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Canada’s doctors, on the other hand, aren’t significantly influenced by drug plans. In Canada, more than half the former Lipitor patients have been switched to the newest still-patented anti-cholesterol drug, Crestor, which is not proven to be any more effective than generic atorvastatin. And it’s certainly more expensive than the lower priced generic.

Even as provincial governments have rules for enforcing generic substitution, many people are covered by their employer-sponsored private insurance plans, which have no such rules.

Those two drugs are not widely used in Canada. But they represent a growing problem that affects Canadians: The sudden, inexplicable price increases of older, off-patent medications are part of a global trend that threatens the affordability and accessibility of life-saving medications, according to Steve Morgan, professor of health policy at the University of British Columbia's School of Population and Public Health.

"We've seen drug prices go levels we've never conceived of," he said. And the problem isn't confined to older generic drugs. Many new patented brand-name medications are being introduced at prices so high they threaten the sustainability of the health-care system, Dr. Morgan said. When a new drug comes on the market, its manufacturer is given a patent so it can recoup development costs and make a profit.

Once the patent expires, generic drug manufacturers can make their own versions at drastically reduced prices. But in the past few years, prices for some oncecheap generic drugs have skyrocketed. Sometimes, the increase is linked to shortages of raw ingredients used to make the medication or problems in the supply chain.

But increasingly, companies are making older generics that are no longer being produced or are being made in small quantities. Typically, the drugs aren't prescribed very often, which has allowed the price increases to fly largely under the radar. No one knows exactly how often these huge price hikes occur. Philip Emberley, director of professional affairs at the Canadian Pharmacists Association, said it's relatively rare but that "it seems to be coming up more frequently."

The regulations for generic drug prices are mandated by provincial governments, which set price caps based on a percentage of the former patented drug's price. But in cases where there is only one company manufacturing a generic drug - with no branded version to calculate the price - companies are free to charge any amount they want.

Canadian experts say they are deeply concerned about affordable access to life-saving medication and that it's time for government action. "We're not dealing here with the next cool widget," said Jillian Kohler, associate professor in the Leslie Dan Faculty of Pharmacy at the University of Toronto. "We're dealing here with products that are essential to enhancing the quality of life or even saving lives." Mr. Emberley said rules must be developed to prevent companies from targeting generic drugs for price increases. "There's no regulatory capacity to address this kind of situation," he said.

Jeff Connell, vice-president of corporate affairs with the Canadian Generic Pharmaceutical Association says that, over all, the cost of generic drugs in Canada is on the decline and that numerous measures are in place to protect against unfair pricing. UBC's Dr. Morgan said he believes rising generic drug prices are following a trend set by the increasingly exorbitant costs of brand-name patented drugs. It's become increasingly common for drug companies to set high prices for new products, which is putting a strain on provincial drug plans, private insurers and Canadians who must pay out-ofpocket.

One of the most frequently cited examples is Soliris, a drug used to treat the rare diseases paroxysmal nocturnal hemoglobinuria and atypical hemolytic uremic syndrome. The drug costs up to $700,000 for one year, and patients on it must continue treatment indefinitely to see benefit. Pharmaceutical companies say such prices are a reflection of the research, development and other associated costs required to bring a drug to market.

But others, such as Dr. Morgan, argue that drug companies will simply charge what the market will bear. A few hundred thousand dollars for a drug would have been unheard of in the 1990s, but it's now the norm because companies have been allowed to get away with it, he said. "Our notion of what is an exorbitant price has shifted," Dr. Morgan said. "It's an attempt from a manufacturer to seek everything the market will pay for a drug."

Ms. Rius said there were six problem areas - from MSF's perspective - in the early leaked versions of the TPP. Three have been eliminated in the final text, although she said some of those were "absurd" in the first place. Among them was a provision that would have made it illegal to oppose a patent before it was granted and another that would have forced governments to allow surgical techniques to be patented. There are three key remaining problem provisions, according to the MSF analysis. One would allow pharmaceutical companies to "evergreen" their product patents, essentially making small changes to a drug's use to extend its protection from competition. Another would extend patent protection if there are delays in regulatory approval of a new product.

