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globe editorial

Medicare is not yet in crisis, but it soon will be. It has been the main issue of concern for Canadians for much of the past 20 years. Governments are balancing cost pressures that will become intolerable against a population with growing health care needs and a waning tolerance for long waiting times. We can no longer muddle through.

To survive, Canada's health care system should be guided by three central principles. First, essential services should be taxpayer-funded and paid by a single payer. Second, those services needn't be publicly provided. And third, everyone - from providers and governments to patients themselves - must be part of a relentless drive to control costs in the health-care system.

Those principles reflect, by and large, current reality. But an ossification of political debate obscures that reality. And that has prevented us from confidently exploring necessary reforms.

Taxpayer-funded health care paid for by provinces is one of the great Canadian legacies. It continues to offer reliable service at low administrative cost, providing a good measure of satisfaction and certainty. By and large, Canadians never have to worry about how they'll pay their health care bills, or that health care problems will force them or their family into bankruptcy.

There is little evidence that Canadians are prepared to countenance radical change. User fees for doctor visits could make health worse, as poor and middle-income people might prefer to go without. And two-tier health care, where those who can afford it get the chance to buy their way to the front of the line for medically necessary services, undermines a system that can, with reforms, be made to work.

But two-tier care and privately delivered care are not the same thing. A good deal of the system is private already. And where it generates savings, if we maintain the same standards we expect from providers in the public system, more of it should be.

Opponents of privatization need a dose of reality on this point. After all, the Canada Health Act does not have the word "private" in it at all.

Some of the most successful private experiments have driven down costs for cataract surgeries and hip and knee replacements. Such experimentation can be applied to more complex care. Most European countries manage to provide universal or near-universal coverage and have shorter waiting times for many procedures, while allowing for many private players, even private hospitals.

Experimentation can extend to the public system. More hospitals, doctors and health care teams are getting paid per patient. That can mean better health at a lower cost. And provinces can continue centralizing their drug purchasing, a cost-saving measure that doesn't affect patients directly.

Restraint will also have to be shown by health care workers themselves. They'll need to tame their salary demands to help governments get through today's fiscal crunch, or else the political consensus opposed to two-tier care could crumble. An arbitrator's decision this week to award a 4 per cent salary increase over two years to 17,000 Ontario nurses, for example, does little to keep health care sustainable. Similarly, physicians who enjoy high fee payments for services that now take a fraction of the time to provide should be prepared to make concessions.

We need to reconsider what an "essential service" is. Mental health, access to drugs and care for the elderly get consistently short shrift, and demand for these is only going to expand.

We could apply experimental and private approaches to these evolving needs. A single national, taxpayer-funded elder care program may not work. But private groups of health care workers and homecare facilities could be allowed to bid on the right to provide elder care services in a given region. Add in more assistance for family members (through enhanced employment insurance benefits and more flexibility from employers), and we can start addressing the crunch faced by the sandwich generation.

A looming showdown between the provinces and the federal government over health care funding will consume much of the political attention over the next few years. But we are already learning how to deliver compassionate care more affordably. And there's every reason to believe that patients and families will do whatever it takes to keep medicare, a great Canadian inheritance, sustainable for future generations. What they need is some political leadership to implement the solutions at hand.