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In dollar terms, the size of all of that post-recession debt is staggering. Some fear that when interest rates return to normal, governments will face crippling debt-servicing costs. But the scope of the problem is a matter of significant debate in policy circles. Experts do agree that whether or not government debt is a serious problem depends on where you live. Government books in Western Canada are relatively healthy. East of Manitoba however, debt is already forcing hard choices. Political debate over government finances is typically focused on the annual bottom line, which shows whether there is a annual surplus or a deficit.

Economists say the often overlooked - but far more important figure - is the size of government debt in relation to the size of the economy. As a percentage of gross domestic product, the net debt of all provinces and territories has grown to 28.6 per cent in 201314 from 20.5 per cent in 2007-08. The federal debt grew to a peak of 33.3 per cent in 2012-13 from 29.2 per cent in 2007-08. That's nowhere near the 67.1 per cent debt levels reached by Ottawa in 1995-96, when The Wall Street Journal warned that Canada was at risk of hitting the "debt wall." The size of the federal debt has already started to decline, reaching 32.3 per cent in 2013-14. The 2015 budget forecast that the federal debt-to-GDP ratio will reach prerecession levels by 2017 and decline further to 25 per cent by 2021. The debt picture among the provinces varies dramatically.

Alberta and Saskatchewan are currently facing hard times owing to low oil prices, but they are the darlings of Confederation when it comes to low debt. Alberta had no debt at all as of last year. The real debt troubles can be found in Central and Atlantic Canada. Quebec's net debt is the largest, at 50 per cent of GDP, followed by Ontario, at 38.4 per cent, and Nova Scotia at 37.7 per cent, using figures for 201314. While Quebec announced a balanced budget this year, Ontario's deficit was up slightly to $10.9-billion last year. Ontario insists the deficit will be erased by 2017-18.

Provincial governments are responsible for programs such as education and health care that can affect people more directly than federal programs. Spending restraint is easier said than done. The 2015 budget season has coincided with student protests in Quebec, New Brunswick and Nova Scotia, while Ontario is dealing with labour unrest from teachers' unions. Many provinces have also been negatively affected by a recent change to the federal health-transfers formula. The move to per-capita funding won out over arguments that the average age of provincial populations should be factored into the equation. Some of the most indebted provinces also face the most challenging demographics, with a shrinking ratio of younger workers to cover the costs of growing numbers of older citizens. The Parliamentary Budget Officer has said that while federal finances are sustainable over the long term, the provinces are facing structural shortfalls that will demand spending cuts, higher taxes or both. University of New Brunswick economics professor David Murrell said the return to surpluses in Ottawa will likely rekindle pressure from the provinces for more generous transfers. Shrinking deficits, growing debt

Provincial finance ministers are quick to pat themselves on the back over shrinking deficits and balanced budgets, but economists urge Canadians to view these claims with a bit of skepticism. Accounting methods vary across the country, making comparisons difficult. Unlike the federal government, provinces generally present two sets of books: an operational budget and a capital budget. Boasts of balanced budgets are in reference to operational spending. A province's overall debt could still be rising on the capital side even though the government is in an operational surplus. Supporters of this accounting method - including Calgary Mayor Naheed Nenshi - argue that it separates good debt from bad debt: Using debt to build public assets such as roads and bridges is better than slipping into the red to pay for public service salaries and other operational costs.

Critics such as tax-policy expert Jack Mintz have warned this approach allows provinces to play "hide the deficit." Charles Lammam, director of fiscal studies with the Fraser Institute, a conservative think tank that regularly warns about the dangers of mounting government debt, agrees that claims of improving budget balances can be misleading. "This is a real problem in places like British Columbia and Ontario," he said. "It doesn't seem like the growth in government debt will let up." Mr. Lammam's research found that Canadian governments - including municipalities - spend more than $60-billion a year servicing debt, which is about the same as the entire cost of providing primary and secondary education across the country. Ontario's recent budget said a one-point increase in interest rates would cost the government $400-million. "There's a real risk that provinces like Ontario, provinces like Quebec, can be subject to this very negative situation where they're paying even more to service their outstanding debt," he said. The new debt debate

Mr. Rankin said that Ottawa should be working with the provinces, territories and municipalities to ensure they can provide an appropriate combination of services, treatment and support for those dealing with mental illness. He pointed to the national mental-health strategy developed by the Mental Health Commission of Canada in 2012 as a roadmap for improving services.

We would obviously want to look at each of those recommendations [in the strategy], but the general thrust of those recommendations, we would implement, absolutely," Mr. Rankin said. Among other points, the strategy calls for increased access to qualified psychotherapists and counsellors and the removal of financial barriers for children, youth and their families.

Mr. Rankin also called for a revival of the Health Council of Canada and a new federal health accord to foster communication between the federal government and the provinces on health. Both expired last year. Dr. Fry said the Liberals, if elected, would work closely with the provinces to develop a more integrated approach to health-care services, including mental health.

She said the last accord, which expired in 2014, had begun to look beyond the physician and the hospital and toward health care that could be provided by multidisciplinary teams. "We want to integrate mental health, in a fulsome way, into our health-care system," Dr. Fry said. "And that would mean a lot of the things that the Mental Health Commission talked about." However, she said the Liberals would not commit to specific actions before consulting with the provinces

We have to talk to the provinces about it," she said. "That's what we can commit to doing." Dr. Fry said a partnership between the federal government and the provinces on health care is necessary but declined to specify if a Liberal government would establish another health accord or bring in a different system. The length of the next partnership could also be up for discussion, she said.

Research suggests that psychotherapy, which is provided by a licensed therapist, is an effective treatment for many people struggling with anxiety and depression, the two most common psychiatric diagnoses. Therapy by private psychologists or social workers is not currently covered by any of the provinces. A spokesman for Health Minister Rona Ambrose said the provinces and territories are responsible for health-care delivery, including psychotherapy. The Conservative government created the Mental Health Commission of Canada and recently renewed its mandate for another 10-year period, he said.

A written statement from Ms. Ambrose, provided to The Globe and Mail, said the Canada Health Act does not preclude provinces and territories from extending public coverage to other services or providers such as psychologists. "Provinces and territories may choose to extend public coverage for such services," she said. With reports from Erin Anderssen in Ottawa This is part of a series about improving research, diagnosis and treatment

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.