More broadly, allowing greater monopoly protection for brand-name drug makers will diminish innovation at other firms, Ms. Rius said. "If you are trying to develop a pediatric formulation of a product, if you are trying to combine different pills into one pill, ... if you are trying to improve a medicine and create a second generation, all of that technology and knowledge is going to be protected by secondary patents." The final text of the sweeping trade pact, which has been in the works for eight years, was released in early November. Canada is one of 12 countries that have negotiated the pact, although it was the former Conservative government that signed on. Prime Minister Justin Trudeau said his government will wait for parliamentary hearings on the TPP before deciding on ratification. Each country has to ratify the agreement before it comes into effect.

For generic drug makers, she said, the TPP will create additional legal barriers that will get in the way of making new products, and that will stunt the industry. The TPP will actually raise drug prices, especially in developing countries, she said, and this "will affect our capacity, and the capacity of the ministries of health with whom we work, to scale up treatment programs and reach as many people as needed."

A third would allow developers of certain advanced drugs - called biologics - to keep their clinical data private for up to eight years. That would make it much tougher for competitors to create similar drugs, or at least delay that from happening. This "data exclusivity" rule would be new for some of the countries that are part of the TPP group, although Canada already has a similar provision in place. Indeed, many of the provisions of the TPP are already part of the Canadian scene, at least in some form, said trade lawyer Larry Herman, of Herman & Associates in Toronto. The former Conservative government had said the TPP was "in line" with Canada's existing patent laws, and this appears to be true from his read of that part of the text, Mr. Herman said.

Still, he said, from a global perspective "there is no doubt that the agreement increases patent protection and enhances the monopoly rights of the patent owner." From the perspective of Canada's generic drug industry, the TPP has to be looked at in conjunction with the Comprehensive Economic and Trade Agreement (CETA) between Canada and the European Union, said Jim Keon, president of the Canadian Generic Pharmaceutical Association.

CETA, which has not yet taken effect, would extend patent protection for drugs and cut into the business of Canadian generic drug makers - thus boosting drug costs - Mr. Keon said. But it also contains some specific protection for the generic industry to mitigate that impact. It is not clear yet whether the TPP will allow those mitigating measures to be implemented in Canada, he said. And because of the immense complexity of the TPP, "you've got all sorts of potential for misinterpretation here," Mr. Keon added.

only some of the savings will be reinvested in health care

In other jurisdictions, generic drug purchases are put out to tender, which can lower prices further.

Jim Keon, the president of the Canadian Generic Pharmaceutical Association, said his organization was pleased that the provinces took the bulk-purchasing route instead.

The Canadian Medical Association said Friday's agreement is a good first step, but more needs to be done. "It doesn't really replace an overall pharmacare strategy for the country that would cover a very broad range of prescription drugs," said the CMA's chair, Dr. Anna Reid.

The average person over 55 enjoys more than $165,000 additional wealth in their homes after inflation compared to 1977. I'm glad my mom accumulated this wealth. But she and I wonder why the federal government prioritized cutting taxes for the aging population. Income splitting for seniors costs $1.1 billion annually. The pension income credit costs $1.1 billion. The "age" tax break for anyone over 65 costs $3 billion.

Then, we must carry larger mortgages, working an extra month to make annual payments compared to a generation ago - even though interest rates are low compared to the 1980s. For many, this crushes dreams of home ownership, while imposing rents driven by higher property prices. The housing market that frustrates younger Canadians has been good for my mom's demographic.

The average cost of housing is up $116,000 after inflation compared to 2005. Housing costs more even as apartments get smaller in our bigger cities. This squeezes younger generations for space, time and money just when we want to start our families. Compared to when Harper began as PM, we must work an extra two to three years to save a 20 per cent down payment.

