NETWORK): And it has the possibility of alleviating a lot of suffering from unnecessary treatments that may not actually be… you know, be effective. But I think this is the challenge. If we want to be able to afford these, if we actually work together we're actually more able to afford them when we bulk-buy these medications. But the key is going to be that, you know, this is where the future is going and we're going to have to figure out a way to pay for them.

WENDY MESLEY (HOST): What are you looking forward to? CARA TANNENBAUM (GERIATRIC PHYSICIAN, PHARMACY CHAIR, UNIVERSITÉ DE MONTRÉAL): I'm really looking forward to seeing all these new treatments that we have spent decades researching. You know what the investment in health research has been in order to find new targets for drugs, in order to increase quality of live, in order to cure cancer, and then to send a message, oh, sorry, we're not going to give them to you or you can't afford to pay for them, then I think there is a lack of consistency in the messaging that we're giving to Canadians around equity for health care. So you could get your diagnosis and you could see a physician, but we way not be able to afford treating you. So I think this is something we need to think about it. It's very exciting, I think we live in exciting times, and looking at different funding strategies to make sure that people get the appropriate care that they need at the right time to improve their health is really what we're going to be looking forward to. WENDY MESLEY (HOST):

Tricky, though. It's a provincial jurisdiction, you've got to get all the provinces to agree to a list, and the list is getting longer. DANIELLE MARTIN (WOMEN'S COLLEGE HOSPITAL): Absolutely. I mean, I think actually one of the big myths out there about drug plans is that higher-quality plans are the ones that cover everything. And, in fact, that's not true. You know, we can use a national plan or a pan- Canadian plan or whatever you want to call it to target our prescribing and guide our prescribing in order to make it more appropriate, and that's another way that we're going to save money in the long run. WENDY MESLEY (HOST): Well, I learned a lot tonight. I hope our audience did too. Thanks so much for being with us. DANIELLE MARTIN (WOMEN'S COLLEGE HOSPITAL): Thank you.

In Britain the coalition has mimicked this approach. Circle, backed by private equity firms, runs Hinchingbrooke hospital in Cambridge.

Since 2010 private companies have had the right to set up large GP-style services

Corporates have set up 200 healthcare centres in two years, although critics point out that the majority have been in wealthier urban areas.

The Social Democrats, the main Swedish opposition party, have given up the idea of renationalising the health service and instead argue that profits should be capped and quality of care more tightly regulated.

more than 500 beds are being removed from the country's best known health centre, the Karolinska University hospital, and the services are being moved into the community to be run by private companies

a business-backed research institute, the Centre for Business and Policy Studies, looked at the privatisation of public services in Sweden and concluded that the policy had made no difference to the services' productivity. The academic author of the report, who stood by the findings, resigned after a public row.

Last year Stockholm county council, which controls healthcare for a fifth of the Swedish population, withdrew contracts from a private company after staff in a hospital were allegedly told to weigh elderly patients' incontinence pants to see if they were full or could be used for longer.

Swedish tax authorities are, however, taking some companies to court because pay in private equity groups is often linked to the profits made on deals and has been incorrectly taxed for years, it is said, at rates lower than that required for income in Sweden.

travel time is not included in the salary

So, if an employee works 40 hours, she would receive 40 x 12 cents = $4.80, regardless of the number of kilometres she has travelled. And, travel allowances are not paid by all of the 50 agencies which exist in the province. Car insurance is paid by the home care worker.

Travel mileage between clients is 12 cents per hour.

Also, the days when a worker has only a client or two - for example, one in the morning, the other in the afternoon - she is paid only for the time necessary to service a client, thus losing any opportunity for other part-time work. She has the right to two weeks of paid vacation per year.

Often, services are not offered on public holidays, constituting a loss of hours for the home care worker, since this time is not made up later.

No pension

The vast majority of these employees are women.

This work requires an evaluation of the position and level of responsibility to ensure that the work is paid for its proper value. The government has already done this work and knows full well the real wage which should be paid.

This salary discrimination should no longer be tolerated.

Huberte Gautreau of Moncton is Francophone Vice-Chair of the NB Coalition for Pay Equity.