With an aging population requiring medical care, the PBO report says health-care costs will increase significantly as a share of the GDP and the lower levels of government will be forced to foot an increasing share of the bill. "Provinces are responsible for health-care delivery," Melissa Lantsman, a spokeswoman for Finance Minister Joe Oliver, said in an e-mail. "Nevertheless, our government is increasing health funding at a higher rate than provinces are spending it. Record sustainable funding will reach $40-billion annually by the end of the decade."

That is about the point when the PBO says the provinces and territories will be in the best financial position, after which increasing health-care expenditures will force a long, steep slide toward deficits and, by 2034, their budgets will be chronically in the red. Premiers who met this month in St. John's called on the federal government to provide more money for health. Newfoundland Premier Paul Davis said the provinces and territories want Ottawa to increase the Canada Health Transfer to cover at least 25 per cent of their health-care spending.

British Columbia Health Minister Terry Lake told The Globe and Mail on Tuesday that the current system, in which the federal money is allotted on a per-capita basis, ignores the fact that some provinces have much older populations than others. "When an older province has higher health-care costs because we have older residents, that should be reflected in the Canada Health Transfer as a population-needs based approach," Mr. Lake said. The PBO report said some other recent federal expenditures should have little negative effect on the bottom line in the years to come. The universal child-care benefit, which was increased in this year's budget and resulted in the delivery of $3-billion in cheques to Canadians this week, will have only a minor impact on fiscal room because the cash transfers are not indexed to inflation, the report said. And, while the increase in the amount Canadians can put in a tax-free savings account will reduce government revenues, the PBO says those declines will be offset by increases elsewhere.

The report also says the federal government is on track to eliminate its own net debt over the next 35 years. But, for the provinces, healthcare spending will be a problem. Melissa Newitt, the national co-ordinator of the Canadian Health Coalition, an advocacy group for public health care, said the PBO report is more evidence that a new national health accord is needed. That accord, she said, should provide stable funding, set national standards and include a national drug plan and a national seniors plan.

Those negotiations have not yet begun. At last week's meeting of provincial health ministers, to which federal Health Minister Jane Philpott was invited, she shooed away any mention of money, which, at this stage of the game, is the correct approach. Meanwhile, the provincial health ministers said they would work on what a national prescription-drug plan would look like and cost - the cost having squelched the idea of national pharmacare in the past. Several academics, often quoted in the press, believe that national pharmacare would save money. Almost nobody else does, which is why the idea has never got off the ground. Quebec has discovered that its public plan, more elaborate than any other, costs a lot more than anyone had anticipated. Prime Minister Justin Trudeau's instructions in Dr. Philpott's mandate letter are much more limited. Since Ottawa spends in the order of $1-billion on drugs for aboriginal people and the military, let Ottawa join the provinces in more bulk drug purchases to lower costs. She is also to "explore" the idea of a national formulary - an excellent idea since no logical reason exists for every province to have one. Again, though, this is far from national pharmacare.

What the Liberals do want is directed spending on home care. Here, the federal-provincial negotiations will be fascinating, and perhaps consequential for patients. The federal Liberals are always tempted to put strings around the health-care dollars Ottawa sends to the provinces. Ottawa doesn't deliver health care to Canadians (except the military and aboriginal people) and it's paying a smaller share of overall health-care spending than years ago.

Yet the Liberal itch to influence, if not direct, how federal transfers should be spent never dies. The trouble is that every time previous Liberal governments pulled out string to wrap around the transfers, at least some of the provinces said: Just give us the cash and stuff the strings away. We do health care; you write cheques. We set priorities; you help pay. This time, though, the provinces are aware of their burgeoning number of older citizens, an increasing share of whom need or prefer to be cared for at home rather than in institutions. Provinces need to save money, too, and care at home costs less than care in a hospital bed. Home care also keeps some patients from emergency rooms and reduces calls to paramedics.

The strategic health-care plans of almost every province underscore the importance of home care. So do provincial health-care budgets, which are giving new money to home care and little or none to hospitals. Now, along comes a federal government willing to hand over money - how much remains to be seen - in what the minister's mandate letter describes as a "long-term funding agreement" that would "support the delivery of more and better home-care services."

Beefing up home care is what Ottawa wants. It seems to be what the provinces want. But will the provinces sign an agreement that binds them to spend at least some of the federal money for this purpose only? Or will the provinces offer vague assurances that cannot be monitored? Perhaps some (hello, Quebec) will say: Give us the money to spend as we wish, health care being provincial jurisdiction. Maybe home care; maybe not. We'll decide. Home care is the correct priority in a health-care world with endless priorities and incessant demands. Can the often-disputatious Canadian governments pull together around this common objective?

Those changes included cutting wait times, improving home care, electronic records and telehealth, better access to care in the North, a national pharmaceuticals strategy, improvements in prevention in public health and accountability and better reporting to Canadians. Philpott's assessment Tuesday was the provinces had intended to live up to their commitments but that it hadn't happened. "The transformation to the system didn't follow," she said. Philpott said Canadians want to be able to measure where new money is going, such as the number of hours of therapy delivered in a mental health program or the number of additional home care visits added. Manitoba Health Minister Kelvin Goertzen said in a later conference call he agrees there needs to be more reform and innovation, particularly when it comes to accountability and meeting specific performance targets. "I would take exception that there hasn't been any innovation," he said. "Could there have been more? Sure."

Goertzen said Manitoba will be announcing more health-care targets shortly, with plans to better account for the dollars spent. He said additional funding for home care or mental health would be welcome but Ottawa needs to be a better partner on the day-to-day business of health-care delivery, and the three per cent increase isn't enough. The provinces have long complained Ottawa was to contribute half the cost of medicare but its contribution is now around one-fifth. They want the accord to move Ottawa to contributing 25 per cent. "We didn't get that commitment today," said Goertzen. The provinces want to discuss the health accord with Prime Minister Justin Trudeau when they all meet in Ottawa in December. Trudeau called that meeting to discuss climate change and the new carbon price he is requiring all provinces to impose. Health care is not currently on the agenda. mia.rabson@freepress.mb.ca

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.

To download all those tasks to the provinces would risk turning many Canadians into second-class citizens.

"The big, rich provinces can do it, [but] with what consequences? The small, poor ones cannot; at any rate without massive help from that central government which [further decentralization] would enfeeble."

As my father regularly pointed out, the BNA Act (now the Constitution Act, 1867), gave the Dominion government broad powers "to make laws for the Peace, Order and Good Government of Canada," embracing all matters – foreseeable or otherwise – that were not "assigned exclusively to the legislatures of the provinces."

