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But the offering of psychological care doesn't have to be an open buffet like other aspects of health care, and some of the hundreds of millions now paid for (not always trained) doctors to provide psychotherapy can be spent more smartly. If done right, the investment should pay off down the road, in lower health costs, disability-insurance payouts and absenteeism. Because the greatest costs of mental illness arise when it is left untreated, and festers. Mental illness is common: 10 per cent to 25 per cent of women and 5 per cent to 12 per cent of men experience a major depression; 4 per cent to 7 per cent of Canadians suffer from anxiety disorder; 7 per cent to 12 per cent experience posttraumatic stress disorder; 10 per cent suffer from phobias; 5 per cent experience panic disorders; 2 per cent to 4 per cent suffer from obsessive compulsive disorder or eating disorders; 1 per cent to 2 per cent suffer from bipolar disorder or schizophrenia. For years, we have been focusing efforts on combatting the stigma, urging Canadians with mental-health disorders to come forward. But the care is not available for those who need it; waits stretch from months to years, and an estimated one in three adults and one in four children don't get care at all.

Sadly, the offerings in our health system are driven as much by tradition as they are by evidence. We needn't be prisoners of our outmoded structures. In the fifties and sixties, we created a system to provide care in hospitals and in physicians' offices and it's almost impossible to break that mould and innovate - for example, by putting psychological care on an even footing with psychiatric/medicinal treatment. What we really need to do is provide care where people bring their mental-health problems - in primary care. As most provinces try to transition from a solo, fee-for-service model to multidisciplinary teams, it provides a perfect opportunity to bolster mental-health care by integrating psychologists onto teams. Other countries have done so, notably Britain and Australia, and the early evidence is that it's paying off. The fear, of course, is that providing public funding of psychological care will cost more. Of course it will. Estimates range from $950-million to $2.8-billion a year.

Psychotherapy can help fill the gap. There are 8,000 psychologists in Canada. About three-quarters are in private practice, charging $100 to $200 an hour, and roughly one-third work exclusively in the public system, where there is no charge to patients. Canadians spend about $950million on psychological care, most of it covered by private insurance and workers compensation; but a good chunk, about one-third, is paid out of pocket. We have a mixed health-funding model in this country, but when it comes to mental-health care, we don't have the mix right. Too many people are being denied care because they can't afford it, or because their workbased insurance provides paltry benefits for psychological care. As it stands, mental-health care remains an orphan. We can take another big step toward correcting this by adopting a more rational approach to the use and funding of psychological care.

Low-income adults who do not have employer-sponsored dental coverage through a publicly funded program - and most don't - must pay for their own dental care. Because the cost is often prohibitive, too many adults avoid seeking treatment at dental offices. Instead, they turn to family doctors and emergency departments for antibiotics and painkillers, which cannot address the true cause of the problem. In 2012, in Ontario alone, there were almost 58,000 visits to Ontario hospital emergency rooms due to oral health problems. Why is access to dental care essential now?

A person's oral health will affect their overall health. Dental disease can cause pain and infection. Gum disease has been linked to respiratory infections, cardiovascular disease, diabetes, poor nutrition, and low birth weight babies. Poor oral health can also impact learning abilities, employability, school and work attendance and performance, self-esteem, and social relationships. It is estimated that 4.15 million working days are lost annually in Canada due to dental visits or dental sick days. Persons with visible dental problems may be less likely to find employment in jobs that require face-to-face contact with the public.

Why is there such a difference in coverage? In short, dental care and pharmacare were not included within the original scope of Canada's national system of health insurance (medicare), and despite repeated evidence of the need to correct this oversight, is still not covered today. Instead, we are left with a patchwork of private employer-based benefits coverage, limited publicly funded programs, and significant out-of-pocket payments for many. Publicly funded dental programs for children and youth do exist for low-income families, including the dependents of those on social assistance. Most provinces and territories have some access to drug coverage, mostly for seniors and social assistance recipients, and there is some support for situations where drug costs are extremely high.

Pharmaceutical coverage in Canada remains an unco-ordinated and incomplete patchwork of private and public plans - one that leaves many Canadians with no prescription drug coverage at all. This has many negative consequences including: Three million Canadians cannot afford to take their prescriptions as written. This leads to worse health outcomes and increased costs elsewhere in the health-care system.

One in six hospitalizations in Canada could be prevented through improved regulation and better guidelines. Medicines are commonly underused, overused, and misused in Canada. Two million Canadians incur more than $1,000 a year in out-of-pocket expenses for prescription drugs. The uncontrolled cost of medicines is also a growing burden on businesses and unions that finance private drug plans for approximately 60 per cent of Canadian workers. Canada pays more than any comparable health-care system for prescription drugs. We spend an estimated $1 billion on duplicate administration of multiple private drug plans. Depending on estimates, we also spend between $4 billion and $10 billion more on prescription drugs than comparable countries with national prescription drug coverage plans.