He also cut $168 million per year in taxes for affluent seniors by changing rules governing registered retirement income funds - at a cost that is greater in one year than the total Harper added to student grants over the next three. Ironically, the opposition accuses Harper of cutting government spending because of his tax cuts. But this isn't accurate. Annual spending on old age security increased by $8 billion after inflation over Harper's decade, and the Canada Health Transfer increased $10 billion. Forty-seven per cent of health-care spending goes to the 16 per cent of the population over 65.

Not done there, Harper doubled the contribution limit for tax free savings accounts in his election budget. Canadians over 60 are three to five times more likely to max out their TFSAs compared to those 18 to 49. TFSAs shelter deposits from further taxation no matter how well investments pay off.

What Harper didn't increase substantially is spending on younger generations. Ottawa contributes to a federal/provincial spending pattern that invests more than $33,000 per person over 65 compared to less than $12,000 per person under 45. This calculation includes the PM's universal child care benefit, and income splitting for one in three families with kids.

Harper's main rivals promise to do better, but don't always budget enough. The NDP talks about $15/day child care. But the $1.9 billion they budget isn't a quarter of what is required. The Liberal platform so far budgets the most of the big three parties for families raising kids. But their promise to extend parental leave by six months is backed by too little money to make a meaningful difference.

By the platform numbers, the national party last in the polls is currently first for proposing more for younger Canadians. The Greens would eliminate tuition for a first post-secondary degree, and reallocate three times more money for child care services than the NDP. The Greens promise more money than other parties for a national housing strategy.

And the Greens are concrete about pricing pollution so that markets ensure younger Canadians aren't primarily left the costs of keeping our air, water, and land clean, while mitigating climate change. No matter which party you prefer, it's time all parties commit Ottawa to reporting how spending breaks down by age, and whether we are leaving at least as much as we inherited.

Although such reporting would cost Ottawa only a little staff time, it is a prerequisite for Canada to work for all generations. Dr. Paul Kershaw is a policy professor at the University of B.C., and Founder of Generation Squeeze (gensqueeze.ca).

Canada's youth faces a precarious financial future thanks to the actions of the federal government, Paul Kershaw writes. • Melissa Renwick/Toronto Star file photo

The General now sits in the middle of the pack among large teaching hospitals, with infection numbers similar to several comparable hospitals in Toronto, Hamilton and London. The Civic is at the low end among comparable hospitals, with C. difficile infection numbers almost identical to those of three Toronto hospitals: St. Michael's, Princess Margaret and Toronto Western. Moreover, the General campus beat the hospital's target of 0.45 infections per 1,000 patient days seven out of 12 months last year.

In 2013, it did that only twice. The Civic was below target 10 out of 12 months in 2014 after doing so only four times the previous year. "We're very pleased to see the rates come down," said Dr. Kathy Suh, the hospital's medical director of infection prevention and control. "It's been a long time coming for us.

"We've had our challenges, which have been quite prolonged, with C. difficile, so we're pleased to see the rates drop like this." C. difficile, which is found in stool, is typically spread in hospitals after patients or stafftouch soiled surfaces such as toilets, handles and bedpans. Patients taking antibiotics are especially vulnerable because the medication kills good bacteria as well as bad, allowing C. difficile bacteria to multiply more easily.

Suh attributed the reduction to several initiatives, including an emphasis on hand hygiene, the use of bleach to clean patients' rooms and a program to improve the use of antibiotics, a key driver for C. difficile. A team of physicians and pharmacists reviews individual cases to ensure that antibiotics are only used when necessary, that they're stopped when no longer needed and that the most appropriate antibiotics are prescribed, Suh said. The hospital also continues to use anti-infection "SWAT teams," first introduced two years ago, whenever cases of C. difficile are diagnosed. The multi-disciplinary teams review processes in the affected unit and ensure that patients are promptly isolated and tested.