     Federal jurisdiction has been chipped away since then

despite those rulings, the federal government retains its powers in many fields, and shares jurisdiction with the provinces in a number of others

  To further limit or eliminate the federal spending power would severely disrupt the practical balancing mechanisms that characterize Canadian federalism. It would also go against the principles of fairness and welfare (or well-being), which are inherent in the Canadian tradition.

Section 36 of our repatriated Constitution Act, 1982, which explicitly states a shared commitment to:

"(a) promoting equal opportunities for the well-being of Canadians; (b) furthering economic development to reduce disparity in opportunities; and (c) providing essential public services of reasonable quality to all Canadians.”

radically decentralist goal

"instead of sending money to the provinces, Ottawa would cut its taxes and let them use the fiscal room that has been vacated.”

this is the position of “two of the greatest conservative statesmen of our generation, Preston Manning and Mike Harris,” as well as of the Fraser Institute

     Bernier's portrayal of Macdonald, Cartier, and the rest as avid provincialists is thoroughly debunked in Dad's popular and authoritative handbook How Canadians Govern Themselves

cite the historical record to show that our country was intended from the start to be "a real federation, a real 'union,' "une grande et puissante nation," not a league of states or of sovereign or semi-independent provinces."

"Only a real country," he said, "with a powerful national Government and Parliament, can have any hope of controlling inflation and restoring full employment. Only a real country can maintain the unemployment insurance, the family allowances and child tax credits, the Medicare, which we now enjoy. Only a real country can give the people of the poorer provinces anything like modern educational and social services."

deteriorating patchwork of policies and programs that weaken the system and aggravate disparities between provinces

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.

Canada has catching up to do compared to other OECD countries. Canadians have difficulty accessing primary care, particularly after hours and on weekends, and are more likely to use emergency rooms.

only 32 per cent of Canadians had access to more than one primary health care provider

In Peterborough, Ontario, for example, a region-wide shift to team-based care dropped emergency department visits by 15,000 patients annually and gave 17,000 more access to primary health care.

We believe that jurisdictions are now turning the corner on primary health care

Sustained federal funding and strong jurisdictional direction will be critical to ensuring that we can accelerate the update of electronic health records across the country.

The creation of a national pharmaceutical strategy was a critical part of the 10-year plan. In 2011, today, unfortunately, progress is slow.

Your committee has produced landmark reports on the importance of determinants of health and whole-of- government approaches. Likewise, the Health Council of Canada recently issued a report on taking a whole-of- government approach to health promotion.

there have also been improvements on our capacity to collect, interpret and use health information

Leading up to the next review, governments need to focus on health human resources planning, expanding and integrating home care, improved public reporting, and a continued focus on quality across the entire system.

John Wright, President and CEO, Canadian Institute for Health Information

the Canada Health Act

Since 2008, rather than repeat annual reporting on the whole, the Health Council has delved into specific topic areas under the 2003 accord and the 10-year plan to provide a more thorough analysis and reporting.

We have looked at issues around pharmaceuticals, primary health care and wait times. Currently, we are looking at the issues around home care.

John Abbott, Chief Executive Officer, Health Council of Canada

I have been a practicing physician for 23 years and a CEO for 10 years, and I would say, probably since 2005, people have been starting to get their heads around the fact that this is not sustainable and it is not good quality.

Much of the data you hear today is probably 18 months to two years old. It is aggregate data and it is looking at high levels. We need to get down to the health service provider level.

The strength of our ability to report is on the data that CIHI and Stats Canada has available, what the research community has completed and what the provinces, territories and Health Canada can provide to us.

We have a very good working relationship with the jurisdictions, and that has improved over time.

One of the strengths in the country is that at the provincial level we are seeing these quality councils taking on significant roles in their jurisdictions.

As I indicated in my remarks, dispute avoidance activity occurs all the time. That is the daily activity of the Canada Health Act division. We are constantly in communication with provinces and territories on issues that come to our attention. They may be raised by the province or territory, they may be raised in the form of a letter to the minister and they may be raised through the media. There are all kinds of occasions where issues come to our attention. As per our normal practice, that leads to a quite extensive interaction with the province or territory concerned. The dispute avoidance part is basically our daily work. There has never actually been a formal panel convened that has led to a report.

each year in the Canada Health Act annual report, is a report on deductions that have been made from the Canada Health Transfer payments to provinces in respect of the conditions, particularly those conditions related to extra billing and user fees set out in the act. That is an ongoing activity.

there has been progress. In some cases, there has been much more than in others.

How many government programs have been created as a result of the accord?

The other data set is on bypass surgery that is collected differently in Quebec. We have made great strides collectively, including Quebec, in developing the databases, but it takes longer because of the nature and the way in which they administer their systems.

I am a director of the foundation of St. Michael's Hospital in Toronto

Not everyone needs to have a family doctor; they need access to a family health team.

The family doctors in our hospital feel like second-class citizens, and they should not. Unfortunately, although 25 years ago the family doctor was everything to everybody, today family doctors are being pushed into more of a triage role, and they are losing their ability.

The problem is that the family doctor is doing everything for everybody, and probably most of their work is on the social end as opposed to diagnostics.

At a time when all our emergency departments are facing 15,000 increases annually, Peterborough has gone down 15,000, so people can learn from that experience.

I have to be able to reach my doctor by phone.

They are busy doing all of the other things that, in my mind, can be done well by a team.

That is right.

if we are to move the yardsticks on improvement, sustainability and quality, we need that alignment right from the federal government to the provincial government to the front line providers and to the health service providers to say, "We will do this."

We want to share best practices.

it is not likely to happen without strong direction from above

Excellent Care for All Act

quality plans

with actual strategies, investments, tactics, targets and outcomes around a number of things

Canadian Hospital Reporting Project

by March of next year we hope to make it public

performance, outcomes, quality and financials

With respect to physicians, it is a different story

We do not collect data on outcomes associated with treatments.

which may not always be the most cost effective and have the better outcome.

We are looking at developing quality indicators that are not old data so that we can turn the results around within a month.

Senator Eaton

There are different types of benchmarks. For example, there is an evidence-based benchmark, which is a research of the academic literature where evidence prevails and a benchmark is established.

The provinces and territories reported on that in December 2005. They could not find one for MRIs or CT scans. Another type of benchmark coming from the medical community might be a consensus-based benchmark.

universal screening

A year and a half later, we did an evaluation based on the data. Increased costs were $400 per patient — $1 million in my hospital. There was no reduction in outbreaks and no measurable effect.

A thorough research of the literature simply found that there are no evidence-based benchmarks for CT scans, MRIs or PET scans.