Affordable access to safe and appropriate prescription medicines is so critical to health that the World Health Organization has declared governments should be obligated to ensure such access for all. Unfortunately, Canada is the only developed country with a universal health care system that does not include universal coverage of prescription drugs. From its very outset, Canada's universal, public health insurance system - medicare - was supposed to include universal public coverage of prescription drugs. The reasoning was simple. It is essential to deliver on the core principles of "access," "appropriateness," "equity" and "efficiency." Building universal prescription drug coverage into Canada's universal health-care system, based on the above principles, is both achievable and financially sustainable.

A public body - with federal, provincial and territorial representation - would establish the national formulary for medicines to be covered. This body would negotiate drug pricing and supply contracts for brand-name and generic drugs. Importantly, it would use the combined purchasing power of the program to ensure all Canadians receive the best possible drug prices and thereby coverage of the widest possible range of treatments. To patients, the program would be a natural extension of medicare: when a provider prescribes a covered drug, the patient would have access without financial barriers.

To society, universal access to safe and appropriately prescribed drugs and access to dental care will improve population health and reduce demands elsewhere in the health system. The single-payer system will also result in substantially lower medicine costs for Canada. In short, Canada can no longer afford not to have a national pharmacare program and a national dental care program. Disclaimer: The Guelph and Wellington Task Force for Poverty Elimination is a non-partisan organization. However, the poverty task force does have ties with two Guelph federal party candidates. Andrew Seagram, the NDP candidate, is a current member of the task force and Lloyd Longfield, the Liberal candidate, is a past member.

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

The document is expected to propose shifting much of the CCACs' home-care planning and oversight roles to the 14 Local Health Integration Networks (LHINs) that now are responsible for overall regional planning, funding and health-care integration. The job of co-ordinating face-to-face services, which now falls to CCAC staffers, may be moved to primary care agencies, such as hospitals or community health clinics led by doctors or nurse practitioners. The goal is to save more than $200 million by eliminating the bureaucracy-heavy CCACs, with their high-paid executives, and directing the savings to front-line services.

More than 700,000 Ontario residents receive care annually at home or in community settings. The province spends $2.5 billion a year on home and community care, about 4 per cent of its total health budget. Despite overwhelming evidence that the system is in dire need of reform, Hoskins seems reluctant to move ahead with any speed. Two months ago his office cancelled a private lock-up for home-care stakeholders at which they were to discuss a "white paper" on reforms. Hoskins also scrapped plans for a special home-care task force on the grounds it would be viewed as just another stalling tactic. Still, Hoskins is indeed moving, albeit slowly.

On Nov. 20, he spoke privately with the board chairs and chief executive officers of the 14 CCACs about the coming changes. On Nov. 30, Bob Bell, the deputy health minister, met with the same CCAC bosses and while he didn't share any "concrete plans," he did suggest health ministry officials will consult with CCACs and other agencies about the proposed changes "in the new year." And on Dec. 1, Hoskins wrote to the CCAC bosses to explain that his ministry has every intention of "working together with CCACs to build a health care system that truly responds to the needs of patients and their families." Again, no specifics were mentioned. Clearly, Hoskins is dealing with a health-care establishment that is reluctant to change. That includes the CCACs, LHINs, doctors and his own bureaucrats.

LHIN officials, for example, don't want to be in charge of direct delivery of care. They have few staffers who actually know how to run a big health system on a day-to-day basis. At the same time, the LHINs have their own troubles, as Lysyk noted in her report. She said their "marching orders are not clear enough" and performance gaps are widening, especially on wait times. In the weeks ahead, Hoskins must address whether the LHINs are ready to assume greater duties, whether they should be in the health-care delivery sector at all and how to achieve better integration of hospitals, public health, primary care and home-care agencies. Also, he should look at whether all - not just some - home-care delivery should be left to private and non-profit service providers. Hoskins and his bureaucrats may be delaying the reform push until they develop "the perfect plan."

