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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.

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.

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.

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.

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.

Polls show Canadians overwhelmingly support these conditions. Medicare's key limitation, however, is that it applies only to services offered by doctors and hospitals. It does not apply to home care. Increasingly, provincial governments are trying to save money by encouraging acute-care hospitals to discharge patients as quickly as possible. In most provinces, these patients find themselves reliant on badly underfunded home-care services. Unlike hospital care, such services are usually neither comprehensive nor universal. As an Alberta oil worker with incurable cancer found when he tried unsuccessfully to come home to Ontario to die near his family, they are not even portable. Ontario pays $3 billion on home care each year. But Queen's Park saves more than that in foregone hospital and nursing home costs. In that sense, home care is a revenue tool. It allows provincial governments to evade the spirit, if not the letter, of the Canada Health Act. In Ontario, as my Star colleague Bob Hepburn has pointed out, the results are sometimes absurd. When the provincial Liberal government boosted wages for badly paid home-care workers earlier this year, some cost-conscious agencies responded by cutting services. In the weird world of Canadian health care, it was the logical thing to do. But there is a way to fix the home-care anomaly. Roy Romanow's royal commission on health care pointed to it 14 years ago.

Romanow argued it made no sense to exclude home care from medicare. He recommended home care services for the mentally ill, for patients just released from acute care hospitals and for those needing palliative care be written into the Canada Health Act immediately. By 2020, he said, all home care services should be covered by medicare. Interestingly, federal Health Minister Jane Philpott is also focusing on home care, mental health and palliative care. How would she get the provinces onside? Many assume a final deal over medicare spending can be hammered out only by the first ministers meeting in a marathon bargaining session - as happened in 2004. In that session, the premiers ran roughshod over then Prime Minister Paul Martin. Quebec demanded and received the principle of asymmetric federalism - that it could do whatever it wished with the massive health transfers Martin was offering. Alberta then demanded and received the principle of provincial equality - which meant any province could mimic Quebec. As a result, no real conditions applied to any of the money Ottawa agreed to hand over.

This is one way of doing things. The other is for Ottawa to ignore provincial objections. That's what Lester Pearson's Liberal government did in 1966 when, in concert with the New Democrats and over the strident objections of Ontario, Quebec, Alberta and the federal Conservatives, it passed Canada's first national medicare act. The Canada Health Act is the successor to that 1966 law. It is a federal statute that can be amended unilaterally by Parliament. In 2016, it makes sense that it be amended to include home care as a core medicare service. Some provinces may disagree. If so, they won't have to take any extra money that Ottawa puts on offer. Thomas Walkom's column appears Monday, Wednesday and Friday.

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.

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

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.

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.

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

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.

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)?

Kat Lanteigne, executive director for BloodWatch.org and writer of the play Tainted based on three-years of research about the tainted blood scandal, travelled to Alberta to help spread the message about concerns about private, donor-paid plasma collection. Lanteigne said these types of clinics had started to show up in Ontario in the last few years. "This is a big-pharma push," she said. "If they can build a clinic and get a licence from Health Canada then they can open without the province's permission." She said that the private sale and collection of blood and plasma introduces risk into the system. She also dispelled another myth that plasma is being imported into the country. She said that is not the case, as about 70 per cent of the drugs produced from plasma is what is being imported. When successful in the fight to get Ontario to legislate against private, donor-paid plasma collection at the end of 2014, and because Quebec has a similar law, Lanteigne said they made the mistake of thinking that because the largest provinces in Canada had done this, the rest of the provinces would follow suit.

Instead, as part of one of her first decisions, the new federal Liberal Health Minister approved CPR opening a clinic in Saskatchewan. Lanteigne says the Saskatchewan government, led by Premier Brad Wall, then approved the private, donor-paid plasma collection business to open in Saskatoon, "in between a pawn shop and a pay-day loan company." "This collection facility is a blood broker. They are literally a middle man Ñ a source to get profits. "We're asking the provinces and territories to pass voluntary blood donation acts which adds blood and plasma to their existing human tissue acts ..." Lanteigne explained. There is a lot of information on the BloodWatch.org website about the issue, including an informative timeline. The organization also has a Heart Watch rating system. Alberta currently has three hearts and Lanteigne would like to see that increase to five. "Saskatchewan has broken our hearts," she adds.

Kim Storebo, CUPE Local 46 president who works with Canadian Blood Services (CBS), also spoke at the event. She said CUPE supports a public, voluntary-based blood system in Canada, adding CBS needs to increase the number of its own plasma collection sites. The organization has been slowly closing locations since 2012. "There is no evidence the collection of plasma from paid donors will create self-sufficiency," she said. "Under no circumstances should there be payment of blood plasma donors with cash or cash-in-kind equivalents." The union wants to see blood and plasma collection remain the sole responsibility of Canadian Blood Services and for the organization to expand its plasma collection and its work hours and ensure stable and consistent hours for its employees. As part of the wrap-up of the Alberta tour officials with FOM, BloodWatch.org and CUPE presented an online SumOfUs petition with more than 15,000 signatures to provincial health minister Sarah Hoffman asking for all provincial governments to "implement legislation that ensures no for-profit, donor-paid blood plasma collection clinics are allowed to operate in Canada." Azocar assured those at the meetings that Friends of Medicare would continue to lobby the Alberta government this fall and next spring during the Legislature sittings.