The evidence is pretty clear for the high acuity; however, for the lower acuity, I do not think we know what a reasonable wait time is

If you are told by an orthopaedic surgeon that there is a 99.5 per cent chance that that lump is not cancer, and the only way you will know for sure is through an MRI, how long will you wait for that?

colorectal screening

the next time they do the statistics, there will be a tremendous improvement, because there is a federal-provincial cancer care and front-line provider

adverse drug effects

over-prescribing

There are no drugs without a risk, but the benefits far outweigh the risks in most cases.

catastrophic drug coverage

a patchwork across the country

with respect to wait times

The interesting thing about Saskatchewan is that, on a three-year trending basis, it is showing positive improvement in each of the areas. It would be fair to say that Saskatchewan was a bit behind some of the other jurisdictions around 2004, but the trending data — and this will come out later this month — shows Saskatchewan making strides in all the areas.

In terms of the accord itself, the additional funds that were part of the accord for wait-times reduction were welcomed by all jurisdictions and resulted in improvements in wait times, certainly within the five areas that were identified as well as in other surgical areas.

We are working with the First Nations, Statistics Canada, and others to see what we can do in the future about identifiers.

Have we made progress?

I do not think we have the data to accurately answer the question. We can talk about proxies for data and proxies for outcome: Is it high on the government's agenda? Is it a directive? Is there alignment between the provincial government and the local health service providers? Is it a priority? Is it an act of legislation? The best way to answer, in my opinion, is that because of the accord, a lot of attention and focus has been put on trying to achieve it, or at least understanding that we need to achieve it. A lot of building blocks are being put in place. I cannot tell you exactly, but I can give you snippets of where it is happening. The Excellent Care For All Act in Ontario is the ultimate building block. The notion is that everyone, from the federal, to the provincial government, to the health service providers and to the CMA has rallied around a better health system. We are not far from giving you hard data which will show that we have moved yardsticks and that the quality is improving. For the most part, hundreds of thousands more Canadians have had at least one of the big five procedures since the accord. I cannot tell you if the outcomes were all good. However, volumes are up. Over the last six years, everybody has rallied around a focal point.

The transfer money is a huge sum. The provinces and territories are using the funds to roll out their programs and as they best see fit. To what extent are the provinces and territories accountable to not just the federal government but also Canadians in terms of how effectively they are using that money? In the accord, is there an opportunity to strengthen the accountability piece so that we can ensure that the progress is clear?

In health care, the good news is that you do not have to incent people to do anything. I do not know of any professionals more competitive than doctors or executives more competitive than executives of hospitals. Give us the data on how we are performing; make sure it is accurate, reliable, and reflective, and we will move mountains to jump over the next guy.

There have been tremendous developments in data collection. The accord played a key role in that, around wait times and other forms of data such as historic, home care, long term care and drug data that are comparable across the country. Without question, there are gaps. It is CIHI's job to fill in those gaps as resources permit.

The Health Council of Canada will give you the data as we get it from the service providers. There are many building blocks right now and not a lot of substance.

send him or her to the States

Are you including in the data the percentage of people who are getting their work done elsewhere and paying for it?

When we started to collect wait time data years back, we looked at the possibility of getting that number. It is difficult to do that in a survey sampling the population. It is, in fact, quite rare that that happens.

Do we have a leader in charge of this health accord? Do we have a business plan that is reviewed quarterly and weekly so that we are sure that the things we want worked on are being worked on? Is somebody in charge of the coordination of it in a proper fashion?

Dr. Kitts: We are without a leader.

Mr. Abbott: Governments came together and laid out a plan. That was good. Then they identified having a pharmaceutical strategy or a series of commitments to move forward. The system was working together. When the ministers and governments are joined, progress is made. When that starts to dissipate for whatever reason, then we are 14 individual organization systems, moving at our own pace.

You need a business plan to get there. I do not know how you do it any other way. You can have ideas, visions and things in place but how do you get there? You need somebody to manage it. Dr. Kitts: I think you have hit the nail on the head.

The Chair: If we had one company, we would not have needed an accord. However, we have 14 companies.

There was an objective of ensuring that 50 per cent of Canadians have 24/7 access to multidisciplinary teams by 2010. Dr. Kitts, in your submission in 2009, you talked about it being at 32 per cent.

there has been a tremendous focus for Ontario on creating family health teams, which are multidisciplinary primary health care teams. I believe that is the case in the other jurisdictions.

The primary health care teams, family health care teams, and inter-professional practice are all essentially talking about the same thing. We are seeing a lot of progress. Canadian Health Services Research Foundation is doing a lot of work in this area to help the various systems to embrace it and move forward.

The question then came up about whether 50 per cent of the population is the appropriate target

If you see, for instance, what the Ontario government promotes in terms of needing access, they give quite a comprehensive list of points of entry for service. Therefore, in terms of actual service, we are seeing that points of service have increased.

The key thing is how to get alignment from this accord in the jurisdictions, the agencies, the frontline health service providers and the docs. If you get that alignment, amazing things will happen. Right now, every one of those key stakeholders can opt out. They should not be allowed to opt out.

the national pharmaceutical strategy

in your presentation to us today, Dr. Kitts, you said it has stalled. I have read that costing was done and a few minor things have been achieved, but really nothing is coming forward.

The pharmacists' role in health care was good. Procurement and tendering are all good. However, I am not sure if it will positively impact the person on the front line who is paying for their drugs.

The national pharmaceutical strategy had identified costing around drugs and generics as an issue they wanted to tackle. Subsequently, Ontario tackled it and then other provinces followed suit. The question to ask is: Knowing that was an issue up front, why would not they, could not they, should not they have acted together sooner? That was the promise of the national pharmaceutical strategy, or NPS. I would say it was an opportunity lost, but I do not think it is lost forever.

What if the Prime Minister linked a climate deal to a health deal? That could be politically explosive. But McGill economist Chris Ragan thinks it's a good idea. One reason is that Mr. Ragan thinks the federal government will end transferring more money to the provinces anyway. Although the growth in provincial health spending has actually slowed in recent years, there are forecasts that it will grow by 3 per cent of GDP - by 2040. Mr. Ragan figures Ottawa will eventually give in, and might one day pay a third, that would be about $30-billion in 2027. The feds might as well admit it now and get a climate-change deal out of it, he argues. In other words, mix talks on health and climate together. "The more things you choose to put on the table, of course it becomes more complicated, but it also becomes a lot easier," Mr. Ragan said. "Because one of the things you bring to the table is a bunch of money."