But Hoskins, who has shown true vision in this initiative, should view the document as the starting point - not the end point - for wholesale reforms that cut out an entire layer of costly bureaucracy and that improve the delivery of services that patients need and deserve. Everyone in the health-care sector is primed and ready to act, although not eagerly in all cases. Just as important is the fact that more delays and more wasted tax dollars won't fix the broken system. So it's time for Hoskins to end the needless holdups and move swiftly and boldly on behalf of the people who really matter - Ontario patients. Bob Hepburn's column appears Sunday. bhepburn@thestar.ca

Ontario Health Minister Eric Hoskins may be delaying action until his team develops "the perfect plan" for home-care delivery, Bob Hepburn writes. • Chris Young/THE CANADIAN PRESS file photo

New research points to a close relationship between our oral and overall health. In Oral Health in America: A Report of the Surgeon General published by the U.S. National Institute of Dental and Craniofacial Research, the authors conclude that "the oral cavity is a portal of entry as well as the site of disease for microbial infections that affect general health status." And: "Animal and population-based studies have demonstrated an association between periodontal diseases and diabetes, cardiovascular disease, stroke and adverse pregnancy outcomes." My own experience getting total knee-replacement surgery offers indisputable proof of that all-important connection between mouth and body. And the inherent risk to my overall health from the lack of dental medicare proved undeniable. An abscess under my crown went untreated because I could not afford to properly replace the tooth once it was extracted.

Due to the infection, my kneereplacement surgery was postponed because the bacteria from the gum and tooth infection could have wreaked havoc on the surgery site, destroying any chance of a new knee now or in the future. So I had the tooth and infection removed and my surgery was rescheduled. I chose a better life and being able to walk again over worrying about an unsightly hole in my mouth. But why should I have to choose?

I am immensely grateful that the medical costs of replacing both my knees are covered. But when an infection in my tooth and gums adversely impacts this lifechanging surgery, it seems unbelievably obtuse and ludicrous that there is no universal medical coverage for my mouth. That is like trying to purify and clean a jug of water while ignoring a small patch of toxic material floating on the top. Brushed Aside: Poverty and Dental Care in Victoria, A Report

from the Vancouver Island Public Interest Research Group by University of Victoria researcher Bruce B. Wallace raises important questions: Are Canadians - regardless of income - entitled to basic health care, including basic oral health care? Why do we disconnect the jaw from the body? A person's dental health affects their whole health status, and yet we refuse to treat it. In Canada, while we pride ourselves on our provision of universal health care, we exclude oral health. As a society we are agreeing to not provide basic health care to a significant part of our population." Let's show the world that we know how to take care of each other. Universal dental care should get top billing in the fall federal election campaign. Doreen Marion Gee is a Victoria writer and activist.

The government has been warned for decades about the need to co-ordinate and support home care to accommodate: The fast-growing number of Ontarians with Alzheimer's and related dementia. There were 181,000 of them in 2011, and that number is expected to grow by 40 per cent before 2021. The 13,042 people currently on wait-lists for home-care services. (This does not include those cut from the lists because Community Care Access Centres had to tighten eligibility due to a lack of funding.) The increasing need for home care to help seniors retain their independence. But instead of properly supporting and funding home care - to save money, never mind provide compassionate care - the current $2.4-billion budget for home care provides less per patient than in 2002/03, according to the health coalition's calculations. This year, the Ontario government topped up the entire $4.9-billion budget for both home and community care (which includes community health centres) by $270 million and plans to increase that gradually to $750 million over the next couple of years. Still, the Ontario Health Coalition is recommending:

Patient advocates or an ombudsman to help people access timely, sufficient home care. Increased funding to ensure those in need are cared for. More controversially, an end to the current mix of private and public health-care services. (It argues the home-care system should be a public, not-for-profit service.) Their report is a well-researched, well-thought-out eye-opener - backed up on many issues by the government-commissioned report. Health Minister Eric Hoskins should act on both immediately. The most vulnerable of patients - those waiting for help at home - depend on it.

we have three recommendations

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

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

The second recommendation

Our third recommendation

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

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

foreign credential recognition

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

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

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

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

Canada does not have a single national health human resources plan

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

Pan-Canadian Health Human Resource Strategy

Internationally Educated Health Professionals Initiative

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

ACHDHR will be providing a written brief

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

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

Dr. Brian Conway, President, Société Santé en français

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

Acadian and francophone communities outside Quebec

Senator Eggleton

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

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.

To make aging at home a reality for all Canadians, we must redesign the delivery of home care to make it more accessible, accountable and affordable.

As government funding continues to decline, unpaid caregivers — typically a spouse or child — are having to fill the gap or pay out of pocket to hire care privately. In 2007, approximately 3.1 million Canadians, largely women between the ages of 45–64 years old (44%) (StatsCan 2012), were estimated to act as an informal caregiver to their loved ones, providing over 1.5 billion hours of care annually.

These caregivers provide 10 times the number of care hours by formal services, which is not only taxing on their personal well-being and their relationship with their recipient, but also on Canada’s economy — the cost to businesses from absenteeism and turnover related to unpaid care was estimated to be $1.28 billion in 2007.

The Caring Economy is made up of for-profit marketplaces that serve the needs of others. Like the Sharing Economy, it is a marketplace that empowers neighbours to care for neighbours— removing the need for corporations to intervene. Through the latest mobile technology, businesses in the caring economy connect the supply of care to the demand for care.