And user fees? Even a Senate committee that had been warm to the idea of charging patients each time they saw a doctor changed its mind when faced with the evidence.

But the real problem with two-tier medicine, as former Saskatchewan premier Roy Romanow noted on the same CTV show, is that it simply shifts costs.

Manning made much of the fact that Quebec’s government devotes proportionally less of it provincial budget to health —30 per cent of program spending as opposed to about 40 per cent in Ontario. He appeared to attribute this to the fact that Quebec, unlike Ontario, allows physicians to opt out of medicare and bill patients privately. But the real reason why the Quebec government spends less in proportional terms on health care is that it spends more in absolute terms on everything else. Provincial government program spending per capita in Quebec is $11,457. In Ontario, the figure is $9,223.

total health spending in Ontario represents 11.9 per cent of the province’s gross domestic product. In Quebec, the comparable figure is 12.4 per cent

The Germans, Dutch and French, all of whom are praised by two-tier fans, spend more of their gross domestic product on health care than we do.

Surely it’s more productive to build on what we have — a successful, publicly funded, universal health insurance system that covers doctors and hospitals. It could be improved or even expanded. But it works. That’s why Canadians keep fighting for it. Over and over and over again.

it will remove money and jobs from health care precisely at those times when they are needed most

since its inauguration by the Liberals in 1968, medicare has been under attack from those who think the federal government has no business in health care.

By 2002, Ottawa was contributing only 18 per cent of the public cash going to medicare.

This is why Roy Romanow’s 2002 Royal Commission into health care recommended a boost in federal cash contributions. And it is why the federal-provincial health accord two years later was so important.

That accord eliminated any linkage between federal health transfers and economic growth. More important, it committed Ottawa to put more real cash into medicare.

Thanks to that accord, the federal government’s cash share of health-care funding has gone back up to about 25 per cent.

the Conservative arrangement would eventually return the country to where it was in 2002 — with Ottawa putting little into medicare and the federal government losing all ability to enforce national standards that Canadians accept as given.

Stage two has not yet been announced.

Prime Minister Stephen Harper can now tell the premiers that he’ll turn a blind eye if they try to make up this shortfall through creative solutions — even if such solutions (delisting of all but core services? user fees?) run directly counter to the letter and spirit of medicare.

"This is not just a British Columbia issue," Martin plans to say in her speech. "The ramifications will be felt across our entire country. If the case goes to the Supreme Court (of Canada), there's the threat of having the Canada Health Act itself under threat."

Depending on the outcome of a vote, Unifor may donate $25,000 to Canadian Doctors for Medicare and the B.C. Health Coalition to help cover the costs of the legal battle.

"In order to protect patients, the B.C. government must hold private clinic owners and operators accountable when they break the laws prohibiting extra-billing and user fees," said lawyer Steven Shrybman, a partner at Sack Goldblatt Mitchell who is acting for the B.C. Health Coalition and Canadian Doctors for Medicare, intervenors in the court challenge. Shrybman is well-known for his successful Supreme Court challenge against Ontario's attempted sale of Hydro One and the recent election fraud cases in Federal Court. "Though the challenge was launched in British Columbia, it has the potential to bring two-tier care to Canadians across the country," he warned. "Advocates of public health care from Ontario and across the country are calling on the B.C. government to take a tough stand in these negotiations. These are the laws that uphold Medicare and defend patients," said Dr. Ryan Meili, Vice-Chair of Canadian Doctors for Medicare. "A simple slap on the wrist encourages more violations in provinces from coast to coast."

The problem is already creeping into Ontario, according to Natalie Mehra, executive director of the Ontario Health Coalition, where the government is proposing to expand private clinics. "Patients are being confused by private clinic operators who are manipulating them into paying thousands of dollars for health care services that they have already paid for in their taxes," she warned. "The public should know that you cannot be charged by a doctor or private clinic operator for surgery, diagnostic tests or any other medically necessary hospital or physician service. Extra user fees charged to sick and elderly patients are unlawful and immoral and governments should be delivering that message." Advocates warned that this court case should also raise alarm bells in Ontario's government about the dangers of private clinics. At risk is our public health system in which access to health care is based on need, not wealth. SOURCE Ontario Health Coalition

Health Canada’s annual reports show that Quebec has sometimes complied with its concerns. But in its 2003-2004 report, the agency observed that the Quebec government was “not at liberty to reveal the status of the province’s investigation” into user charges imposed by a private surgical clinic. A year earlier, Health Canada expressed concern “about private surgical clinics that allow individuals to privately pay for medically insured services and thus jump the queue. … Health Canada asked Quebec to confirm that the matter had been resolved.” A long-standing complaint of Quebec by Health Canada is that it allows patients to be charged for MRIs and CT scans if they are done in private clinics. In its 2004-2005 report, Health Canada held discussions with British Columbia, Alberta and Nova Scotia about charging for medical imaging in private clinics, but Quebec refused to participate. 

Health Canada officials did not respond to requests for an interview since last Thursday. Reacting to the Quebec lawsuit last week, federal Health Minister Jane Philpott said she’s a strong supporter of the CHA, and did not rule out reducing transfer payments to provinces that flout the law.

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.