There are a few problems. One is that Mr. Trudeau's government already wants something else from the provinces, a deal on home care. Ottawa is offering $3-billion and wants provinces to agree to meet targets for home-care services. Another is that Ottawa might not be ready to concede that it's going to have to transfer more to provinces. The recent years of slower growth in provincial health-care costs is an argument that the provinces don't really need the extra money. But that doesn't mean it will stay that way: Many economists believe those costs will rise sharply again in the near future. Then there is politics. Health transfers are to help the sick. Linking it to something else is likely to be seen as crass. But in the end, health-care transfers are dollars, and no one can really identify which dollar is spent on what. Mr. Ragan suggests they could be spent both on health and a climate deal.

Mr. Ragan is also chair of the Ecofiscal Commission, an organization of economists studying climate policy, which argues pricing carbon is the most efficient way of reducing greenhouse-gas emissions, because it will cost the economy less. The Ecofiscal Commission's models indicate that as long as the revenues are pumped back into the economy in the right ways, the costs of carbon pricing will be modest. In other words, if you are going to reduce emissions, a carbon price is the least costly way. In fact, the premiers, including Mr. Wall, agreed last spring to work on carbon-pricing options. Ms. McKenna is now brandishing a federal carbon tax as a stick to demand they seal a deal. But money is the traditional carrot. Mr. Trudeau might find it too politically dangerous to link health transfers to a climate deal. But it would allow him to offer what it usually takes to make a deal: money.

During the spring federal election campaign, Prime Minister Stephen Harper effectively snuffed out debate on health funding by vowing to maintain the 6-per-cent escalator. He did not, however, say for how long, and has played his cards close to the vest since, aside from saying, intriguingly, that the feds will expect more accountability in exchange for the money in the future.

strict conditions on the CHT as a way of ensuring specific programs are undertaken

This was done in the 2004 health accord with wait times and was moderately successful.

The provinces have largely been saying that they want a repeat of 2004, when they got a 10-year deal with 6-per-cent increase per annum, and virtually no conditions on the money.

No one honestly believes that is going to happen, not at a time when most provinces are vowing to keep increases in health spending below 3 per cent a year, and least of all in the current economic conditions.

One possibility is extending the 2004 deal to 2016 which, not coincidentally, will be time for the next federal election.

Ottawa could buy time for its larger plan to radically revamp federal transfers to the provinces (including the CHT, CST and equalization.)

A second possibility is negotiating separate deals with each of the provinces and territories rather than one national accord.

Regardless of the direction negotiations take, the current formula, which is as convoluted as it is complex, is changing.

the cash portion each province receives varies because of the way equalization payments are calculated

In 2014, that will change so that cash is distributed on a per capita basis, without accounting for tax points. Practically, this will mean significantly more cash for Alberta and Ontario, and less for B.C. and Quebec.

Another hot issue, especially for the Atlantic provinces, is a desire to adjust the CHT to reflect demographics – namely that health-care delivery is more expensive in provinces with older populations, like those in Eastern Canada.This approach, known as needs-based funding, is already used by several provinces in calculating transfers to their regions.

Regional bickering will make it a lot easier for Ottawa to negotiate a deal (or deals). It’s in Mr. Harper’s interest to drag out the talks in the hope that the common front will crumble.

It’s also in the country’s interest that the Prime Minister and the premiers be willing to go out on a limb and fundamentally revamp health financing – starting at the top – because the current formulas aren’t working.

Harper is inviting provinces, with some federal guidance, to do as they see fit in their own jurisdictions while inviting them to co-operate in establishing national benchmarks for delivering health services.

The West welcomes the certainty of the new model. It sees as a key victory the fact that Ottawa will allocate funds on a per capital basis rather than disproportionately favouring poorer provinces. The East calls the offer insufficient and an abuse of the federal-provincial process.

By offering money with no strings attached, Mr. Romanow said, richer provinces can experiment with new services – via public or private routes – that other provinces can’t afford.

The Conservatives decided on a unilateral approach several months ago, government sources said.

Officials identified three potential windows for releasing the new numbers. The first was Mr. Flaherty’s November fiscal update. But cabinet had not approved the new deal then. The second opportunity was Monday’s meeting of federal and provincial finance ministers. The Conservatives also contemplated holding off until January, when the premiers meet to discuss health care

Finance Canada documents said that the slower growth is because “governments are working to move health care funding to a balanced and sustainable path,” but a CIHI official said the institute can’t explain the one year drop, or whether it is a statistical blip.

Boudreau has said the move will save the province millions of dollars through efficiencies brought in by a private company. However, the union's document paints a poor picture of privatization of services in health-care facilities in other jurisdictions. "We believe it is important for New Brunswickers to understand the impact of such a move, especially when it comes to the cleanliness of a building which the public relies on everyday," Robinson said. Last year, the Horizon Health Network started a regular audit of the cleanliness of hospitals being serviced by unionized public sector workers. Auditor General Kim MacPherson reported that health-care workers weren't cleaning their hands as required and that the standards to do so weren't even the same within the two regional health authorities.

Robinson said Friday that policies have been established and changes made that are addressing cleanliness concerns. "And they have improved on their targets of cleaning in the hospital sector," she said. The union claims its research into the three companies they believe are being considered to take over those services - Sodexo, Aramark and Compass - shows a poor track record. The union said it's also concerned about the quality of food declining. The union wants to keep the management of hospital environmental services in-house. It also wants fair wages and benefits for cleaning and food services staff to ensure against high turnover and gaps in training. The union also stated lay-offs and staff reductions would be a poor way to balance the budget.

"The cost associated with treating hospital-acquired infections, managing public relations fiascoes and defending lawsuits would defeat any possible savings while destroying the public trust." The Province of New Brunswick expects to have completed talks with a private contractor for the management of health-care cleaning and food services before the end of the year.

Bruce McFarlane, Health Minister Victor Boudreau's director of communications, said Friday that the province is "still in current discussions with the preferred proponent and we hope to have completed the process sometime this fall." McFarlane sent The Daily Gleaner an email statement Friday afternoon after the New Brunswick Council of Hospital Unions CUPE local 1252 released a 20-page document critical of the government's plan to privatize housekeeping, food services and porter services at hospitals. "We want to clarify that we are only outsourcing the management of the services," said McFarlane, who added that the ministry had not yet received the document.

"CUPE staff will remain in their union and will continue to be employees of the Province of New Brunswick." Norma Robinson, president of CUPE Local 1252, said she is "very concerned that the Liberal government is negotiating with a private firm to take over the management of food and cleaning services in the province's hospitals." Robinson said she's worried the move could lead to further privatization. In an interview with Brunswick News in April, Boudreau said the government wants to give the private sector a greater role in the province's health-care system.