In the Caring Economy, there are two key end users: the demand side that needs to hire care and are willing to pay and the supply side that has time and is looking to help. Demand side users can build their own personalized team of care providers, communicate directly within the platform, and pay on demand via mobile payments — a seamless, convenient and transparent process. This is made possible through a peer-to-peer marketplace that uses mobile technology to efficiently manage the relationships between paid care-workers to primary caregivers and their loved ones — on demand. Simply put, it is Uber for home care.

At its core, this model redesigns how care is delivered to make ‘aging in place’ a reality. The model’s objective is threefold — to help seniors age with dignity, to unburden their family caregivers, and to turn compassionate people and Personal Support Workers (PSWs) into ‘micro-entrepreneurs’ — providing them with an opportunity to earn a 20–30% higher wage- a win, win, win.

The Uplift® smartphone platform delivers on-demand home care services — at the touch of a button. As a company, we are laser focused on harnessing the latest mobile technology and analytical problem solving to deliver a superior user experience that fulfills the aging population’s demand for higher quality care. We are setting the new standard.Our app is an affordable solution to expensive agency fees. We offer 30–50% lower fees than private agencies. We are also an innovative substitute to long-term care.As an organization, we are devoted to making a positive impact in the world. Moreover, we are a pioneer of the ‘caring economy’ — where neighbours can care for neighbours and caregivers are empowered.

As long as the objective is to as quickly as possible get them back to their home community, then it can be the best choice in some circumstances," said Schick. Under the new protocol, someone seeking long-term care will retain their spot on the wait-list to eventually move into one of their three preferred care facilities in the city. They could otherwise return home and utilize home care services, or move into a private personal care home. Corinne Pauliuk sees the latter as a poor solution.

"Not all care homes are equipped to accommodate those of a higher level of care," said Pauliuk, president of Regina and District Personal Care Home Association. Her own care home, Sunrise Country Haven near McLean, is one. "Once individuals here meet the criteria for a longterm care facility, I can't meet their needs safely, so I wouldn't qualify as a care home to look after those individuals, period, and I'm not sure how they could function with home care because usually it's 24-hour care that is required," she said.

Pauliuk knows of at least 25 care homes that would be unable to accommodate a resident with serious care needs. NDP health critic Danielle Chartier said home care and private care are not viable alternatives. "Your only other option is to use this government's already-stretched-thin home care and supplement with private care and many people can't afford private care," said Chartier.

"We have the concern in home care that they're pretty much maxed out in regards to workload," added Scott McDonald, president of CUPE 3967, which represents care aides. Chartier thinks of her own parents, who are 82. "I couldn't imagine having them moved 150 km from home, both from their perspective getting to see their family less, but also from my ability as a daughter" to make a long drive to see them often, said Chartier. Pauliuk agrees.

"I can't see family members being able to do that when they're already working full time ... They'd be lucky if it was once a week," she said. Chartier said government should enhance home care, create more long-term care spaces in the city and implement proper staffing. For the past 12 years, rural clients have received the first available long-term care bed 150 km from their home within the RQHR. Five other health regions in the province have a first available bed policy regionwide. Five others, including Saskatoon, are some distance within the region, from a 45-minute drive to 150 km away. amartin@leaderpost.com Twitter.com/LPAshleyM

Failing to link the supply of health care to the needs of the population means the cost of our health care system is determined by the number of providers. Because the number of suppliers has been increasing at a rate far faster than the size of the population, even after allowing for an aging population, we now face a crisis in meeting the costs of keeping the increasing supply of health care providers fully employed.

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.

Sadly, that is no longer saying very much. As last month's report by Ottawa's advisory panel on health-care innovation noted, the performance of Canada's healthcare system has been "middling" even though "spending is high relative to many [developed] countries." Ottawa already turns over cash for health care without any requirement on the part of the provinces to account for how they use it. (It only asks that the provinces conform to the principles of the 1984 Canada Health Act, which bans such practices as extra billing by doctors.) And no federal leader is about to pick a fight with the premiers by insisting it should be otherwise.

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 federal government has made a start with the creation of the Employer Panel for Caregivers and the Family Caregiver Tax Credit. However, it must do more to make a meaningful difference in the lives of Canadians caring for family members. For example, making the caregiver tax credit refundable would help mitigate care costs such as paying out of pocket for prescriptions, groceries and personal care items or taking time off work for medical appointments. Until all levels of government come together to form a comprehensive pan-Canadian seniors strategy, piecemeal initiatives will have a limited impact.