As analysts Ake Blomqvist and Colin Busby note in a new C.D. Howe Institute study, "Many other countries, in Europe and elsewhere, also have systems that cost much less than the American one and that, arguably, are at least as equitable as Canada's, if not more so." Yet, "No other country is modelling their health-financing system around the Canadian example," they add. "None of them seem to think that a monopoly approach to paying for most health services is the best way to achieve equity and efficiency goals."

Many of these restrictions do not flow from the Canada Health Act, but rather from provincial laws. For example, Victoria, not Ottawa, prohibits doctors who opt out of the Medicare system from getting any payments from public funds, or doctors who work within the public system from billing patients over and above what the government pays. These restrictions, the study argues, impose big costs. To illustrate this, it focuses on how health care is paid for in four countries - the U.K., Australia, Switzerland and the Netherlands - whose health systems are considered to be among the world's best.

"Their guiding principles are similar to those within the Canadian health care system. All endorse universal public coverage and access for a defined core set of services, the belief that costs should be borne by society at large ... and high standards of care." In all these countries, public spending covers a significantly smaller percentage of hospital and doctor-related costs than in Canada, leaving the balance to be paid by private insurance for those who have it. (The range is from 65-85 per cent for hospital costs, compared to 92 per cent in Canada, and 60-90 per cent for doctors fees, compared with 99 per cent in Canada.)

But their governments also cover 45-67 per cent of drug and other outpatient medical costs, compared with 35 per cent in Canada. The authors consider, and ultimately dismiss, the view that any deviation from Canada's single-payer system would result in higher costs - an often-cited factor when sky-high U.S. health costs are dissected, but not an issue in countries that have a more carefully balanced mix of public and private funders.

Nor do they buy the argument that the public sector would lose out if privately paid health services were allowed to compete for doctors and patients. Indeed, other countries have found that competition can improve service and lower costs. The bottom line is that Canada's health care system only looks as good as many of us like to think it is when we compare it to the American system. And other countries have figured out better ways to fully respect the same vaunted principles Canada aspires to while providing more or better care at comparable cost. We could learn from them.

In Alberta, where private MRI facilities advertise and operate, the median wait time for an MRI is much longer (80 days) than in Saskatchewan (28 days). Furthermore, the wait has lengthened in the public system in Alberta since privatized facilities came on the scene. The explanations are complex, but siphoning human capacity (doctors and technologists), as well as other resources, from the public system into the private and more lucrative stream plays a big role. So does the market generation of increased demand by deceptive advertising and promotion of privatized services.

Medical tests should be ordered in accordance with evidence-based guidelines about their usefulness and indications. Patient access to MRI is currently prioritized in Saskatchewan health-care facilities on the basis of medical need, from Level I (a life-threatening diagnosis or treatment requiring MRI within 24 hours) to a Level IV (stable patients needing long range diagnosis or management allowing for delay of 30-90 days).

This system works and prioritizes appropriately. While patients sometimes feel that an urgent MRI will make a difference to their outcome, this is rarely the case. When it is the case, patients are prioritized and get urgent access. Allowing private MRI's based on ability to pay and jump the queue will trample this well-developed, equitable system. It will allow the wealthy or anxious to bypass this system and result in two-tiered care.

We live in a society obsessed with health. Selling fear of sickness is profitable. But access to MRIs is not our most urgent health-care need. To suggest otherwise is to obscure the social and economic determinants that define who is healthy and who is not, and to further shift resources away from the sick towards the worried well.

The Wall government and the private MRI operators that will profit from this legislation have proposed a two-for-one deal, suggesting that one public MRI scan will be done for every private MRI performed. Don't be fooled. This will not get around the problem of prolonging public wait lists since it will siphon resources from the public system. If we really need more MRIs, why not increase capacity in the public system instead?

While MRI can be a useful tool, when inappropriately used it can lead to overdiagnosis or "false positives." This then triggers a costly cascade of subsequent investigations or interventions to reassure either physician or patient MRI technology has important limitations, and frequently finds unrelated non-significant abnormalities that frighten patients. For example, 90 per cent of healthy individuals over 60 years of age with no symptoms of back pain show degenerative abnormalities on MRI. Similarly, the vast majority of adults over 50 show knee damage on MRI and only clinical assessment by a doctor identifies whether or not these findings are significant. Early MRI has not been shown to improve outcomes in low back pain and may actually make for worse outcomes. A doctor examining for red flag symptoms can identify the very small number of patients for whom an MRI is useful.