Boudreau has said the move will save the province millions of dollars through efficiencies brought in by a private company. However, the union's document paints a poor picture of privatization of services in health-care facilities in other jurisdictions. "We believe it is important for New Brunswickers to understand the impact of such a move, especially when it comes to the cleanliness of a building which the public relies on everyday," Robinson said. Last year, the Horizon Health Network started a regular audit of the cleanliness of hospitals being serviced by unionized public sector workers. Auditor General Kim MacPherson reported that health-care workers weren't cleaning their hands as required and that the standards to do so weren't even the same within the two regional health authorities.

Robinson said Friday that policies have been established and changes made that are addressing cleanliness concerns. "And they have improved on their targets of cleaning in the hospital sector," she said. The union claims its research into the three companies they believe are being considered to take over those services - Sodexo, Aramark and Compass - shows a poor track record. The union said it's also concerned about the quality of food declining. The union wants to keep the management of hospital environmental services in-house. Calls made to Sodexo, Aramark and Compass were not returned by press time.

Since federal transfers have been growing at more than twice the rate of health spending since 2010, some federal cash destined for health care is presumably being diverted elsewhere or replacing provincial cash. The Canadian Institute for Health Information says spending on health care in Canada grew by 2.1 per cent in 2014. But federal health transfers grew by 6 per cent. Starting in 2017, federal health transfers will grow at the same rate as the economy, with the floor for increases set at 3 per cent. The advisory panel on health innovation led by former University of Toronto president David Naylor rejected provincial calls to maintain the annual 6-per-cent escalator adopted in 2007. It also rejected a "return to earlier approaches that depended on unanimously agreed priorities and formulaic allocations of funds" between Ottawa and the provinces.

Yet, this is precisely what NDP Leader Thomas Mulcair and Liberal Leader Justin Trudeau are promising should one or the other become prime minister after Oct. 19. "If my party forms government, it will call a federalprovincial meeting to reach a long-term agreement on health care funding," Mr. Trudeau wrote last week in a letter to Quebec Premier Philippe Couillard. Mr. Mulcair promises an NDP government would "use any budget surplus" to restore the 6-per-cent escalator. "Money alone cannot solve the problems facing our health-care system. But without money, we won't solve a thing," he told the Canadian Medical Association in 2014.

The approach promised by Mr. Mulcair and Mr. Trudeau has a clear track record of failure. Despite its good intentions, the 2004 health accord negotiated by former prime minister Paul Martin reduced pressure on the provinces to overhaul the outdated architecture of their health systems. As the Naylor panel noted, most of the $41-billion transferred under the accord was used to increase doctors' fees rather than invest in innovation or more cost-effective ways to deliver health care. This is exactly what should have been expected. As William Robson and Alexandre Laurin of the C.D. Howe Institute concluded in a recent report on this history of fiscal federalism: "The more federal transfers appear to respond to provincial fiscal pressures, the weaker are the incentives for provincial governments to raise [provincial taxes] or manage expenditures efficiently."

Now, the premiers are warning that their provinces are about to be submerged by a grey tsunami. Though the proportion of healthcare spending devoted to seniors' care has not budged, remaining steady at 45 per cent since 2002, the CMA projects it will hit 62 per cent by 2036. But that's only if Canada keeps on doing what it has always done - pumping more money into a system designed in the 1960s and which has barely changed since.

It's hard to see how yet more federal cash would incentivize the provinces to innovate their way to health-care sustainability. The Naylor panel's recommendation for the creation of a $1-billion federal health-care innovation fund hits the mark. The most meaningful contribution Ottawa could make to saving Canadian health care right now is as a catalyst for change, not as an enabler of the status quo.

The PBO estimates that provincial governments need to find savings or revenue increases of 1.4 per cent of GDP to put themselves back on a sustainable footing. Coincidentally, the amount the provinces are short is about the same as the feds have in fiscal room. This was the essence of the fiscal imbalance argument back in 2006, when Prime Minister Stephen Harper argued that a transfer to the provinces was required. He lost his enthusiasm for the project in 2007, when he handed a $700-million cheque to then-Quebec premier Jean Charest, who promptly gave it away as a pre-election tax cut/bribe. Not only have the Conservatives not mentioned the words "fiscal imbalance" since then, they are entirely to blame for its return to the political landscape.

In 2017, the $32-billion Canada Health Transfer will only grow at the rate of general growth plus inflation - about three to 3.5 per cent. Provinces have been used to six per cent increases since Paul Martin signed his "fix for a generation" with the provinces in 2004. This shift, announced by the Harper government, is a significant contributor to the fiscal gap the provinces are set to experience in the years ahead. The NDP has promised to maintain the six per cent escalator, which according to the PBO numbers, it has the fiscal room to do, without sending debt levels into the stratosphere. But it cannot also balance the federal budget. The federal election campaign is obviously not the crucible in which to debate serious long-term policy issues. But the next government in Ottawa is going to be forced to address the cost implications of a world where the average male lives an additional eight years by 2065. Provinces are reducing costs and have the option of increasing their own taxes. But the data are persuasive - the feds have too much money and the provinces not enough.

The average number of people on wait lists as of May, 2015, is 611. Some regions have shorter wait lists, such as Toronto Central, which currently has zero. Others are in the four digits, such as the Central East CCAC, which stretches east from Victoria Park Avenue in Scarborough and north to Algonquin Park, and has 1,516 children waiting for speech therapy. Waiting that long can have a large impact on a child's ability to do well in school, according to Anila Punnoose, a director of Speech-Language and Audiology Canada. During the months or years children are waiting to get speech services, they can quickly fall behind in school, she said. A 1996 study found children with language deficits are more likely to experience social difficulties including interacting with their peers, which impacts their behaviour. Other studies have shown that children who don't get speech therapy early are at a greater risk of problems in their academic performance and mental health.

A lot of speech problems carry over to literacy, because a knowledge of speech sounds is crucial when learning to read, Punnoose said. "It's all about what you hear in those sounds. ... Do you know the beginning sounds in that word? A child who doesn't have good phonological awareness doesn't understand any of that," she said. When looking at school performance, Punnoose said early struggles carry through to later years. A child with speech problems who has difficulties learning in the early years won't be able to build on those lessons in later years as effectively as their peers, she said. Early intervention can mitigate and prevent those problems, she said. "If children are having severe difficulties with speech in kindergarten, it's a predictor that there's going to be academic difficulties, and especially reading and writing difficulties, by Grade 3," she said.