In a way, our generation has become a victim of our own success. Progress and innovation in medicine mean Canadians are living longer. At the same time, more people are living with chronic diseases that complicate both their health status and the treatment they need. Treatment of chronic diseases consumes 67 per cent of all direct health-care costs. Chronic disease is the main reason seniors require health care. In 2011, between 74 and 90 per cent of Canada's seniors suffered from at least one chronic condition, while nearly one-quarter had two or more. These conditions jeopardize a person's ability to live independently at home.

On any given day in Canada, "alternative level of care" patients - that is, patients approved for hospital discharge who cannot access appropriate post-hospital care - occupy about 7,500 beds. Hospitals are routinely forced into a state of overcapacity called "code gridlock" in which patient flow grinds to a halt, elective surgeries are cancelled and transfers are put on hold. If you are in a car accident or have a heart attack, our health-care system can effectively mobilize world-class acute health-care services. But the system is woefully inadequate and under-resourced to properly prevent, manage or treat the long-term and chronic health problems facing most of our over 65 population.

Too often, seniors who could and should be getting better are languishing in hospitals when more efficient and effective care could be delivered in their homes or in a long-term care facility. It costs $1,000 to keep a person in a hospital bed for a day. Long-term care costs $130 a day. Home care (excluding the economic costs of caregivers looking after relatives) costs $55. That translates to approximately $2.3 billion a year that could be better spent in the health-care system with some strategic thinking and investing. This country as we know it today was, in fact, built by our seniors - by our own mothers and fathers, aunts and uncles and grandparents. Canada's health-care providers are determined and committed to prioritizing and improving their health. We expect the same of our country's leaders. As the premiers gather just blocks from Parliament Hill, we ask that a comprehensive healthy aging and seniors care strategy be at the top of their agenda.

Christopher Simpson, MD, is president of the Canadian Medical Association. Morel Caissie is president of the Canadian Association of Social Workers. Karima Velji is president of the Canadian Nurses Association.

But ask about the issues that dominate this election, such as the military or fighting terrorists such as ISIS, and Canadians put those in 19th and 20th place - the very bottom! The disconnect between what Canadians prioritize and what politicians emphasize is huge. Simply put, it's syringes, not Syria, that matters most to Canadians. That Canadians put health on top, trumping even defence and terrorism concerns, is no aberration. The pattern consistently holds true in EKOS polls dating back two decades. Any politician clever enough to change gears and campaign on health stands to reap a giant windfall.

Of course, campaigning on health is easier for some parties than others. Ask Canadians who they trust most on health, and they answer the NDP, Liberals and Conservatives in that order - but with each doing a scandalously poor job of articulating their vision for health, the question is somewhat like asking which of Snow White's seven dwarves is the tallest. Only diehard Conservative voters, loyal as always, say that Stephen Harper has improved health care since taking office more than nine years ago. But probe under these knee-jerk, partisan answers by asking about specific actions of the Harper government on health, and a radically different truth emerges.

Canadians of all political stripes - including a majority of Conservatives - disagree with the Harper government's health decisions. Ask Canadians how they feel about the prime minister's refusal to meet with the provincial ministers of health for the last nine years, and they oppose that by a whopping seven-to-one margin. Ask them about cutting funding for the Public Health Agency of Canada, and again the opponents outnumber backers by seven-to-one. Or ask about the Harper government's decision to cut federally funded health research, which is less emotive, and still Canadians deplore this by six-to-one.

These are staggering margins, the sort that pollsters almost never see. That they exist proves the Conservatives have more to lose than gain in a campaign waged on health. Because Conservative voters tend to be older (read: are sicker), a campaign attack that frames the Harper government's actions as the "Death of Medicare" could seismically undermine their base - especially if those long-spurned provincial health ministers piled on.

And Canadians do believe in Medicare, almost as faith. More than three-quarters of those we polled opposed privatization, or letting those with money buy better or faster care. Huge majorities support expanding Medicare to home and community care (81 per cent), psychiatric care (79 per cent) and prescription drugs (77 per cent). The political parties have not wholly ignored these issues, but neither have they dwelled on them.

There are strong electoral lessons here. Certainly any opposition party that wages a negative campaign against the Conservatives' health record has unparalleled room to grow; it is surprising this has not happened already. But the most intriguing result of our poll? By a hair's breadth, most Canadians (50.1 per cent) prefer a coalition to any one party, with a "traffic light coalition" of Reds, Oranges and Greens being the most popular. Astonishingly, those voters feel more comfortable with a coalition running health care than just their preferred party. Could it be ironically true that health is both the most neglected campaign opportunity for each opposition party, and the glue that could bind them in a coalition if none wins? Amir Attaran is a professor in the University of Ottawa's Faculties of Law and Medicine. Frank Graves is a pollster and founder and president of EKOS Research Associates.