Many MRI scans are therefore unnecessary. Allowing patients to purchase an investigation they don't need wastes resources, bypasses the role of an informed health-care provider, and may in the end actually harm patients with needless investigations and interventions. Physicians are engaged in initiatives to "choose wisely" in testing. Throwing the door open to investigations based on ability to pay, rather than medical need, flies in the face of sensible approaches to health resources.

And the queue-jumping is not just limited to getting an MRI. It will extend to preferential and quicker access to treatment options, such as specialist care and surgery based on the MRI results if positive.

Let's promote greater equity, not less, and preserve health care based on need, not two-tiered care based on ability to pay. Let's trust health-care providers to counsel patients about the right test at the right time and to prioritize patients appropriately. The marketplace has no role in these decisions.

Dr. Sally Mahood is a Regina family doctor and an associate professor, Family Medicine, University of Saskatchewan.

That's also a key word when looking at the history - and potential future - of the Hamilton Realty Capital Corporation (HRCC). As The Spectator's Steve Buist has reported, HRCC has completed only one transaction in the past nine years - the purchase of the Cannon Knitting Mills property at the corner of Cannon and Mary streets in downtown Hamilton. And that project seems to be going ... nowhere. On the face of it, HRCC seems like a good idea. The city refers to it as a "joint venture" with Forum Equity Partners, an investment and development company based in Toronto. The goal of the partnership was to spur untold millions of dollars in downtown redevelopment, bring neglected properties back to life and, as a result, create new tax revenues to fill the city coffers.

The result? The city has spent or promised millions of dollars since HRCC was formed in 2006. The company is a privately owned subsidiary of Forum. And while the city paid half the $200,000 purchase price for the Cannon Knitting Mills, the property is 100 per cent owned by Forum. The property was purchased by HRCC in 2011. Redevelopment of the contaminated property is stalled; no purpose for the building that would suit a tenant or tenants has been established. The city is collecting fewer tax dollars on the property. Under the 50-50 funding arrangement, the city is also paying half the property taxes - to itself. It is extremely difficult to categorize this venture as a success of any kind, even if one takes the most optimistic of views. The project is costing city taxpayers every year with virtually no return on the investment. The "joint venture" seems tilted strongly in favour of the private partner, yet the city seems to be left holding much of the risk. If there is an upside for the city in this arrangement, it defies discovery. In 2006, the city and Forum Equity Partners struck a 10-year agreement. Next year might be the right time for the city to cut its losses on this venture. Lee Prokaska

Doing so requires the business community to engage with the Department of Foreign Affairs, Trade and Development and EDC in the effective design and implementation of the government's new initiative. Done well, this initiative could leverage Canada's strengths in finance, natural resources, infrastructure construction and engineering to catalyze private investment that will accelerate the global push toward the United Nations' Sustainable Development Goals (SDGs). The initiative could also build on the skills and experience of Canada's large immigrant communities to strengthen trade and investment links with emerging and frontier markets - countries that are now responsible for the lion's share of global growth, but where Canada's business presence is tiny.

Senior fellow at the Jeanne Sauve Foundation and visiting scholar at Massey College in the University of Toronto. He tweets at @BrettEHouse. In its 2015 Economic Action Plan, the federal government announced its intention to create a $300-million, five-year "development finance initiative" to partner with private capital to create growth and jobs in low-income countries. The budget document anticipates that this initiative - to be located within an expanded Export Development Canada (EDC) - will provide a mix of financing, technical assistance and business advisory services to enterprises operating in line with the government's international assistance priorities.

As outlined in a submission to Parliament last summer by the Centre for International Governance Innovation and Engineers Without Borders, the experiences of Canada's G7 counterparts offer some important lessons for Ottawa's initiative. An effective initiative should address market failures; that is, it should fill gaps in the financial system that prevent good projects, sound businesses and effective entrepreneurs from obtaining the financing they need on reasonable terms. A classic example would be the situation of new immigrant entrepreneurs: They know their former countries well, they are ideally placed to build links between Canada and their birthplaces, but their lack of Canadian credit history makes it difficult for them to gain access to affordable borrowing to grow their businesses. Ottawa's new initiative will need to be empowered with a full range of financial tools - a variety of lending instruments, a mandate to take equity positions, the ability to write guarantees, the option to underwrite insurance products - that it can tune flexibly to take projects from their early days to full bankability.