It all seems to be working. The General reported just three new C. difficile cases in December, a month when infections often spike. In December 2013, for example, it reported 11 new cases. In December 2012, there were 15. At the Civic, there were seven new C. difficile infections in December, the most since February 2014. But most months, the numbers have been low. In three separate months - June, August and November - the Civic reported just a single new infection.

The hospital's objective is to keep infection rates below the 0.45 threshold, Suh said.

BY THE NUMBERS C. difficile infections in Ottawa hospitals in 2014 (2013 numbers in brackets) 74 (112) Ottawa Hospital, General campus 45 (81) Ottawa Hospital, Civic campus 25 (28) Queensway-Carleton Hospital 18 (23) University of Ottawa Heart Institute 19 (34) Montfort Hospital 14 (12) Children's Hospital of Eastern Ontario

The program's launch on Oct. 1 will see the fulfilment of one of the new Liberal government's major health promises from the spring election campaign.

QUEBEC — Extra fees charged in private clinics for procedures covered by medicare are not being controlled and may be abusive, the province’s auditor general said in a report Tuesday. Extra billing has been in dispute ever since the government of Quebec adopted Bill 20 in November. The bill aimed, among other things, to regulate add-on fees by creating a standardized price list. The situation remains ambiguous, confusing and misunderstood, auditor general Guylaine Leclerc wrote in her report. Neither the health department nor Quebec’s health insurance board (RAMQ) has a firm grip on these add-on fees, which are estimated at $50 million a year, she noted. For example, the report said, Quebecers are charged between $300 and $400 for a colonoscopy, $125 to $225 for a vasectomy, $51 to $100 for a biopsy and $5 to $50 for an excision, depending on the clinic. 

Lawyer Jean-Pierre Ménard insisted last week Quebec is the worst offender when it comes to over-billing patients, and that the fees are creating a two-tier health-care system that may violate the Canada Health Act. With Ménard’s help, various patients’-rights groups have come together to launch legal action against the federal government to make sure the Canada Health Act is applied in Quebec and other provinces. Reacting to the report Tuesday, Health Minister Gaétan Barrette reiterated his recent promise to abolish add-on fees by possibly rolling them into doctors’ salaries. “For care that is medically required, there won’t be any fees,” he told reporters.

Parti Québécois MNA Diane Lamarre said Barrette’s “about-face” is the result of relentless criticisms by her and the PQ. “When we started studying Bill 20, we were fighting the fact that the minister introduced an amendment that authorized accessory fees,” Lamarre said. “It was a new opportunity to charge, legally, new medical fees. … We asked the minister many times to (scrap) his amendment and he refused. “(It) was a way to introduce accessory fees and make some patients with no money unable to have access to medical services, which is completely against the law. Now we’re proud that he changed his mind,” she said. Both Lamarre and Coalition Avenir Québec MNA François Paradis said they are concerned Barrette will not be able to convince doctors’ associations to include the fees in their remuneration. If doctors’ salaries are boosted by an additional $50 million in the next contract agreement, for example, it will mean that collectively we will all be paying the fees indirectly, Paradis said.

In fact, only Americans, at $1,147 per capita, spend more on drugs than Canadians, at $890.

unlike citizens of most other developed countries, Canadians pay for the majority of their prescription drugs with private insurance or out-of-pocket.

About 39 per cent of prescription drug costs are financed by the public sector in Canada, compared to 85 per cent in Britain.

Public spending on prescription drugs was $12.1-billion last year, up just 2.2 per cent; private spending was $15.1-billion, up 6.8 per cent.

"Everything's on the table," said TSH CEO Robert Biron, who argued Scarborough's hospitals have suffered a lack of operating and capital funds because they are split, an arrangement he called "to some degree dysfunctional."

The TSH board expected to hear the report of an expert panel on two proposals the LHIN said required more study, the elimination of the birthing centre at the General and a division of programs turning the Birchmount into a centre for day surgery and the General into the facility for operations requiring overnight stays.

"We felt strongly that merger seemed to be the (option) that had the most potential."

