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Figures compiled in CIHI’s database over 40 years show the share spent on physicians hit an all-time high in 1988, then slowly declined until 2007, when it turned around, growing at about 2.2% annually. It now accounts for 15.5%, comparable to levels seen in the late 1980s. Hospital spending has decreased from 45% of total health spending in the mid-1970s to just under 30% today, whereas drug spending has been increasing since the mid-1980s to account for just under 16% of spending.

“The guild has done a great job of protecting our income,” Dr. David Naylor said, referring to medical associations’ success in negotiations with governments. “But wouldn’t you expect [the share of spending on physicians] to drop a little?” Naylor, past president of the University of Toronto and chair of the Advisory Panel on Healthcare Innovation, spoke at a panel discussion on the CIHI findings, held Oct. 29 in Ottawa.

He said the “constancy of focus on doctors, drugs and hospitals … speaks to the stasis in the system. If anything, it’s in a state of arrested development.” While overall health spending has gone up in dollar terms, amounting to $6105 per capita in 2015, it has declined as a proportion of gross domestic product (GDP). After the 2008–2009 recession, health spending fell from 11.6% of to an estimated 10.9% of GDP today. When inflation and population growth are taken into account, health spending also shows a decline.

The first half of this movie seems similar to what happened in the 1990s,” said Don Drummond, an economist at Queen’s University. He said that in the 1990s, government austerity led to a decline in health spending, but a return to a good economy resulted in health spending growing “much faster than economic growth.”

In regard to the similar spending decline after 2011, Drummond asked “did we create efficiencies or just cut off the money and create pressure?” Drummond and Naylor clearly think that efficiencies are lacking. The solution, said Naylor, is integrating services, including home care and virtual care. “There’s not a single province that has taken steps in that direction.”

CMA President Cindy Forbes agreed. “We need integrated, appropriate and high-quality care.” She gave the example of a patient in an acute care hospital discharged to community care and later moving to palliative care. “The patient goes through three different systems. They all have their own budgets and caregivers. These silos have to be broken down so it’s one system.”

She stressed the need for a national seniors’ strategy to address a population that is aging and living longer, often with complex, multiple diseases. Integrated services could address the patients needing an alternative level of care who currently occupy 20% of beds in acute care hospitals, she said. “They are not ‘bed blockers,’” she said. “They are waiting for long-term or home care.”

Naylor also thinks changing the way physicians are paid is part of the solution. “The fee schedule is full of perverse incentives. It doesn’t create ‘integrative quarterbacks.’ There should be rewards for good prescribing and shorter hospital stays.”

Wide variations in the price tag for health care among provinces and territories also stood out in the data. Costs in Canada’s provinces range from $5665 per person per year in Quebec to $7036 in Newfoundland and Labrador. (In the territories, costs are much higher.) Seven provinces devote more than 40% of their budget to health, of which two devote more than 45%.

Demographics and geography account for some of the variation, according to Brent Diverty, CIHI’s vice-president of programs, especially costs to transport critical cases from remote areas. However, panellists expressed concern about inequalities in quality of care and access.

“People who are covered for a drug in one province are not covered in another,” pointed out Forbes. “Especially cancer drugs, which are expensive.”

Naylor added, “There’s a huge challenge for the [federal/provincial/territorial ministers] to understand this variation. We need to unbundle why these disparities occur. How do we get to a common higher ground as Canadians?”

The PBO report estimates that the new health formula – which accounts for economic growth and inflation – will cause transfers to grow at 3.9 per cent annually from 2017-18 to 2024-25. In contrast, the watchdog projects provincial and territorial health spending will grow at 5.1 per cent over the same period.

a spokesman for Mr. Flaherty, disputed the PBO’s claim that provincial and territorial health spending will grow faster than the growth in federal transfers.

The budget officer states provincial-territorial net debt relative to GDP “is projected to increase substantially over the long term.” While the ratio stood at 20 per cent of GDP in 2010-11, the PBO expects that will now climb to over 125 per cent in 2050-51 and to over 480 per cent by 2085-86.

Closing this gap, according to the PBO, would require provinces and territories to take a combination of actions such as higher taxes or lower spending that would amount to $49-billion in 2011-12 - an amount that will grow over time in line with nominal GDP - in order for Canada’s finances to be sustainable.

The PBO report also analyzes the impact of Ottawa’s new transfer arrangement in terms of what it will mean for Ottawa’s contribution toward overall health spending. In 2010-11, the federal share of health spending was 20.4 per cent. The PBO projects the federal share will average 18.6 per cent from 2011-12 to 2035-36, then 13.8 per cent over the following 25 years and 11.9 per cent over the next 25 years.

Historically, federal health transfers averaged about 37 per cent of health spending from 1968-69 to 1995-96. That dropped sharply during the deep budget cuts of the Liberal government in the mid-1990s, hitting 16.3 per cent in 1995-96 and reaching an all-time low of 9.8 per cent in 1998-99.

the federal government ramped up its share of the nation’s total health care spending while private businesses reduced their share

Out-of-pocket spending by consumers rose in 2010 compared with 2009, as many workers paid higher premiums, deductibles and co-payments or lost their insurance coverage. But out-of-pocket spending still grew more slowly than the annual average between 2000 and 2008

In a prebudget letter to Mr. Oliver, the NDP urges the Finance Minister not to delay the budget and to instead scrap the recent tax cut that allows parents with children under 18 to split their income for tax purposes. The NDP says Ottawa should cut spending on advertising, the Senate and corporate subsidies. The letter calls for more spending on health care, child care and pensions and the creation of a credit for small businesses that make new hires.

The government says it is taking a few extra weeks to release a budget in order to get a better understanding of the current changes in the economy. The price of oil has dropped by more than half since June, a development that will mean billions less in tax revenue for Ottawa than had been previously expected.

Federal Employment Minister Jason Kenney is also pledging that Ottawa can hit its target without dipping into a $3-billion contingency fund, a comment that is at odds with recent statements from Finance Minister Joe Oliver, as well as analysis from several private-sector economists. The messaging from the government is shifting quickly in the face of growing signs that current, dramatically lower oil prices will be around for some time. The Bank of Canada will release its quarterly Monetary Policy Report on Wednesday, which is expected to expand on recent warnings that prices could go lower, or remain low, "for a significant period." In a series of interviews broadcast over the weekend, Mr. Kenney said balancing the books has important symbolic value and that "it may take some additional spending restraint" in order for the government to deliver on its promise.