It needs to be risk-loving and clear-eyed about the fact that some projects will fail, and maintain a long horizon on investments that typically take many years to pay out returns and development impact. This new development finance initiative should also embrace open competition. The most successful DFIs work with the most effective firms on the most innovative projects.

They're not limited to working with their own nationals. Both Canada and developing countries will benefit most if this initiative is made accessible to the best people, ideas and execution. Finally, Canada's new development finance initiative needs to take poverty reduction just as seriously as profit generation. Most other DFIs do this imperfectly, at best; some don't even monitor the impact of their projects on development. This makes no sense. Development is good for business and business can be good for development.

Five years from now, development gains will be just as important as profits in making the case for renewed funding of this initiative. All these lessons need be adapted to both the needs of Canadian business and Canada's specific development objectives. The Canadian Chamber of Commerce and Canadian Council of Chief Executives have both been important supporters of this project. Now it's time for the businesses that stand to benefit directly from this initiative to get involved ensuring its success.

When the Canada Health Act passed in the House of Commons in 1984 with unanimous support from all political parties, its primary purpose was to put an end to extra billing like this. Charging patients at the point of care for medically necessary services strikes at the heart of the principle that access to health care should be based on need rather than ability to pay. It undermines equity, increases system costs and reduces commitment to the public health care system. It's also illegal.

Why are we not hearing resounding denunciations of Barrette's plan from our federal politicians? Research has consistently demonstrated that forcing people with less money to pay a fee to access care means they might not seek out medical attention until later in the course of their illness. This means patient outcomes are likely to be worse and treatment more complicated and costly. Given higher levels of illness among people in poverty, these fees also shift costs to those who use the system most but can least afford to pay.

Doctors in Quebec and across the country have expressed alarm at Barrette's amendment to Bill 20, which regulates extra billing rather than prohibiting it. The Canadian Medical Association, Quebec Medical Association, Canadian Doctors for Medicare, Médecins Québécois pour le Régime Publique, and the Quebec College of Family Physicians have all come out against this decision, joining patient groups, all of Quebec's opposition parties, and Raymonde Saint-Germain, the independent Quebec Ombudsman. The measure was passed on Oct. 7, with no public debate. Bill 20 is currently before the National Assembly and is expected to become law this fall.

Barrette is effectively bringing user fees in through the back door. Rather than introducing user fees charged by government, he would let clinics do so. This further fragments care and makes access even more inequitable.

In this federal election campaign, the talk has been around reducing barriers to access by improving coverage of prescription medicines, home care and mental health care. Yet at the same time that our federal parties are committing to such muchneeded expansion, they are silent on protecting the core of medicare: publicly funded doctor and hospital services.

Any party that claims to be committed to the Canada Health Act should immediately state its position on the amendments to Bill 20 in Quebec. To do less is to skirt the core federal responsibility for medicare in Canada. Ryan Meili is a family physician in Saskatoon and an expert adviser with the Evidence Network. Danielle Martin is a family physician and vice-president Medical Affairs and Health System Solutions at Women's College Hospital in Toronto. Both are members of the board of Canadian Doctors for Medicare.

JACQUES BOISSINOT, THE CANADIAN PRESS / Health Minister Gaétan Barrette has put forward a measure that would regulate extra billing rather than prohibit it. It will become law when Bill 20 is adopted.

Former NHS hospitals, free to generate half their income from private patients, will dedicate their staff and facilities to that end, making it impossible to monitor what is public and what people are paying for.

Billing, invoicing, marketing and advertising will add between 30% and 50% to costs compared with 6% in the former NHS bureaucracy.

some of HCA's American hospitals are under investigation for refusing care and performing unnecessary investigations and treatment, including cardiac surgery. A decade ago it paid the federal government $1.7bn to settle fraud charges, while former chief executive Rick Scott – now the Republican governor of Florida – managed to avoid prosecution.