Jocelyn Fedyczko, Eddie's speech pathologist, has worked in a range that includes children from preschool all the way to teenagers. She said early intervention is crucial with young children such as Eddie. "The earlier you can help a child out, the more progress you see," she said. When a child gets to the top of the wait list, they get assessed again, and receive a block of treatment, usually around 10 or 12 sessions, says Peggy Allen, president of the Ontario Association of Speech-Language Pathologists and Audiologists (OSLA). That's often not enough to treat even minor to moderate issues such as Eddie's. Fedyczko said she can get through two to three sounds in that time, depending on the child. Many children have problems with more sounds than that, she said. But when a child finishes their block of treatment and needs more, because they haven't worked through all the sounds, for example, they go back to the bottom of the wait list, Allen said.

A spokesperson for the Toronto Central CCAC said they do not have an upper limit to the number of sessions per block assigned by a speech-language pathologist. The pathologist determines three goals for a child to achieve and assigns the number of sessions according to that. If after these sessions more goals are identified, the child is re-referred to the program, the spokesperson said. Parents who are worried about the impact waiting can have on their child can go to private clinics, if they have coverage or can afford the sessions out of pocket. Trish Bentley, Eddie's mother, decided to go for private therapy with Eddie's older brother Oliver. He was put on a six-month wait list for speech problems slightly more acute than Eddie's.

B.C.: Children's speech therapy is organized through the Ministry of Health, Ministry of Children and Family Development (MCFD) and through the Ministry of Education by way of school districts. Children are divided between preschool and school age. Preschool children go through regional health authorities. School-age children go through the school boards, but the pathologists there will often offer consultative services, rather than oneon-one speech therapy. B.C. also has a "no-wait-list" policy for children with autism, which translates to parents getting around $22,000 a year for therapy until the age of six, and $6,000 a year after that. Alberta: Health Services is in charge of speech therapy in that province. It offers both a preschool and a school program. The school program, unlike Ontario's, is done completely through the schools, with no CCAC-type system to refer out to. Saskatchewan: The school districts are responsible for speech therapy. Each school district divides up services slightly differently, though they all differentiate between children under three years, from three to five years, and from six to 18 years.

Rather than wait those six months, Bentley took him to Canoe. "As time went on, we said enough of this, he's going to be past the point of catching the problem," she said. For families who don't have coverage and who can't afford private services, though, the only option is to wait. Finding the cause of the long waits is hard, but one thing is certain: It's not due to a lack of speech pathologists, according to Shanda Hunter-Trottier, the owner of S.L. Hunter Speechworks, another private clinic in Toronto. She used to have problems finding qualified speech pathologists, but now she's facing the opposite problem. "I've been practising for 26 years. ... In the last five years, [I] have more resumes than I can keep track of," she said. Rather, she says, it's a large web of problems that slows down the system. First among these is a lack of public funding. "There's a lot of speech pathologists that don't have jobs, but these places aren't hiring. The cutbacks have been atrocious," she said.

Dividing services by language issues and other issues doesn't make sense when treating a child, she said. "You shouldn't be splitting up the kid," she said. Punnoose said she wants to see speech therapy come together under one roof. It would mean co-operation from all three ministries, as well as a major reorganization of the funding, but she believes it would be a better model for children. "Students are in schools the better waking part of their lives. Why wouldn't we have the services right there in an authentic environment where it's totally accessible," she said. There are changes coming.

Last December, the Ontario government announced more funding for preschool speech and language programs, as well as efforts to integrate speech services better, through its Special Needs Strategy. Punnoose says it's a good step. "The government recognizes that the system was broken," she said. For now, the choice for parents in many CCACs will be between long wait lists and paying for private service. Hunter-Trottier said many parents, even those with coverage, don't know about the latter option. "We sometimes get parents here in tears, saying, 'Oh my goodness, the services here, I wish I had known about that a year ago,' " she said. Bentley said she won't be looking at public services for Eddie, as she's happy with the service she gets at Canoe. "I'd be open to it, but I'm not going to actively seek that out," she said.

For Eddie, what matters is the progress he makes. Within 10 minutes of his trouble saying "lipstick," he was opening up a treasure chest, with a key. With little prompting, he used the same technique as before, separating the sounds of the word. "Kuh-ey," he said. Could he try it all together? He pauses for a second. "Key," he says, almost flawlessly, beaming at his success. SPEECH THERAPY IN EACH PROVINCE

Speech therapy, like all healthcare matters, is regulated differently in each province and territory in Canada. Information on how each system works is difficult to come by. But generally, most provinces have very similar systems - and challenges - according to Joanne Charlebois, CEO of Speech-Language and Audiology Canada. Charlebois said Ontario's wait times are probably worse than those in other provinces, but she's spoken to people across Canada who tell her similar stories. Here's a breakdown of how it works across the country. Ontario: Speech therapy for children falls under the responsibility of three ministries: the Ministry of Long-Term Care, the Ministry of Education and the Ministry of Community and Social Services. Children in Ontario are divided by age and by the nature of their speech problem. Children under school age qualify for Ontario's preschool speech and language program. Once in school, those children with language problems - major problems speaking or understanding words or sentences - go to a school speech pathologist, while any other problems, such as pronunciation, stuttering, voice and articulation are referred to the Community Care Access Centres, which employ contract speech pathologists.

But the problems go deeper than a lack of funding, according to Allen. She said many of the issues in Ontario stem back to a series of agreements in the 1980s between the provincial Ministry of Long-Term Care, the Ministry of Education and the Ministry of Community and Social Services. These agreements divided up who is in charge of different treatments, between the school boards and the CCACs. At the time of their creation, these agreements made sense, but times and needs have changed, she said. "It's difficult when ministries make agreements that are frozen in time. It's very difficult to provide the kind of services that we all expect and want Ontarians to receive," she said. Dividing up the services is necessary when trying to manage resources, but the fragmentation is hurting children more than it's helping, Punnoose said.

Manitoba: School districts are also in charge here. The inschool speech-language pathologists offer services from classroom-based programming to individual therapy. Quebec: The system here is more like Ontario's. Speechtherapy services are offered through the local community service centres (CLSC), similar to Ontario's CCACs. The CLSCs are not obliged to provide speech therapy in English, though some, especially in areas with a large anglophone population, usually do. Nova Scotia: The province has 28 speech and hearing centres, with 35 pathologists in total. They assess and provide treatment for children and adults. School boards in the province also have speech-language pathologists who also have a teacher's certificate.