The 2014 federal budget reintroduced a two-year freeze on departmental operating budgets that runs through the 2015-16 fiscal year, which is when the Conservatives are promising a return to balance. The 2014 budget said this freeze would save the government $550-million in 2014-15 and $1.1-billion in 2015-16. Mr. Kenney did not explain how extending the freeze might help the government achieve its balanced-budget promise. "They spent the surplus before they had it and now they're scrambling to figure out how to make one plus one equal three," said NDP finance critic Nathan Cullen.

Economists say it makes no practical difference whether Ottawa posts a small surplus or a small deficit, given that federal finances are sound overall in terms of debt levels and longterm spending trends. But Mr. Kenney said balancing the books remains an important goal. "It's a commitment we made to Canadians in the last election," he told CTV. "It's important that, when possible, we no longer go back and borrow money to pay for government spending."

Provincial health-care costs decreased from 39.3 per cent of program spending in 2008 to 37.7 per cent in 2010. In Ontario, the decrease was even more startling, from 45.5 to 40 per cent. Of course, governments increased non-health-care spending during the recession as welfare, employment insurance and other costs rose. But CIHI forecasts provincial health-care spending will fall this year as a share of GDP from 7.8 per cent to 7.5 per cent.

we don’t have to spend a lot more money to the fix the system

90 per cent of patients referred to Ontario spinal surgeons don’t need to have surgery. They may need physical therapies, medication, counselling or acupuncture. But they don’t need surgery and very few of them should even be seeing surgeons.

In Hamilton, 20 psychiatrists are working part-time with more than 100 family doctors, 80 mental health counsellors and dozens of other professionals. Urgent questions for the psychiatrists are answered immediately by cellphone. The psychiatrists also drop into the family practices every week or two where they see patients directly, discuss other cases with staff, and generally raise the already high standards of mental health delivery.

All medical specialists and their teams should be working more closely with primary health-care practices. No Canadian should wait longer than a week for elective specialist input into her case.

we should be spending more public money if it remedies private market failures

public insurance for

drugs, long-term care and home care

Health care increased its share of the public pie from 1997 to 2008 largely because government cut the size of the pie by axing other programs. The feds eliminated the National Housing Program in 1993 and Ontario social assistance recipients have seen their inflation-adjusted incomes fall by 40 per cent since 1995. These policy debacles have made a lot of people sick and applied pressure to hospitals and other health-care organizations.

we need to resuscitate our shrinking public sector

from 2000 to 2010 Canadian governments cut their incomes by 5.8 per cent of GDP, the equivalent of $94 billion

That did little to quell critics who said the NDP has given up even the pretense of trying to rein in spending. Progressive Conservative Leader Brian Pallister said the government could have balanced the books this year if it had "just held the line on spending." "They are making promises with money they are taking from our children and grandchildren here," the Opposition leader said. "It took 109 years for us as a province to get about $18-billion into debt. It's taken six for the premier and the NDP to double that debt. Somebody's got to pay that back." Todd MacKay, prairie director of the Canadian Taxpayers Federation, said the "overwhelmingly irresponsible budget" shows the New Democrats have a spending problem. "They promised to have this budget balanced. Instead, the deficit is going up," he said.

"Future generations are going to pay for this budget. It's completely irresponsible." The infrastructure spending wasn't enough to win over others. Winnipeg Mayor Brian Bowman said it will do little to help the province's largest city. "We need new money. The model is ... fundamentally broken in terms of how we fund our cities," he said. "We have an obligation to fix it." The NDP tries to leave behind internal turmoil that led to a leadership race in March which Mr. Selinger won by 33 votes. The Premier's top five cabinet ministers resigned last year after calling for him to step down in light of plummeting opinion polls following the provincial sales-tax increase. "The government has obviously been preoccupied with something else over the past eight months and has not been focused on governing," said Chuck Davidson, president of the Manitoba Chamber of Commerce. "This was a great opportunity to at least get us on a path ... to getting our economic house in order. They missed the mark."

Growth in physician spending is the highest of the 3 cost drivers, at 4.5%, but is slowing as well because provincial health ministries have negotiated minimal pay increases over recent contract periods.

“With generic pricing control policies for the pharmaceutical industry, the expiration of patents on prevalent medications and fewer new drugs entering the market, we are seeing what amounts to flattened growth.”

With 2.1% projected growth, hospital spending will reach $63.5 billion in 2014. About 60% of these hospital costs relate to worker remuneration, particularly for nurses. Inflation and compensation have been major factors in the growth of hospital costs, as have the costs of new and emerging technology and the expansion of hospital services.

Contrary to fears that senior citizens will suddenly overwhelm Canada’s health care budgets, population aging is estimated to increase health care costs by only 0.9% per year; however, this trend is expected to change incrementally over the next 20 years.

“While concerns regarding demographics are understandable—Canadians over the age of 65 account for less than 15% of the population but consume more than 45% of provinces’ and territories’ health care dollars—the share of public-sector health dollars spent on Canadian seniors has not changed significantly over the past decade,” says Diverty.

Quebec and British Columbia are expected to spend the least, at $5,616 and $5,865.

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

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

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

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

The literature in this area identifies many potential sources of waste and provides a broad range of estimates of the magnitude of excess spending.

The Table shows estimates of the total cost of waste in each of these 6 categories both for Medicare and Medicaid and for all payers.

Failures of Care Delivery: the waste that comes with poor execution or lack of widespread adoption of known best care processes

this category represented between $102 billion and $154 billion in wasteful spending

Failures of Care Coordination: the waste that comes when patients fall through the slats in fragmented care.

represented between $25 billion and $45 billion in wasteful spending

Overtreatment: the waste that comes from subjecting patients to care that, according to sound science and the patients' own preferences, cannot possibly help them

represented between $158 billion and $226 billion in wasteful spending

Administrative Complexity

represented between $107 billion and $389 billion in wasteful spending

Pricing Failures: the waste that comes as prices migrate far from those expected in well-functioning markets, that is, the actual costs of production plus a fair profit.