As the province forces hospitals into "a more competitive model," those in Scarborough need a way to "obtain our fair share," he said.

We're much better positioned if we do that together."

"The days of hospitals doing everything for everybody" are changing, said Dr. Robert Ting, the group's president. "We have to decide what our community needs and focus on certain areas."

So much enthusiasm for a merger was expressed, Warren Law, a TSH board member who is not on the ILC, cautioned colleagues the appropriate time to make the case was "down the road."

Biron insisted the ILC is "starting from a blank slate" and no decision to merge had been made.

In 2011, Dr. John Wright, the former TSH CEO, initiated study of a merger between TSH and Toronto East General Hospital in East York, but the work was shelved last year after objections from medical staffs of both hospitals, residents and the LHIN, which noted the East General was outside its jurisdiction.

The Auditor General found wait times for long-term care that are extraordinary. Crisis clients are waiting more than three months for placement and wait times have tripled.

In Ontario’s privatized clinics (Independent Health Facilities) the Auditor found inadequate monitoring, poor inspections, a lack of financial oversight and inequitable access to care.

Auditor Calls Quebec Extra Billing Out of Control Doctors Call on Health Minister Jane Philpott to Illegal Billing Practices in Quebec TORONTO (May 12, 2016) – Extra-billing in Quebec medical clinics are “excessive” says Auditor General Guylaine Leclerc, but Federal Health Minister Jane Philpott has yet to act on calls to enforce the Canada Health Act and bring them under control.

an
$84 billion, largely for-profit industry

Although a few states have extended some wage and hours protections to homecare workers, these workers enjoy no federal right to form a union or bargain collectively

Caring Across Generations campaign

the campaign’s collaborators spanned the community/labor spectrum, from AFSCME and the SEIU to 9 to 5, the Alliance of Retired Americans, the National Day Laborer Organizing Network and the YWCA

Hand in Hand: The Domestic Employers Association

Her group, mostly employers, goes to rallies, signs petitions and gives testimony in defense of caregivers because, as she says, “My quality of life depends on their quality of life.”

Caring Across Generations, like the National Domestic Workers Alliance, aims to build relationships between those doing the work and those they’re working for.

200 groups were signed on as campaign partners

argues for cuts to the defense budget, imposing financial transaction taxes and increasing corporate taxation

CAG is fighting to expand Medicaid and Medicare, and to protect Social Security and healthcare spending too.

Despite industry complaints that paying minimum wages will drive up the cost of care, CAG and its allies flooded the Labor Department website with positive comments. Since the public comment period closed on March 12, the group has been waiting with bated breath. The department has sixty days to review, after which the Office of Management and Budget has ninety days, and then the rules should go into effect

Since summer, local Care Councils have formed across the country, bringing people on all sides of the care equation together to fight budget cuts and attacks on union rights, and for increased funding for homecare. The councils have planned public Care Congresses in key cities

Homecare, after retail and nursing, is the third-fastest-growing workforce in the United States. But organizing has been slow and sometimes cutthroat

Jennifer Klein, who with Eileen Boris has written a book on organizing homecare

the workers are variously defined as public workers (employed by the state and paid through Medicaid) or independent contractors (working for private agencies) or they may be hired directly by the client

After 74,000 mostly Latina homecare workers in Los Angeles voted to join the SEIU in 1999, the labor movement celebrated—and then fell into a bitter turf war between the SEIU and the state, city and municipal employees’ union, AFSCME, over how California’s remaining homecare workers should be contracted and represented.

In contrast with traditional unions and movement leaders who have prioritized short-term legislative, ballot-measure or electoral campaigns, intersectional organizers emphasize building power over the long term

National Nurses United, does worry about simply going along with the trend toward homecare. “Obviously, we want people to have choices, but it can’t be driven by budgets,” she says. “As nurses, we’re still seeing the blowback from the deinstitutionalization of mental care.”

in several states where they represent caregivers, unions have created a registry of potential clients for their members

we have three recommendations

Patient-centred care, inter-professional care and comprehensive care are all things that deserve and require additional investment and attention.