Prince Edward Island: The province provides free speech services for children until they enter school. Northwest Territories: Speech therapists are only able to visit some remote communities once or twice a year. Instead, the province offers a service called Telespeech, where pathologists can help people without having to be physically present. Nunavut: The territory had no speech pathologists in 2013, according to Statistics Canada.

Equally concerning, wait times are defined here as the interval between seeing a specialist and receiving treatment. But that doesn't count the growing delay most patients face before they meet a specialist. Ottawa isn't impressed. Second, there are indications the federal government wants to strike out on its own. Prime Minister Justin Trudeau's health minister, Jane Philpott, has said she's "not convinced" that putting more cash into the accord is the right way to go.

She believes federal funds should be used instead to boost home care, mental-health services and palliative care. And that has infuriated the premiers. Constitutionally speaking, they are responsible for health-care delivery. Yet here we have a federal minister suggesting she wants to steer the ship.

The provinces have already signalled this means war. Quebec Premier Philippe Couillard and B.C. Health Minister Terry Lake, will lead a spirited defence against further intrusions into provincial jurisdiction. And they have a case to make. When universal health care was first introduced in Parliament, the provinces feared that any such commitment would ruin them. The federal government met that concern by pledging to fund half the costs.

But that isn't what happened. Today, Ottawa pays only a quarter of the bill, and that bill is rapidly rising. In 1975, health expenditures, countrywide, were less than $50 billion. Today, they've reached $230 billion, and these are constant dollars, adjusted for inflation. The result is that, as federal cost-sharing declines, the provinces are struggling to make up the shortfall.

In 2013, more than 12,000 jobs in health care and social assistance were eliminated in B.C. That is one symptom of the emerging crisis. There are many more: Too few GPs, unacceptable wait times to see a specialist, crowded hospital emergency departments. If Philpott chooses to redirect the remaining federal cash to new priorities that will create additional strains on the system, fur will fly.

The minister's desire to steer funding into neglected areas of care is admirable. But first, she needs to get the ship off the rocks. Adding more ballast to a foundering vessel is no solution. Certainly Philpott is in a stronger position than Paul Martin, whose minority government hung by a thread when the first accord was negotiated. But the need for federal assistance is growing clearer, and more urgent. Our health-care program was a uniquely Canadian creation. The government of Canada has an obligation to step up and save it.

Hurley is travelling throughout the province, to explain how over the last decade Ontario's acute hospital funding has been on the slide compared to other provinces. In 2005-06, Ontario was "in the ballpark," with per capita funding of $1,112 compared to $1,159 for the rest of Canada, Hurley said, citing figures from the Canadian Institute for Health Information. Ten years later, Ontario's funding was $1,396 compared to $1,750 for the rest of Canada. He said the numbers extrapolated for Windsor are conservative, taking into account only the City of Windsor's 211,000 population, even though Windsor Regional's patients come from all over the Windsor-Essex region (population 389,000) and beyond.

Hurley said while Ontario did increase its funding for hospitals during the last decade, it did not come close to accounting for inflation, population growth and the aging population. This year, hospitals received a one per cent increase, but their actual costs rose 4.5 per cent, he said. "So their budgets have been cut again." Windsor Regional declined to comment on Hurley's assertions. In a statement, Health Minister Eric Hoskins said his government is doing what citizens want - continuing to invest in a health-care system that "puts patients first," asserting that 94 per cent of Ontarians now have a family doctor, and that wait times for some procedures are among the shortest in the country.

This year, it's increasing health funding by $1 billion, a 2.1 per cent increase, and it's increasing funding to hospitals by $345 million this year. "In Windsor, (since 2003) we've increased funding for local hospitals by more than $126 million - an increase of almost 50 per cent," said Hoskins. He also said Ontario is investing additional millions into home care, community health centres and home-based hospice and palliative care, because people prefer to receive their health care at home instead of a hospital. Hurley said the province argues that while it has been actively downsizing the acute care system, at the same time it's increasing investments in home care and longterm care, to "pick up the slack." But he said Ontario is actually spending less on long-term care and home care than the rest of the provinces. He said Ontario's high readmission rates are a sign the system is suffering. "So we have fewer beds, there's tremendous pressure to get people out of those beds and send them home, and often when they're sent home they haven't been made well actually and they return to hospital for a more lengthy and expensive readmission." Hurley said his council is calling on the government to fund hospitals "at least" at a level that reflects their rising costs, to stop reducing the number of beds and staffing, and to increase access to the people who need it.

The people being hardest hit by this are elderly, he said, who often have lived a long time without serious health problems, until they're hit with a health crisis that lands them at a hospital doorstep. "First they queue up in an ER for hours, and if they're going to be admitted it's likely a stretcher in a hallway," he said. And once admitted, there's likely pressure to get them discharged before they're fully well, he added. "For the elderly in particular they feel the brunt because there's rationing going on, the beds are so scarce." bcross@postmedia.com

Michael Hurley, president of the Ontario Council of Hospital Unions, discussed health-care funding in the province Thursday during a news conference at the Royal Canadian Legion Branch 255.

He wants the OMA to return to the negotiating table and discuss lowering some of the 7,300 fees on the physicians’ pay schedule. He said the province has made no less than 80 offers since talks broke down two years ago — close to one a week — to no avail. If they don’t, he said he’s prepared to make another unilateral cut (even though the cuts imposed in 2015 have already sparked the second Charter challenge from the OMA this decade). “If necessary we will be forced to make those changes,” he said. Hoskins doesn’t want to cut back on all doctors’ pay, but create a more equal system that doesn’t go over budget every single years, as has historically been the case.

“The top biller, an ophthalmologist, billed more than $6.6 million last year. The top diagnostic radiologist billed more than $5.1 million and the top anesthesiologist billed more than $3.8 million,” a government fact-sheet states. That’s far above the average doctor’s gross payment of $368,000 a year. And though the OMA argues that often doesn’t account for overhead and staffing costs, the province also subsidizes pay in many indirect and direct ways, including allowing doctors to incorporate, which reduces tax and liability burdens. Ontario, unlike many provinces, covers 80 per cent of doctors’ liability insurance. Hoskins said the ministry even sometimes covers hardware costs like computers.

Hoskins says his goal is to make things more equal and better distribute the money going to certain specialists whose work has gotten easier. MRIs and CT scans used to take an hour, now they take 20 minutes. Same with cataract surgery — that’s why diagnostic radiologists and eye surgeons are so disproportionally represented on the list.