US prices for diagnostic procedures such as MRI and CT scans are several times more than identical procedures in other countries.

represented between $84 billion and $178 billion in wasteful spending

Fraud and Abuse

represented between $82 billion and $272 billion in wasteful spending

Addressing the wedge designated “overtreatment,” for example, would require identifying specific clinical procedures, tests, medications, and other services that do not benefit patients and using a range of levers in policy, payment, training, and management to reduce their use in appropriate cases. The National Priorities Partnership program at the National Quality Forum has produced precisely such a list in cooperation with and with the endorsement of relevant medical specialty societies.

the 1990s saw a perception of widespread physician shortages though only a handful of provinces had declines in the per capita number of physicians (Ontario, BC, Alberta, PEI and Nova Scotia), and by 2010 these declines have turned into marked increases in most of these provinces

The recent increase in physician numbers more than makes up for the small decline of the 1990s

a positive correlation between physician numbers and health spending is not automatic. In other words, a high per capita number of physicians is not always associated with high per capita health spending. Quebec, for example spends the lowest amount per capita on public health care spending and yet has one of the highest number of physicians per capita. Manitoba, on the other hand has the second highest per capita public health spending in the country but is one of the lowest in terms of physicians per capita.

In 2012, age-related needs were identified as the single most common problem requiring help from caregivers (28%) (Chart 1). This was followed by cancer (11%), cardio-vascular disease (9%), mental illness (7%), and Alzheimer’s disease and dementia (6%).

The majority of caregivers reported providing transportation to their primary care receiver, making it the most frequent type of care provided in the last 12 months (73%)

In addition, about half of caregivers (51%) reported that they performed tasks inside the care recipients’ home in the last 12 months, such as preparing meals, cleaning, and laundry. Another 45% reported providing assistance with house maintenance or outdoor work.

The most common types of care were not always the ones most likely to be performed on a regular basis (i.e., at least once a week). For instance, despite the fact that personal care and providing medical assistance were the least common forms of care, when they were performed, these tasks were most likely to be done more regularly.

Emotional support often accompanied other help to the care receiver. Nearly nine in ten caregivers (88%) reported spending time with the person, talking with and listening to them, cheering them up or providing some other form of emotional support. Virtually all caregivers (96%) ensured that the ill or disabled family member or friend was okay, either by visiting or calling.

Overall, caregivers spent a median of 3 hours a week caring for an ill or disabled family member or friend. This climbed to a median of 10 hours per week for caregivers assisting a child and 14 hours for those providing care to an ill spouse (Chart 3).

Most often, caregivers spent under 10 hours a week on caregiving duties. In particular, one-quarter of caregivers (26%) reported spending one hour or less per week caring for a family member or friend. Another 32% reported spending an average of 2 to 4 hours per week and 16% spent 5 to 9 hours per week on caregiving activities.  

For some, caregiving was a large part of their life - equivalent to a full time job. Approximately one in ten caregivers were spending 30 or more hours a week providing some form of assistance to their ill family member or friend.  These caregivers were most likely caring for an ill spouse (31%) or child (29%).5

The actual time spent performing tasks is often combined with time needed to travel to provide care. Approximately three-quarters (73%) of caregivers indicated that they did not live in the same household or building as their care receiver, meaning they often had to travel to reach the care recipients’ home. Just over half (52%), however, reported having to travel less than 30 minutes by car.  Roughly 12% of caregivers provided help to a family member who lived at least one hour away by car.

Certain health conditions required more hours of care. This was the case for developmental disabilities or disorders, where 51% of these caregivers were spending at least 10 hours a week providing help

Caring for an ill or disabled family member or friend can span months or years. For the vast majority of caregivers (89%), their caregiving activities had been going on at least one year or longer, with half reporting they had been caring for a loved one for four years or more.

Four provinces had rates above the national average of 28%, including Ontario (29%), Nova Scotia (31%), Manitoba (33%) and Saskatchewan (34%) (Textbox Chart 1). The higher levels of caregiving in Ontario, Nova Scotia and Manitoba were largely related to caring for a loved one suffering from a chronic health condition or disability, whereas in Saskatchewan, the higher level of caregiving was attributed to aging needs. 

Historically, caregivers have been disproportionally women (Cranswick and Dosman 2008). This was also true in 2012, when an estimated 54% of caregivers were women.

Although the median number of caregiving hours was similar between men and women (3 and 4 hours per week, respectively), women were more likely than their male counterparts to spend 20 or more hours per week on caregiving tasks (17% versus 11%). Meanwhile, men were more likely than women to spend less than one hour per week providing care (29% versus 23%) (Chart 5).

For instance, they were twice as likely as their male counterparts to provide personal care to the primary care receiver, including bathing and dressing (29% versus 13%).

Caregivers have multiple responsibilities beyond caring for their chronically ill, disabled or aging family member or friend. In 2012, 28% of caregivers could be considered “sandwiched” between caregiving and childrearing, having at least one child under 18 years living at home

The aging of the population, higher life expectancies and the shift in emphasis from institutionalized care to home care may suggest that more chronically ill, disabled and frail people are relying on help from family and friends than in the past. Using the GSS, it is possible to examine the changes in the number of caregivers aged 45 years and older, recognizing that methodological differences between survey cycles warrant caution when interpreting any results.

Bearing in mind these caveats, results from the GSS show that between 2007 and 2012, the number of caregivers aged 45 and over increased by 760,000 to 4.5 million caregivers, representing a 20% increase in the number of caregivers over the five years.

Having less time with children was an often cited outcome of providing care to a chronically ill, disabled, or aging family member or friend. About half (49%) of caregivers with children under 18 indicated that their caregiving responsibilities caused them to reduce the amount of time spent with their children.6

Overall, the vast majority of caregivers (95%) indicated that they were effectively coping with their caregiving responsibilities, with only 5% reporting that they were not coping well.7 However, the feeling of being unable to cope grew with a greater number of hours of care. By the time caregivers were spending 20 or more hours per week on caregiving tasks, one in ten (10%) were not coping well.  

In addition, while most were able to effectively manage their caregiving responsibilities, 28% found providing care somewhat or very stressful and 19% of caregivers indicated that their physical and emotional health suffered in the last 12 months as a result of their caregiving responsibilities.

The health consequences of caregiving were even more pronounced when caregivers were asked specific questions on their health symptoms. Over half (55%) of caregivers felt worried or anxious as a result of their caregiving responsibilities, while about half (51%) felt tired during the past 12 months (Chart 8). Other common symptoms associated with providing care included feeling short-tempered or irritable (36%), feeling overwhelmed (35%) and having a disturbed sleep (34%).8

The financial impacts related to caring for a loved one can be significant. Lost days at work may reduce household income, while out-of-pocket expenses, such as purchasing specialized aids or devices, transportation costs, and hiring professional help to assist with care, can be borne from caring for a loved one. In many cases, financial support, from either informal or formal sources, can ease the financial burden associated with caregiving responsibilities. Overall, about one in five caregivers (19%) were receiving some form of financial support. 