Unitedhealth, which is currently providing services to the NHS, paid hundreds of millions of dollars in settlement of mischarging allegations in the US; Medtronic paid $23.5m for paying illegal kickbacks to physicians to induce them to implant the company's pacemakers and defibrillators; GlaxoSmithKline and Abbott paid $4.5bn in fines relating to improper marketing and coercion of physicians to prescribe antidepressants and antidementia drugs respectively. Novartis, AstraZeneca, Pfizer and Eli Lilly have all paid large fines for regulatory breaches.

Threats to public health care 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.

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.

Low-income adults who do not have employer-sponsored dental coverage through a publicly funded program - and most don't - must pay for their own dental care. Because the cost is often prohibitive, too many adults avoid seeking treatment at dental offices. Instead, they turn to family doctors and emergency departments for antibiotics and painkillers, which cannot address the true cause of the problem. In 2012, in Ontario alone, there were almost 58,000 visits to Ontario hospital emergency rooms due to oral health problems. Why is access to dental care essential now?

A person's oral health will affect their overall health. Dental disease can cause pain and infection. Gum disease has been linked to respiratory infections, cardiovascular disease, diabetes, poor nutrition, and low birth weight babies. Poor oral health can also impact learning abilities, employability, school and work attendance and performance, self-esteem, and social relationships. It is estimated that 4.15 million working days are lost annually in Canada due to dental visits or dental sick days. Persons with visible dental problems may be less likely to find employment in jobs that require face-to-face contact with the public.

Why is there such a difference in coverage? In short, dental care and pharmacare were not included within the original scope of Canada's national system of health insurance (medicare), and despite repeated evidence of the need to correct this oversight, is still not covered today. Instead, we are left with a patchwork of private employer-based benefits coverage, limited publicly funded programs, and significant out-of-pocket payments for many. Publicly funded dental programs for children and youth do exist for low-income families, including the dependents of those on social assistance. Most provinces and territories have some access to drug coverage, mostly for seniors and social assistance recipients, and there is some support for situations where drug costs are extremely high.

Pharmaceutical coverage in Canada remains an unco-ordinated and incomplete patchwork of private and public plans - one that leaves many Canadians with no prescription drug coverage at all. This has many negative consequences including: Three million Canadians cannot afford to take their prescriptions as written. This leads to worse health outcomes and increased costs elsewhere in the health-care system.

One in six hospitalizations in Canada could be prevented through improved regulation and better guidelines. Medicines are commonly underused, overused, and misused in Canada. Two million Canadians incur more than $1,000 a year in out-of-pocket expenses for prescription drugs. The uncontrolled cost of medicines is also a growing burden on businesses and unions that finance private drug plans for approximately 60 per cent of Canadian workers. Canada pays more than any comparable health-care system for prescription drugs. We spend an estimated $1 billion on duplicate administration of multiple private drug plans. Depending on estimates, we also spend between $4 billion and $10 billion more on prescription drugs than comparable countries with national prescription drug coverage plans.

Affordable access to safe and appropriate prescription medicines is so critical to health that the World Health Organization has declared governments should be obligated to ensure such access for all. Unfortunately, Canada is the only developed country with a universal health care system that does not include universal coverage of prescription drugs. From its very outset, Canada's universal, public health insurance system - medicare - was supposed to include universal public coverage of prescription drugs. The reasoning was simple. It is essential to deliver on the core principles of "access," "appropriateness," "equity" and "efficiency." Building universal prescription drug coverage into Canada's universal health-care system, based on the above principles, is both achievable and financially sustainable.

A public body - with federal, provincial and territorial representation - would establish the national formulary for medicines to be covered. This body would negotiate drug pricing and supply contracts for brand-name and generic drugs. Importantly, it would use the combined purchasing power of the program to ensure all Canadians receive the best possible drug prices and thereby coverage of the widest possible range of treatments. To patients, the program would be a natural extension of medicare: when a provider prescribes a covered drug, the patient would have access without financial barriers.

To society, universal access to safe and appropriately prescribed drugs and access to dental care will improve population health and reduce demands elsewhere in the health system. The single-payer system will also result in substantially lower medicine costs for Canada. In short, Canada can no longer afford not to have a national pharmacare program and a national dental care program. Disclaimer: The Guelph and Wellington Task Force for Poverty Elimination is a non-partisan organization. However, the poverty task force does have ties with two Guelph federal party candidates. Andrew Seagram, the NDP candidate, is a current member of the task force and Lloyd Longfield, the Liberal candidate, is a past member.

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