We need a pan-Canadian human resources for health observatory function to provide evidence and data on which to plan. Our workforce science in Canada is at a very primitive stage, and we are lurching from one crisis in one locality or one specialty to another.

The second recommendation

Our third recommendation

Canada needs an injury prevention strategy to elevate in the public's attention and bring resources to bear to reduce needless injuries in our life. The reason for this is that injuries cause a lot of loss of life, disability, long-lasting disability and painful disability, and they cost a lot of money.

Jean-François LaRue, Director General, Labour Market Integration, Human Resources and Skills Development Canada

foreign credential recognition

Marc LeBrun, Director General, Canada Student Loans, Human Resources and Skills Development Canada

Canada student loan forgiveness for family physicians, nurses and nurse practitioners, as introduced in Budget 2011

Robert Shearer, Acting Director General, Health Care Programs and Policy Directorate, Strategic Policy Branch, Health Canada

in 2004 the federal government committed to the following: accelerating and expanding the assessment and integration of internationally trained health care graduates across the country; targeting efforts in support of Aboriginal communities and official language minority communities to increase the supply of health care professionals in these communities; implementing measures to reduce the financial burden on students in specific health education programs, in collaboration with our colleagues in other federal departments; and participating in HHR planning with interested jurisdictions

Canada does not have a single national health human resources plan

Health Canada plays a leadership role in HHR by supporting a range of targeted projects and initiatives of national significance.

Pan-Canadian Health Human Resource Strategy

Internationally Educated Health Professionals Initiative

Health Canada supports collaborative efforts as co-chairs of the federal-provincial-territorial Advisory Committee on Health Delivery and Human Resources known as ACHDHR. This committee was created by the conference of deputy ministers of health back in 2002, to link issues of primary health care, service delivery and HHR.

ACHDHR will be providing a written brief

The federal government also participates on ACHDHR as a jurisdiction that directly employs health care providers and has responsibility for the funding and delivery of certain health care services for populations under federal responsibility, such as First Nations and Inuit, eligible veterans, refugee protection claimants, inmates of federal penitentiaries, and serving members of the Canadian Forces and the Royal Canadian Mounted Police.

Shelagh Jane Woods, Director General, Primary Health Care and Public Health Directorate, First Nations and Inuit Health Branch, Health Canada

Dr. Brian Conway, President, Société Santé en français

account for over a million Canadians who need access to quality health services in their own language.

Acadian and francophone communities outside Quebec

Senator Eggleton

I am interested in the injury prevention idea. We hear of it from time to time. Do you have some specific thoughts on what an injury prevention program or strategy might look like and how it might fit in with the health accord? One of the things the Health Accord brought about in 2004 was the federal government saying to the provinces, “If you do this and you do that we will give you money here and there.” Maybe we should be doing that here. Maybe we should ask the federal government to provide an incentive for the provinces to be able to do something. It would be interesting if you could come up with a vision of what that strategy might look like.

But their specific commitment ran out in 1996. Worse for them, some of the patents on big blockbuster drugs have begun to expire.

So the companies try to rearrange the chemical formulas in products and seek patents for drugs very similar to the ones losing patent protection.

prices fall

In addition, the PMPRB regulates prices such that patented drug prices can’t grow by more than the consumer price index over a three-year period.

When drugs lose their patents, generics replace them – sometimes produced directly by the brand-name companies or under contract, more often by a generic drug company.

With prices held down by the PMPRB and patented drugs losing market share, it’s hard to explain why drugs cost so much. Part of it relates to the absurd Canadian system whereby each province negotiates prices; part of it is because drug use overall has skyrocketed; and part of it is tied to these new patents for drugs being not very different from the previously patented ones. Drug expenditures in Canada from 2000 to 2008 grew at twice the growth in the economy (6.4 per cent), faster than anywhere else.