"The people that I worry about the most in this are actually the working poor," he said

About 40 per cent of households in the two lowest income groups spent more than five per cent of their total after-tax income on health-care services, compared with 14 per cent of those in the highest income group. The spending increase between 1997 and 2009 was greatest for households in the lowest-income group, at 63 per cent.

Lower-income households were more likely than higher-income households to spend more than five per cent of their after-tax income on health care services, Law and his co-authors found.

"I worry about their ability to access prescription drugs," since they have a "relatively low income" and probably don't have benefits through their work

Throughout the study period, the three largest components of out-of-pocket health-care expenditures were: Dental services. Prescription medications. Insurance premiums. In 2009, household spending in those categories averaged $380 (dental), $320 (medications) and $650 (insurance premiums).

"Faster increases in out-of-pocket spending for lower-income households may have implications for access to health care," the report says."Lack of insurance and the burden of out-of-pocket expenditures have been associated with inequitable use of services such as dental care and prescription medications."

Earlier this month, Robyn Tamblyn of Montreal's McGill University published a study in the Annals of Internal Medicine of nearly 1,600 patients in Quebec who received a first prescription between 2006 and 2009. Overall, 31 per cent of the prescriptions weren't filled within nine months and drugs that cost the most were the least likely to be filled.

Government per-capita expenditures in Alberta were almost double those in Texas - Alberta spent $8,607 on average during the 2001-to-2013 period, while Texas spent $4,952. Mr. Prentice acknowledged that Alberta's spending is also out of line relative to other Canadian provinces. Compared to the Canadian average, Alberta spends about $1,300 more per capita on programs and services, and more than half of these costs are from salaries alone, he said. The School of Public Policy at the U of C argues the province could improve the way it forecasts oil revenue. According to author Sarah Dobson, there are "serious problems" with Alberta's forecasts. "In a province so dependent on resource royalties for its revenues, adding the unpredictability of unreliable forecasting methods can only put its fiscal planning at that much greater risk of instability," she writes. Unlike other critics, who in the past worried the province's forecasts were too rosy, Ms. Dobson argues Mr. Prentice might be inflating the government's expected shortfall this time around.

The premier has warned that if West Texas Intermediate crude averages US$65 a barrel this fiscal year, provincial revenue would drop by $6 billion to $7 billion, while a WTI price below US$50 could mean a shortfall of up to $10 billion. That's a big bite out of a $45-billion budget. Ms. Dobson said Alberta is assuming a Canadian dollar exchange rate of 88¢ to the U.S. dollar, which is high compared to most forecasters, who see the Canadian dollar falling further to potentially US75¢ by the end of the year. She estimates the government's high exchange rate view is increasing the shortfall by $2 billion. The exchange rate has a big impact on Alberta revenue because oil is sold in U.S. dollars. The revenue picture could be clearer if the province was more transparent about its royalties revenue, she said. The province doesn't provide key information such as how much production has reached "payout" and is subject to higher royalties, how much bitumen has been upgraded, how much bitumen qualifies for a royalty discount, or information on the productivity of crude oil wells, Ms. Dobson said. Rather than being protective of the ways of the past, Mr. Prentice is leading the shakeup and asking Albertans to do their part. The question is whether the resolve sticks when the oil-price roller-coaster turns in Alberta's favour, and the unbridled optimism that comes with oil booms temps politicians to reopen the taps.

NDP Leader Gary Burrill called the budget a "surplus of words." In particular, Burrill was critical of the lack of help for post secondary students and said the government should have moved as New Brunswick did last week to provide more up-front financial assistance. When asked why there had been such a significant swing from deficit projections in December, when Delorey blamed softened government revenues on a drop in tax revenue and offshore royalties, the minister said it was because of a combination of things including more tax information from the federal government.

Revenue did soften within departments," he said. "What you will also see though is that through the decisions we made and good management we have reduced our expenses more than the revenue has softened, which has enabled us to improve our position." The budget promises include modest amounts for a series of spending initiatives, many of which were previously announced, while continuing promised multi-year spending in education.

There is $6.6 million to improve a childcare system which a recent report said employs the lowest paid early childhood educators in Canada. The government says the money would be used to improve wages and subsidies to parents, although the amount of the increases won't be released until Education Minister Karen Casey gives her official response to her department's report within the next week. Delorey didn't reveal any details either, but did say the funding would push pay for daycare workers "closer to the national average."

CUPE Nova Scotia president Dianne Frittenburg said the overall funding figure falls short of what workers in the sector expect. She compared the figure to the $10.2 million included to refloat the ferry from Yarmouth, N.S., to Portland, Maine. "I'm not saying the Yarmouth ferry isn't important but it (early childhood education) should have equal footing," said Frittenburg. In a completely new measure, the budget allocates $7.5 million towards increasing income assistance by $20 a month beginning May 1 for up to 25,000 eligible people.

Other spending measures include $3.6 million to help children with autism access specialized therapy and a 25 per cent refundable food bank tax credit for farmers that will cost $300,000. Education will get $21 million as part of a four-year $65 million government pledge. The money includes $6.4 million to cap class sizes up to Grade 6 and $7.5 million to help improve literacy and math skills.

The only tax increase in the budget hits smokers, with cigarettes going up two cents each or 50 cents a pack and the tax rate on cigars going up by four per cent at midnight. The moves are expected to bring $15.8 million to provincial coffers. Health spending, at $4.1 billion, takes up 40 per cent of the overall budget. It includes $14.4 million for home care, including home support and nursing. As previously announced there is $3.7 million earmarked for the redesign of the decrepit Victoria General Hospital in Halifax, but no money to replace it.

However, in an accounting measure, the government said it was taking a one-time $110 million payment from Ottawa and the Halifax Regional Municipality for the city's new convention centre and applying it to the debt.

Officials said the payment on the debt would free up money in the future to launch a multi-year redevelopment of the Queen Elizabeth II Health Sciences Centre.