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

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

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

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

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

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

"She was there for a month before she caught the flu and died. Staff never returned our many phone calls or responded to our e-mails. "This system has to change. It's a disgrace on all levels, both home care and facility care. "Julie Cameron, Vancouver "When the Ontario government cut acute-care beds in the 1990s, adequate home care was not put in place first, reflecting the headin-the-sand approach of successive governments to an aging society. "Home care has long been the Cinderella of the health-care system, underfunded and undervalued, yet it is of increasing importance. "Preventative support to keep seniors independent in the community has markedly decreased, because resources are concentrated on the acute needs of patients discharged from hospitals. This leads to unnecessary early institutionalization. "The burden is increasingly born by patients and their informal caregivers. These caregivers are often frail and vulnerable themselves or, if they are the patient's children, there is the economic impact of taking them away from their work. "Inevitably, there is a two-tier system, where the wealthy are able to obtain necessary support, while the rest are on waiting lists, receiving less than adequate care.

"With an aging society, the problem will become worse. "It is time to review the whole community care system and, learning from other jurisdictions, put in place a comprehensive, transparent and properly funded home-care system. "Rory Fisher, professor emeritus, medicine, University of Toronto

"My wife has advanced multiple sclerosis. Two years ago, she got a cut on her foot, which became infected. She was seen at a local hospital, where it was determined she would need intravenous antibiotic every eight hours. With the first treatment at 1 p.m., every third treatment was at 5 a.m. "After the fourth visit, a nurse at the hospital asked why we were not getting these treatments through home care. We did not know it was an option. "She picked up the phone and by the time we returned home, we had a message from the Champlain CCAC to schedule a nursing visit for the treatment.

"Within 48 hours, my wife was assessed and services assigned that exceeded our expectations in quality and oversight of her condition. Over a two-year period, she has received regular reassessment, with treatment plans adjusted according to her needs. "There is no doubt in my mind that home care is not only more cost-effective, but allows treatment to be delivered in a more comfortable setting without travel and waiting room purgatory. "There is also no doubt that the government planning process has failed this system miserably. "We are an hour from Ottawa, which may have something to do with it, but I cannot believe we are the only people in Ontario who have been this fortunate. "Ken Duff, Vankleek Hill, Ont.

"I used to "warn" my patients' families that the first thing CCAC tries to do is to get the family to take over care, even though they "promise" home care while in hospital (to get them out of the hospital). Then, CCAC cuts back on the hours until they "decide" that they must not need home care, because they are only getting four or five hours per week (instead of the 15 or 20 they were originally promised!). It is not the doctors and nurses trying to "get rid of patients," it is administration because of bed times (days in hospital). "Linda Steele, Grand Bend, Ont. "Government needs to put this on speed dial. "April Nairne, Vancouver

"Let's not paint the home-care system with one brush. My husband had excellent, timely and compassionate care through the last weeks of his life which allowed him to die at home, as was our wish. Nurses, personal support workers and supervisors were kind and empathetic. We could never thank them enough. "Ann A. Estill, Guelph, Ont. "Caregivers are frustrated and burning out. One in five Ontarians is a caregiver and they are not receiving the support they need to keep their loved ones at home - be it aging and/or ill parents, spouses or children. "Ontario has acknowledged the need for caregiver supports and more home care. That is great - but where is the change, instead of just lip service?

"In the meantime, families increasingly abandon their loved ones at hospital emergency departments, more caregivers fall into depression, and care recipients end up in hospital or longterm care when they could have stayed home. "We are ready for improvements to home care - any time now. "Lisa Levin, chair, Ontario Caregiver Coalition "Anyone wondering why we baby boomers are demanding the right to assisted suicide should read Kelly Grant and Elizabeth Church's excellent coverage of the Ontario home-care situation to learn the reasons. "Brian Caines, Ottawa " "Associated Graphic "'Care recipients end up in hospital or long-term care when they could have stayed home.'

"ADAM BERRY/GETTY IMAGES

There are many other health issues begging for more attention. Advocates of pharmacare and physician-assisted suicide are pushing hard to get their concerns front and centre. But there has been little discussion so far about health care during the campaign, despite the fact that time and time again it ranks as the top issue of concern among voters. The exception is Green Party Leader Elizabeth May. On Wednesday, she announced her party's strategy for seniors, including a universal drug program and a guaranteed livable income.

Meantime, health-care professionals like Sinha are left to deal with the fallout from the widening cracks in the system. "The issue my patients struggle with the most is getting access to home and community care services. I spend way too much of my time trying to navigate the complicated system on behalf of my patients to make sure we can cobble together what they may need," he said. Physicians are equally worried. More than 500 members of the Canadian Medical Association gathered last week for their annual meeting in Halifax where they reiterated their call for the creation of a national seniors' strategy.