While sales rise, R&D declines. The ratio of R&D to sales rose from 2000 to 2008 in France, Germany, Italy, Switzerland, the United States and Britain, but fell in Canada.

Countries with pharmaceutical head offices definitely get more R&D than branch plant countries such as Canada.

In some of these countries with much greater R&D, patented drug prices are below those in Canada, meaning that no link exists between research intensity and domestic prices.

Canada has the worst of both worlds: high prices, internationally speaking, with a low R&D intensity

Brand-name drug companies have been extensive users of the research tax credits on offer from federal governments (augmented sometimes by provincial ones). These have come under assault from two federal studies into Canada’s lagging innovation. It would appear the Harper government is prepared to shake up this credit

country is being short-changed relative to what it pays for drugs, how it protects them under patent, and compared with what happens in comparable countries

And in case anyone rushes to the defence of generic (off-patent) drug companies, Canadians pay among the highest prices for generic drugs in the world

The Duffy trial is sucking up all the oxygen because there's nothing else happening. The leaders all have significant policy announcements up their sleeves, but they are saving them for next month, when more people are paying attention. One Conservative candidate may be indulging in wishful thinking when he said "absolutely no one cares about Duffy - it's an Ottawa story."

I'm not sure that's true. The Duffy trial testimony has simultaneously undermined Harper's "strong leadership" pitch and bolstered the case for change. But it is clear the caravan will move on after the trial goes on hiatus at the end of next week. We will be celebrating Thanksgiving one week before election day. The odds are when the mornings are as crisp and golden as an apple, Nigel Wright's testimony will be a vague recollection for most folks. As a memory experiment, who remembers the details of Justin Trudeau's "32-point plan to restore democracy in Canada," unveiled exactly two months ago? Other issues will come to the fore and one battleground that Quebec Premier Philippe Couillard is keen to highlight is the way Ottawa funds health-care.

The case for a demographic funding formula received a boost last month in a paper by the Parliamentary Budget Office that suggested the demographics of an aging population are set to defeat all attempts by provinces at containing healthcare costs. The phrase was not used, but the implication was that a genuine fiscal imbalance is emerging.

Health-care is always high on the agenda of concerns when voters are asked by pollsters. Yet, the Harper Conservatives have neutralized the issue in recent elections by closely shadowing the policies of their opponents.

This time will be different. The Conservatives have long promised that in 2017, the CHT will grow at the rate of general growth plus inflation - about three per cent to 3.5 per cent. Provinces have been used to six-per-cent increases since Paul Martin signed his "fix for a generation" in 2004.

The NDP has said it will maintain that six-per-cent escalator, while the Liberal Party says it will be focused on preparing the system for the wave of baby-boomer retirements in a new health accord.

Couillard wrote to the leaders of all federal parties late last week, renewing calls for them to take into account aging populations when calculating the $32-billion Canada Health Transfer. Backed by the Canadian Medical Association, Couillard issued a challenge to the party leaders to top up the CHT to take account of changing demographics.

The report pointed out that the ratio of people aged 15-64, compared with those over 65, will fall from 4.3:1 in 2014 to 2.6:1 by 2034. The PBO suggested that provincial governments need to find savings or revenue increases of 1.4 per cent of gross domestic product, about $28 billion annually, to put themselves on a sustainable footing. At the same time, the federal government will have a similar amount of money to spare, as a result of falling public debt levels.

The wrinkle for both the NDP and Liberals is that they can commit extra billions of dollars to health-care or pledge to balance the budget. It stretches credulity to suggest they could do both, alongside the commitments they have already made. The Conservatives have already made their choice, committing themselves to reducing debt levels and ensuring the budget is balanced.

Contrasting policy positions on one of the subjects that Canadians say they really care about could provide some relief from the inertia afflicting the 42nd general election campaign. When temperatures, and tempers, cool, the leaves will cascade, the seasons will turn and so will the concerns of many voters.