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.