Outgoing president Dr. Chris Simpson told the gathering that there is widespread public support for a seniors strategy to meet the growing health needs of an aging population, but that politicians have been disappointingly silent on the issue. In his closing speech, Simpson warned that doctors are not going to let politicians off the hook. "We will be tracking commitments made by the parties, and we'll publish the results at the end of the campaign so that Canadians who are worried about seniors can make an informed decision when they're at the ballot box." Alan Freeman, Senior Fellow at the University of Ottawa's Graduate School of Public and International Affairs, isn't surprised that the issue of health care has not received much attention.

Any substantive discussion would involve mention of transfer payments and equalization formulas - complicated topics that make people's eyes glaze over. That absence of debate serves Conservative Leader Stephen Harper just fine, Freeman contended. "This works out quite well from the federal government's point of view, especially Harper's point of view, in that he's not interested in an activist role for the federal government in health care," Freeman said.

A similar sentiment was expressed in a recent editorial in the Canadian Medical Association Journal. Deputy editor Dr. Matthew Stanbrook wrote that the federal government seems to be trying to get out of the health-care business. "Recent years have seen Canada's health-care system race to the bottom of quality rankings compared with other nations that have prudently invested in maintaining a strong social safety net," he wrote, warning that the most complex problems in the health-care system cannot be solved without federal leadership.

Ontario Health Minister Eric Hoskins agrees that Ottawa's hands-off approach is hurting the health system. He's specifically concerned about the Conservative government's plan to reduce the rate of increases in health transfers to the provinces. "As Canadians, we owe it to ourselves and to our children to begin a frank and earnest conversation about the state of our health-care system and what a modern health-care system should look like in 2015 and beyond," Hoskins said in an email to the Star. "It's up to all of us - both political leaders and the citizens we represent - to speak up and ensure it has a place in that electoral debate." Conservative party spokesperson Stephen Lecce noted that just Stephen Harper promised to maintain funding for the Canadian Partnership Against Cancer, an agency devoted to combating the disease.

"Since 2006, under prime minister Harper's leadership, health transfers have increased by 70 per cent while balancing the budget and keeping taxes low. Federal funding is a record levels, and will reach $40 billion annually by end of decade, providing certainty and stability, and an enhanced quality of life for Canadians," he said. Barry Kay, a political science professor at Wilfrid Laurier University, expects that in a long campaign, the parties are biding their time before getting into substantive debates.

"I think the leaders are holding their fire till later on when the campaign moves beyond the 'spring training' phase and more people are watching," he said.

A second poll, commissioned by the Canadian Alliance for Long Term Care (CALTC), found that just 18 per cent of citizens believe that hospital and longterm care homes would be able to meet the needs of the aging population, and only 20 per cent think there will be enough trained staff to provide adequate care. The CALTC survey also showed that the top three concerns about the health-care system are long wait times for surgery, lack of access to long-term care and insufficient home-care services. Candace Chartier, chief executive officer of the Ontario Long Term Care Association, agreed that public angst is growing. "How we are going to care for our aging population is the No. 1 concern of Canadians," she said. "The public realizes what's coming down the pipeline and they're frustrated that governments aren't reacting." In fact, both polls showed that voters want the federal government to take a leadership role on seniors' care, but they also realize this has to be done in conjunction with the provinces.

In the survey conducted for the CMA, 89 per cent said the next prime minister needs to make addressing the health needs of Canada's aging population an "urgent priority," while the CALTC poll found that 93 per cent believe Ottawa has an obligation to ensure Canadians have equitable access to care, regardless of where they live. A significant number of those surveyed, 57 per cent, said that how they vote in the Oct. 19 federal election will depend, at least in part, on which party has the best plan to address seniors' health care. Seniors now represent 15 per cent of the population, up from 8 per cent in 1971. By the time all of the baby boomers have reached 65, they will make up an estimated 25 per cent of the population.

While this demographic shift is having an enormous impact on demand for services, the health system has been slow to adjust and is struggling to keep pace. The result is seen, among other things, in the rationing of home care, ever-worsening shortages of nursing home and longterm care spots, hospital beds filling up with frail seniors with nowhere else to go, inadequate hospice and palliative-care services, and stubbornly long wait times for surgery.

Dr. Simpson stressed that the answer to these woes is not necessarily more money but delivering care differently by, for example, shifting spending from institutional care to home care, and placing much more emphasis on prevention. "Seniors today want to age well at home and in the community, and health-care professionals (and politicians) need to tune in to those aspirations," he said. The CMA poll, conducted by Ipsos Reid, surveyed 2,008 Canadian adults between July 20 and 24. It is considered accurate to within 2.5 percentage points, 19 times out of 20. The CALTC poll, conducted by Nanos, surveyed 1,000 Canadian between June 18 and 20. It is considered accurate to within 3.1 percentage points, 19 times out of 20.