HALIFAXHighlights of the Nova Scotia budget introduced Tuesday: ° Surplus of $17.1 million is projected on a spending program of about $10 billion. ° Net debt of $15.2 billion in 2016-17. ° Budget provides $6.6 million for childcare with money to increase the parent subsidy and to increase wages for early childhood educators. ° Education will get $21 million, with $6.4 million going toward class cap sizes extended up to Grade 6 and $7.5 million to help improve literacy and math skills. ° There will be $7.5 million for boosting income assistance by $20 a month for people eligible. ° Tobacco tax increased by two cents a cigarette or 50 cents a pack, $4 dollars per carton. ° Government will introduce a new 25 per cent refundable food bank tax credit for farmers at a cost of $300,000. ° $3.6 million for the Early Intensive Behavioural Intervention Program to ensure children with autism access a specialized therapy.

The health care reform law enacted last year calls for cutting more than $400 billion from Medicare over the next decade, primarily by slowing the rate of growth in payments to health care providers and phasing out unjustified subsidies to private Medicare Advantage plans that insure roughly a quarter of all enrollees. Republican leaders, who denounced those cuts in 2010, have since embraced Representative Paul Ryan's proposal, which adopts virtually all of the same reductions. Even these will be difficult to achieve without driving out providers, according to the government's nonpartisan budget analysts.

Since January 2010 the growth in Medicare spending has actually slowed to an annual rate of about 4 percent, less than half the annual rate for the previous decade

The only way to make Medicare sustainable is to have it grow at the same rate as the economy that provides the tax base to support it. In recent years, Medicare spending has been growing faster than gross domestic product, by roughly 1.7 to 2 percentage points.

Policy experts of varied political stripes have proposed a host of ways to eliminate excess spending without harming beneficiaries or the medical system. Some would charge higher Medicare premiums for those able to afford them, or raise the age of eligibility, or increase cost-sharing by beneficiaries to deter unnecessary use of medical care. All such proposals have strengths and weaknesses that need to be carefully analyzed.

A more radical proposal, championed primarily by Republicans, is to stop providing Medicare payments for specified benefits no matter the cost and instead give beneficiaries a set amount of money to buy private insurance policies that might not provide the same benefits. These so-called premium-support or voucher plans come in many flavors - some good, some bad - and would need to be carefully vetted. The most extreme version, proposed by Representative Ryan, would save the federal government a lot of money mainly by shifting big costs to beneficiaries and driving up costs for the rest of the health care system.

Medicare's system for paying health care providers is a big part of its spending problem. The traditional Medicare program pays doctors separate fees for each of 7,000 different services, such as a diagnostic test, office visit or surgical procedure. This encourages excess use of medical tests and procedures

The solution, most experts agree, is to have Medicare pay doctors and other health care providers fixed sums to manage a patient's care and then let the doctors decide which services are truly necessary. Close monitoring would be needed to ensure that doctors don't deny medically important services to improve their bottom lines.

Medicare's coverage has some glaring gaps that need fixing. There is no provision for long-term care in nursing homes or at home, forcing many middle-class people to impoverish themselves to qualify for Medicaid. And patients can be socked with very high or very low rates of cost-sharing depending on whether care is delivered in a hospital, nursing home, by a doctor or at home. This crazy-quilt pattern confuses patients about the costs they will have to pay and almost certainly complicates and drives up the costs of administering the program.

Imagine if a Canadian diagnosed with cancer were told she could receive chemotherapy paid for by the health-care system, but would have to cough up the cash herself if she needed radiation. Or that she could have a few weeks of treatment, and then be sent home even if she needed more. That would never fly. If doctors, say, find a tumour in a patient's colon, the government kicks in and offers the mainstream treatment that is most effective. But for many Canadians diagnosed with a mental illness, the prescription is very different. The treatment they receive, and how much of it they get, will largely be decided not on evidence-based best practices but on their employment benefits and income level: Those who can afford it pay for it privately. Those who cannot are stuck on long wait lists, or have to fall back on prescription medications. Or get no help at all. But according to a large and growing body of research, psychotherapy is not simply a nice-to-have option; it should be a front-line treatment, particularly for the two most costly mental illnesses in Canada: anxiety and depression - which also constitute more than 80 per cent of all psychiatric diagnoses.

Why aren't we providing evidence-based care?" .. The case for psychotherapy Research has found that psychotherapy is as effective as medication - and in some cases works better. It also often does a better job of preventing or forestalling relapse, reducing doctor's appointments and emergency-room visits, and making it more cost-effective in the long run.

Therapy works, researchers say, because it engages the mind of the patient, requires active participation in treatment, and specifically targets the social and stress-related factors that contribute to poor mental health. There are a variety of therapies, but the evidence is strongest for cognitive behavioural therapy - an approach that focuses on changing negative thinking - in large part because CBT, which is timelimited and very structured, lends itself to clinical trials. (Similar support exists for interpersonal therapy, and it is emerging for mindfulness, with researchers trying to find out what works best for which disorders.) Research into the efficacy of therapy is increasing, but there is less of it overall than for drugs - as therapy doesn't have the advantage of well-heeled Big Pharma benefactors. In 2013, a team of European researchers collated the results of 67 studies comparing drugs to therapy; after adjusting for dropouts, there was no significant difference between the most often-used drugs - selective serotonin reuptake inhibitors (SSRIs) - and psychotherapy.

The issue is not one against the other," says Montreal psychiatrist Alain Lesage, director of research at the Douglas Mental Health University Institute. "I am a physician; whatever works, I am good. We know that when patients prefer one to another, they do better if they have choice." Several studies have backed up that notion. Many patients are reluctant to take medication for fear of side effects and the possibility of difficult withdrawal; research shows that more than half of patients receiving medication stop taking it after six months. A small collection of recent studies has found that therapy can cause changes in the brain similar to those brought about by medication. In people with depression, for instance, the amygdala (located deep within the brain, it processes basic memories and controls our instinctive fight-or-flight reaction) works in overdrive, while the prefrontal cortex (which regulates rational thought) is sluggish. Research shows that antidepressants calm the amygdala; therapy does the same, though to a lesser extent.

But psychotherapy also appears to tune up the prefrontal cortex more than does medication. This is why, researchers believe, therapy works especially well in preventing relapse - an important benefit, since extending the time between acute episodes of illnesses prevents them from becoming chronic and more debilitating. The theory, then, is that psychotherapy does a better job of helping patients consciously cope with their unconscious responses to stress.

According to treatment guidelines by leading international professional and scientific organizations - including Canada's own expert panel, the Canadian Network for Mood and Anxiety Treatments - psychotherapy should be considered as a first option in treatment, alone or in combination with medication. And it is "highly recommended" in maintaining recovery in the long term. Britain's independent, research-guided scientific body, the National Institute for Health and Care Excellence, has concluded that therapy should be tried before drugs in mild to moderate cases of depression and anxiety - a finding that led to the creation of a $760million public system, which now handles therapy referrals for nearly one million people a year.

