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

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

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

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

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

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

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

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

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

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

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

I think the answer is probably straightforward. Hip replacement is usually the final stage of a long, chronic process of joint deterioration due to arthritis. A good doctor would, I think, be able to anticipate the eventual need for his or her patient to have a hip replacement several years before it becomes essential.

Before the surgery, most people will need to take some time to prepare - for example, making their homes more accessible, since they are going to be on crutches for quite a few weeks after the operation. In short, hip replacement is not an emergency, and it is best planned months in advance. A well-managed wait list for hip replacements is not a sign that the medicare system is broken - it indicates that the system is working properly.

With privatized medicine, your number on the wait list is determined not by medical need, but by your ability to pay. Canadians of my age can remember that system, and we don't want it back. David Josephy Guelph

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.

In his book, Down to the Wire, David Orr explains the difference between optimism and hope, an important distinction when we try to balance our pride in the Canadian health system with our frustrations about its challenges.

Dr. Michael Rachlis's book, Prescription for Excellence,

Monica Dutt is the chairwoman of Canadian Doctors for Medicare, a public-health and family physician, and is based in Cape Breton, N.S. Vanessa Brcic is a board member with the Canadian Doctors for Medicare, a family physician and a clinician scholar in the department of family practice at the University of B.C.

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

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

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

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

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

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

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

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

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

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

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.

Instituting a means test: An equitable system does not mean you have to provide equal services to all at equal cost; user fees and co-payments are not necessarily unfair, but these approaches have to be used smartly

Regulating rather than outlawing private insurance and care. One of the most important lessons we have to take from Europeans is that we need a combination of a well-regulated private system and a well-managed public system.

Every health system worth its salt has a mix of private and public delivery and payment.

The question is not whether or not we have private and public care. It’s getting the mix right.

There are things private enterprise does well. There are things that public and non-profit enterprises do well. Let’s be pragmatic and benefit from both, as most European countries do.

We need to pay much more attention to equity – making sure everyone is cared for – and less to who is delivering the services.

Reform is going to happen only if the political environment changes, if we stop shouting down every proposal for change because it threatens vested interests.

We don’t need more tiresome private-public rhetoric. We don’t need Chicken Little screaming that medicare is unsustainable.

Another is the Canada-Europe Trade Agreement now being negotiated by the federal government with little visible objection from the provinces other than Newfoundland. A CETA agreement might increase drug costs at the level of billions - largely through the extension of the life of patent rights for the giant European and British pharmaceutical companies and by extension the denial of growth of generic drug production.

The provinces have not objected to CETA despite this damaging impact. Such objections would be effective since the feds must guarantee provincial and local government adherence to CETA.

Perhaps more menacing is a new agreement called TISA, or Trade in Services Agreement. What little we know about it includes health among services to be shifted to the corporate sector in a wholesale global privatization process that includes education, prisons and other public services. A bizarre aspect of TISA is its extraordinary level of secrecy - all participants are sworn to secrecy for five years even if the negotiations fail.

CETA and TISA would not only overwhelm the projected savings of pharmacare but most seriously destroy Medicare and replace a democratic-based state institution with the antithesis of democratic responsibility, competence and control. Meyer Brownstone, professor emeritus, Chair Emeritus Oxfam Canada, Toronto

All of them - Conservatives, New Democrats, Liberals, Greens, Bloc Quebecois - support universal, publicly funded health insurance. All of them believe Ottawa should transfer significant amounts of federal tax dollars to the provinces for health care. And all of the parties conveniently ignore that Canada has the least universal, most expensive, and least cost-efficient universal health system in the world, and that the provinces have almost no accountability for the federal money they receive. There are some differences among the parties, of course, but they are largely philosophical, and revolve around interpretations of the constitutional divisions of power - not very good fodder for sound bites. The Conservatives (at least under Stephen Harper) believe health is strictly a provincial responsibility and Ottawa should transfer money with no strings attached. The separatist Bloc has the same position.

The New Democrats, Liberals and Greens believe that Ottawa's role should be to create a semblance of a national health plan and show moral leadership (for lack of a better term). But to do so they need to, among other things, earmark money, to demand it be spent on specific programs. But the leaders don't want to say so out loud because no federal leader wants to pick a fight with the provinces during an election. NDP Leader Thomas Mulcair has made a number of healthcare promises aimed at specific demographic groups - such as home care and long-term care for seniors and a mental health plan for teens - but has been fuzzy on the details and an overall plan. Similarly, both the Liberals and the NDP promise to renew the health accord by holding talks with the premiers, but offer no hard numbers. (To refresh memories, in 2004, the Liberals unveiled the health care "fix for a generation," which principally involved increasing health transfers to the provinces by 6 per cent a year for 10 years. The Conservatives extended the 6-percent escalator to 2017; after that it will be tied to inflation, and no less than 3 per cent per annum.)

Pharmacare - providing affordable access to prescription drugs for all Canadians - is another hot topic in health circles, but not on the hustings. The Greens have a firm plan to implement pharmacare, saying it will save up to $11-billion annually, but promising a national plan is easy when you have little chance of winning power. Other parties are more circumspect about a topic whose details really matter. In fact, that's the overriding reason health care is difficult to discuss on the campaign trail: It's a sprawling, complex topic, with many potential pitfalls.

Health care is not one issue, it's 1,000 issues. The politician who wades too deeply into the morass risks bleeding support, suffering the proverbial death by a thousand cuts.