The doctors' campaign has, however, prompted me to wonder how it is that paying doctors more will function to alleviate conditions of overwork?

Also concerning is that the doctors' recent efforts to link declining levels of government investment in health care come in the wake of both long-standing and ongoing efforts to standardize, regulate and privatize care in the sector. More than this, through their organization, the Ontario Medical Association (OMA), physicians have long stood silently by and watched as other front-line workers have been forced to battle against the Dalton McGuinty and Wynne governments' efforts to freeze wages, cut hospital funding and otherwise undermine the working conditions of health-care workers, from cleaners to tradespeople to registered practical nurses and personal support workers.

To put matters into perspective, over the past five years, government spending on doctors has increased - in real terms - by an average of 2.5 per cent a year. Over the same period, government spending on other health-care staff has declined by an annual average of -0.5 per cent. In other words, whereas doctors have seen a 29 per cent increase to their pay over the past seven years, other health-care staff have seen their wages decline in real terms.

Of course, declining wages are not necessarily reflective of working conditions. In that regard, it is notable that Ontario hospitals now receive less funding per capita than hospitals in every other Canadian province. As a result, Ontario hospitals - often with the support of doctors and their representative associations - have worked to find "efficiencies" in ways that have frequently increased the workload of front-line staff, and thereby undermine the conditions these workers face and the quality of care they are able to provide patients.

A visit to any Ontario hospital will make clear that it's not just doctors who have been going above and beyond. Rather, workers throughout the hospital have been stretching, often under increasingly difficult circumstances, to provide excellent care with far fewer resources than are required. And like Ontario's doctors, they are failing; our hospitals are not as clean as they need to be in order to prevent the spread of hospital acquired infections, readmission rates are climbing and too many patients are forced to fend for themselves at home.

Ontario's doctors have nonetheless continued to push for the province to open more private surgery and procedures clinics, even as those clinics leach badly needed resources from our hospitals and undermine care in ways that have been well documented in jurisdictions like the United Kingdom.

Government-sponsored and doctor-supported programs that have aimed to increase the efficiency of the province's health-care system through, for example, jargon-laced policies like "continuous quality improvement" or the "health-based allocation model" have actually worked to undermine patient care. By ignoring the voices of front-line staff, many doctors and administrators have conspired to streamline and standardize care in ways that cut off key lines of communication and create a series of very predictable but nonetheless "unexpected consequences" that undermine patient care and frequently fail to generate the promised level of savings.

Nonetheless the OMA's recent efforts, like those of doctors throughout the province are both laudable and bang-on: there is a crisis in health care in Ontario, and the cuts that the Wynne government has imposed are having a serious and deleterious impact.

Those cuts, however, have hardly been focused on doctors' salaries, but have instead focused on other health-care workers and on hospitals. Ultimately, working conditions, wages and the quality of patient care have long been sacrificed at the altar of efficiency and austerity.

What the OMA should consider is the degree to which Ontario's doctors are now victim to the cold and careless logics of efficiency, standardization and privatization, which they both helped author and supported.

Until Ontario's doctors and the OMA find ways to bridge the divide that they have helped to open between themselves and other health-care workers, any improvement to their wages will not lead to long-term and sustainable improvements in our health system and the quality of care we provide patients together.

Michael Hurley is president of the Ontario Council of Hospital Unions (OCHU), the hospital division of the Canadian Union of Public Employees (CUPE) in Ontario. CUPE represents more than 75,000 health care staff provincewide.

Doctors are campaigning against a pay cut imposed by Kathleen Wynne's government, but Michael Hurley writes that they have supported efficiencies and standardizations in other parts of the health-care system.Sean Kilpatrick, Canadian Press file photo

Approximately three-quarters of B.C. care aides surveyed said they are forced to rush through basic care for the elderly and disabled because of high workloads and reduced staffing. And let's not forget the workers who bear the brunt of health care cuts. Between January 21 and February 26, nearly 1,500 health care workers were laid-off at care homes and hospitals across B.C. because of contracting out or contract flips. Any former workers rehired at these facilities can expect to start at the bottom of the employment ladder. Some will lose their pension, others will receive lower probationary wages and most will have zero-earned vacation time. It's plain to see public health care is going down a bad road.

As we head towards a federal election, Canadians have an opportunity to think about how they can best vote for health care in 2015. The next government in Ottawa can take immediate steps to put our nation's signature social program back on the right track. That means your vote - and the vote of your family and friends - can make a difference in electing MPs that will fight for health care. They say voters get the government they deserve. And we certainly are due for leadership in Ottawa that puts the future of a strong public health care system front and centre in their election promises. To learn more about what can be done to save public health care, please visit saveourhealthcarebc.ca online. Bonnie Pearson, HEU Secretary-Business Manager