In 2012, Canada's Mental Health Commission estimated that only about one in three adults and one in four children are receiving support and treatment when they need it. Ironically, anti-stigma campaigns designed to help people understand mental illness may only make those statistics worse. In Toronto, for instance, putting up posters in subway stations in 2010 had the unexpected effect of spiking the volume of walk-ins at nearby emergency rooms by as much as 45 per cent in 12 months. Dr. Kurdyak treated many of them at CAMH. The system, he says, "has been conveniently ignoring this unmet need. It functions as if two-thirds of the people suffering won't get help." What would happen if the healthcare system outright "ignored" two-third of tumour diagnoses?

Essentially, argues Dr. Lesage, adding therapy into the health-care system is like putting a new, highly effective drug on the table for doctors. "Think about it," he says. "We have a new antidepressant. It works as well as many others, and it may even have some advantages - it works better for remission - with fewer side effects. The patients may prefer it. And [in the long run] it doesn't cost more than what we have. How can it not be covered?" ..

A heavy price This isn't just a medical issue; it's an economic one. Mental illness accounts for roughly 50 per cent of family doctors' time, and more hospital-bed days than cancer. Nearly four million Canadians have a mood disorder: more than all cases of diabetes (2.2 million) and heart disease (1.4 million) combined.

Mental illness - and depression, in particular - is the leading cause of disability, accounting for 30 per cent of workplace-insurance claims, and 70 per cent of total compensation costs. In 2012, an Ontario study calculated that the burden of mental illness and addiction was 1.5 times that of all cancers, and more than seven times the cost of all infectious diseases. Mental illness is so debilitating because, unlike physical ailments, it often takes root in adolescence and peaks among Canadians in their 20s and 30s, just as they are heading into higher education, or building careers and families. Untreated, symptoms reverberate through all aspects of life, routinely trapping people in poverty and homelessness. More than one-third of Ontario residents receiving social assistance have a mental illness. The cost to society is clearly immense.

Yet, when family doctors were asked why they didn't refer more patients to therapy in a 2008 Canadian survey, the main reason they gave was cost. For many Canadians, private therapy is a luxury, especially if families are already wrestling with the economic fallout from mental illness. Costs vary across provinces, but psychologists in private practice may charge more than $200 an hour in major centres. And it's not just the uninsured who are affected.

Although about 60 per cent of Canadians have some form of private insurance, the amount available for therapy may cover only a handful of sessions. Those with the best benefits are more likely to be higherincome workers with stable employment. Federal public servants, notably, have one of the best plans in the country - their benefits were doubled in 2014 to $2,000 annually for psychotherapy. Many of those who can pay for therapy are doing so: A 2013 consultant's study commissioned by the Canadian Psychological Association found that $950-million is spent annually on private-practice psychologists by Canadians, insurance companies and workers compensation boards. The CPA estimates t

These are the patients that family doctors juggle, the ones who eat up appointment time, and never seem to get better, the ones caught on waiting lists. Sometimes, they have already been bounced in and out of the system, received little help, and have become wary of trying again. A 40-something mother recovering from breast cancer, suffering from chronic depression post-treatment, debilitated by fear her cancer will return. A university student, struggling with anxiety, who hasn't been to class for three weeks and may soon be kicked out of school. A teenager with bulimia removed from an eatingdisorder program because she couldn't follow the rules. They are the ones dangling on waiting lists in the public system for what often amounts to a handful of talk-therapy sessions, who don't have the money to pay for private therapy, or have too little coverage to get the full course of appointments they need.

Canada's investment does not match that burden. Only about 7 per cent of health-care spending goes to mental health. Even recent increases pale when compared to other countries: According to a study by the Canadian Mental Health Association, Canada increased per-capita funding by $5.22 in 2011. The British government, meanwhile, kicked in an extra 12 times that amount per citizen, and Australia added nearly 20 times as much as we did. Falling off a cliff, again and again

In Winnipeg, Dr. Stanley Szajkowski watched for months as his patient, a woman in her 80s, slowly declined. Her husband had died and she was spiralling into a severe depression. At every appointment, she looked thinner, more dishevelled. She wasn't sleeping, she admitted, often through tears. Sometimes she thought of suicide. She lived alone, with no family nearby, and no resources of her own to pay for therapy. "You do what you can," says Dr. Szajkowksi. "You provide some support and encouragement." He did his best, but he always had other patients waiting.

hat 30 per cent of private patients pay out-ofpocket themselves. When the afflicted don't seek help, the cost isn't restricted to their own pocketbook. People with mental-health problems are significantly more likely to abuse drugs and alcohol, and to become physically sick, further increasing health-care costs. A 2014 study by Oxford University researchers found that having a mental illness reduced life expectancy by 10 to 20 years, roughly the same as did smoking and obesity. A 2008 Statistics Canada study linked depression to new-onset heart disease in the general population. A 2014 U.S. study found that women under the age of 55 are twice as likely to suffer or die from a heart attack, or require heart surgery, if they have moderate to severe depression. The result: clogged-up doctors' offices, ERs, and operating rooms. And an inexorable burden for the patients' families forced to fill the gaps in caregiving - or carry on when they lose a loved one.

Patients refer to it as falling repeatedly off a cliff. And they can only manage the climb back up so many times. Family doctors interviewed for this story admitted that they are often "handholding" patients with nowhere else to go. "I am making them feel cared for, I am providing a supportive ear that they may not get anywhere else," says Dr. Batya Grundland, a physician who has been in family practice at Toronto's Women's College Hospital for almost a decade. "But do I think I am moving them forward with regard to their illness, and helping them cope better? I am going to say rarely." More senior doctors have told her that once in a while "a light bulb goes off" for the patients, but often only after many years. That's not an efficient use of health dollars, she points out - not when there are trained therapists who could do the job better. However, she says, "in some cases, I may be the only person they have."

Family doctors aren't the only ones struggling to find therapy for their patients. "I do a hundred consultations a year," says clinical psychiatrist Joel Paris, a professor at McGill University and research associate at the Montreal Jewish General, "and one of the most common situations is that the patient has tried a few anti-depressants, they have not responded very well, and from their story it is obvious they would benefit from psychotherapy. But where do they go? We have community clinics here in Montreal with six-to-12-month waiting lists even for brief therapy." A fractured, inefficient system

"You fall into the role that is handed to you," says Antoine Gagnon, a family doctor in Osgoode, on the outskirts of Ottawa. He tries to set aside 20-minute appointments before lunch or at the end of the day to provide "active listening" to his patients with anxiety and depression. Many of them are farmers or self-employed, without any private coverage for therapy. "Five of those minutes are spent talking about the weather," he says, "and then maybe you get into the meat of the problem, but the reality is we don't have the appropriate amount of time to give to therapy, even to listen, really." Often, he watches his patients' symptoms worsen over several months, until they meet the threshold of a clinical diagnosis. "The whole system could save on productivity and money if people were actually able to get the treatment they needed."

But these issues aren't insurmountable, as other countries have demonstrated. Britain, for instance, has trained thousands of university graduates to become therapists in its new public program, following research showing that, as long they have the proper skills, people don't need PhDs to be effective therapists. Australia, which has created a pay-for-service system, also makes wide use of online support to cost-effectively reach remote communities.

Except for a small fraction of GPs who specialize in psychotherapy, few family doctors have the training - or the time - to provide structured therapy. Saadia Hameed, a GP in a family-health team in London, Ont., has been researching access to psychotherapy for an advanced degree. Many of the doctors she has interviewed had trouble even producing a clear definition of therapy. One told her, "If a patient cries, than it's psychotherapy." Another described it as "listening to their woes." A 2007 survey of 163 family doctors in Ontario found that almost four out of five had not received training in cognitive behavioural therapy, and knew little about it. "Do family doctors really need to do that much psychotherapy," Dr. Hameed asks, "when there are other people trained - and better trained - to do it?"

What further frustrates treatment for physicians and patients is lack of access to specialists within the system. Across the country, family doctors describe the difficulty of reaching a psychiatrist to consult on a diagnosis or followup with their patients. In a telling 2011 study, published in the Canadian Journal of Psychiatry, researchers conducted a real-world experiment to see how easily a GP could locate a psychiatrist willing to see a patient with depression. Researchers called 297 psychiatrists in Vancouver, and reached 230. Of the 70 who said they would consider taking referrals, 64 required extensive written documentation, and could not give a wait-time estimate. Only six were willing to take the patient "immediately," but even then, their wait times ranged from four to 55 days. Psychiatrists are in increasingly short supply in Canada, and there's strong evidence that we're not making the best use of these highly trained specialists. They can - and often do - provide fee-for-service psychotherapy in a private setting, which limits their ability to meet the huge demand to consult with family doctors and treat the most severe cases.

A recent Ontario study by a team at CAMH found that while waiting lists exist in both urban and rural centres, the practices of psychiatrists in those locations tend to look very different. Among full-time psychiatrists in Toronto, 10 per cent saw fewer than 40 patients, and 40 per cent saw fewer than 100 - on average, their practices were half the size of psychiatrists in smaller centres. The patients for those urban psychiatrists with the smallest practices were also more likely to fall in the highest income bracket, and less likely to have been previously hospitalized for a mental illness than those in the smaller centres.

And those therapy sessions are being billed with no monitoring from a health-care system already scrimping on dollars, yet spending a lot on this care: On average, psychiatrists earn $216,000 a year. There is nothing to stop psychiatrists from seeing the same patients for years, and no system to ensure the patients with the greatest need get priority. In Australia, Britain and the United States, by contrast, billing for psychiatrists has been adjusted to encourage them to reduce psychotherapy sessions and serve more as consultants, particularly for the most severe cases, as other specialists do.

As the Canadian system exists now, says Benoit Mulsant, the physician-in-chief at CAMH and also a psychiatrist, the doctors in his specialty "can do whatever they please. If I wanted, I could have a roster of actor patients who tell me entertaining stories, and I would be paid the same as someone who is treating homeless people. ... By treating the rich and famous, there is zero risk of being punched in the face by a patient." Left out in all this, by and large, are other professionals who can provide therapy. It doesn't help that the rules are often murky around who can call themselves psychotherapists. While psychologists and social workers are licensed under their professional associations, in some provinces a person can call himself a marriage counsellor or music therapist with no one demanding they be certified. In 2007, Ontario passed a law to regulate psychotherapists, requiring them to register with a provincial college that would set standards and handle complaints. Currently, however, the law is in limbo, although the government has said it will finally bring it into force by December. The brain keeps many secrets

Science, however, has yet to find depression's equivalent of insulin. Despite being scanned, poked and stimulated over and over and over again, the brain keeps its secrets. The "chemical imbalance" theory is now viewed as simplistic at best. It may not do much for patients, either: A 2014 study published in the journal Behaviour Research and Therapy suggested that, rather than reassuring them, focusing on the biological explanation for depression actually made patients feel more pessimistic and lacking in control. SSRIs work by increasing the amount of serotonin, a chemical that helps deliver messages within the brain and is known to influence mood. But researchers aren't sure why the drugs help some patients and fail with others. "Basically, it's like we have a bucket of water and we pour it over the patient's head," says Dr. Georg Northoff, the University of Ottawa's Michael Smith chair of Neurosciences and Mental Health. "But you want a drug that injects the water in a very specific brain regions or brain system, which we don't have."

Critics of therapy have argued that it's basically "good listening" - comparable to having a sympathetic friend across the kitchen table - and that in the real world of mercurial patients and practitioners of varying abilities, a pill just works better. That's true in many cases, especially when the symptoms are severe and the patients is suicidal: a fast-acting medication is safer, and may even be necessary before starting talk therapy. The staunchest advocates of therapy do not suggest it should be the first course of treatment for psychosis, or debilitating chronic depression, or mania - although, in those cases, there is evidence that psychotherapy and medication work well in tandem. (A 2011 meta-analysis found that patients with severe depression who received a combination approach had higher recovery rates and were less likely to drop out of treatment.) But drugs also don't work as well as the manufacturers would like us to think. Roughly one-third of patients given a drug will see no benefit (although they often respond to a second or third medication). In randomly controlled trials, drugs often perform only marginally better than sugar pills.

Yet it's talk therapy that the public often views most skeptically. "Until you go to a therapist, or a member of your family has a serious psychological problem, people are unsympathetic [about therapy]," says Dr. Paris, the Montreal psychiatrist. "They are very skeptical, and they don't believe the research. It's amazing, because pharmaceutical trials will get approval for a drug on the basis of two clinical trials that they paid for. And we have 100 clinical trials and no one believes us."

Dr. Ajantha Jayabarathan, an assistant professor at Dalhousie University's medical school, spent her early years as a family doctor in Spryfield, N.S., trying to manage an overload of mental-health cases. Most of her patients had little insurance; there was one reduced-cost counselling service in town, but the waiting lists were long. In 2000, her group practice became a test site for a shared-care project, which gave the doctors access to a mental-health team, including weekly in-person consultations with a psychiatrist. "It was transformative," she says. "We looked after everything in-house.

Over time, Dr. Jayabarathan says, she learned how to properly assess mental illness in patients, and how to use medication more effectively. "I just made it my business to teach myself what to do." It's the kind of workaround GPs are increasingly experimenting with, waiting for the system to catch up. Who would pay - and how?

The case for expanding publicly funded access to therapy is gaining traction in Canada. In 2012, the health commissioner of Quebec recommended therapy be covered by the province; it is now being studied by Quebec's science-based health body (INESSS), which is expected to report back next year. A new Quebec-based organization of doctors, researchers and mental-health advocates called the Coalition for Access to Psychotherapy (CAP) is lobbying the government.

In Manitoba, the Liberal Party - albeit well behind in the polls - has made the public funding of psychologists one of its campaign platforms for the province's spring 2016 election. In Saskatchewan, the government commissioned, and has since endorsed, a mental-health action plan that includes providing online therapy - though politicians have given themselves 10 years to accomplish it. Michael Kirby, the former head of the Canadian Mental Health Commission, has been advocating for eight annual sessions of therapy to be covered for children and youth in need.

There are significant hurdles: Which practitioners would provide therapy, and how would they be paid? What therapies would be covered, and for how long? Complicating every aspect of major mentalhealth change in Canada is the question of who should shoulder the cost: the provinces or Ottawa. In a written statement in response to questions from The Globe and Mail, federal Health Minister Rona Ambrose lobbed the issue back at her provincial counterparts, pointing out that the Canada Health Act does not "preclude provinces and territories from extending public coverage to other services or providers such as psychologists."

One result can be overloaded family doctors minimizing mental-health problems. "If you have nothing to offer someone," asks Dr. Anderson, "how much are you going to dig around to find out what is going on?" Some doctors also admit that the lack of resources can lead to physicians cherry-picking patients who don't have mental illness. And yet family physicians alone bill about $361million a year for counselling or psychotherapy in Canada - 5.6 million visits of roughly 30 minutes each. This is a broad category, and not always specifically related to mental health (some of it includes drug counselling, and a certain amount of coaching is a necessary part of the patient-doctor relationship). When it is psychotherapy, however, doctors admit it's often more supportive listening than actual therapy.

So how would Canada pay for access to such therapy? It wouldn't be cheap, in the short term. The savings would come from what Canadians would not have to spend in the long term: in additional medical and drug costs, emergency-room visits and hospital stays, and in unnecessary disability payments, to say nothing of better long-term health outcomes for patients given good care earlier. Some of the figures being tossed around sound staggering. Rolling out a version of Britain's centre-based program across Canada would cost $950-million. Michael Kirby's plan would amount to $1,000 annually per patient. A 2013 report commissioned by the Canadian Psychological Association calculated that, based on predicted need, and assuming no coverage from private health-care plans, providing an average of six sessions of therapy a year would cost an estimated $2.8-billion annually.

But any of those figures would still be a fraction of the roughly $210-billion that Canada spends annually on health care. Figuring out how to make the system most costeffective is, according to sources, currently delaying the INESSS report to the Quebec government. "You need to facilitate the government," says Helen- Maria Vasiliadis, a professor of community health at the University of Sherbrooke. "You can't be going to policymakers and showing them billions and billions of dollars. People start having heart attacks. With evidence in hand, we have to present possible solutions."

An insurance-based plan is the proposal that has emerged from the Quebec-based CAP group, which sent its proposal to Quebec's health minister last month. In its design, the system would work much like Quebec's public drug plan - Quebeckers not covered through work plans would contribute to a provincial insurance program for therapy. That would be similar to the system that Germany has used for decades. One step forward, one step back

Last year, the Sherbrooke clinic where Marie Hayes works received provincial funding for a part-time psychologist and a full-time social worker. With a roster of 25,000 patients, the clinic team laid out clear guidelines for the psychologist, who would consult on cases and screen patients, and be limited to a mere four sessions of actual counselling with any one patient. "We wanted to be careful she didn't become a waiting list - like everything in the system," says Dr. Hayes. The social worker helps guide patients into services such as housing and addiction counselling. They have also offered group sessions for depression management at the clinic. As stretched as those new professionals are in such a large practice, Dr. Hayes says the addition of that mental-health team is improving the care she can provide patients. Recently, for instance, the 32- year-old mother with anxiety attended sessions with the psychologist. "She is making progress," says Dr. Hayes, "slowly."

At Women's College Hospital in Toronto, Dr. Grundland is not so lucky. Asked to describe a difficult case, the family-practice physician mentions a patient suffering from depression after a lifechanging accident. Every month, doctor and patient would repeat the same conversation they'd already had more than a dozen times - and make little real headway. Her patient, says Dr. Grundland, needs a trained therapist: someone she can see regularly, to help her move past her frustration, counsel her about addiction, and ease the burden on her family.

But there's no extra money in the patient's budget for a psychologist. "I do my best," Dr. Grundland says, "but it's not my area of expertise." Meanwhile, the patient isn't getting better, and in the time that it takes to make it through one appointment with her, Dr. Grundland could see three other people with problems she was actually trained to treat. "But," says Dr. Grundland, "she has nowhere else to go." Erin Anderssen is a feature writer at The Globe and Mail. OPEN MINDS How to build a better mental health care system

The Centre for Addiction and Mental Health has purchased advertisements to accompany this series. While CAMH professionals are quoted in this story, the organization had no involvement in the creation or production of this, or any other story in the series. $20.7-billion The cost, according to a 2012 Conference Board of Canada report, of lost productivity each year due to mental illness. What else does $20-billion represent?

$20B: Canadian spending on national defence, 2012-13 $20B: Market valuation of Airbnb, 2015 $21B: Kitchener-CambridgeWaterloo region's GDP, 2009 $21B: Amount food manufacturing contributed to the economy, 2012

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

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

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

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

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

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

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

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

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

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

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