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Alberta Children's Hospital in Calgary on Nov. 24, 2019.Larry MacDougal/The Canadian Press

Just before the end of last year, François Legault told reporters he was more optimistic about the premiers and the federal government reaching a health care funding deal. “We are heading in the right direction,” the Quebec Premier said after a meeting with Prime Minister Justin Trudeau.

Heading in the right direction – at this point? The premiers have been writing the Prime Minister on this issue since at least December, 2021. To borrow from George Marshall, the patient is sinking while the politicians deliberate.

To outline just the most recent health care crunch, the last weeks of 2022 saw children’s hospitals in crisis mode. In Edmonton, it was a shift to mandatory overtime and cancellation of staff vacations. In Calgary, it’s a trailer outside the main doors to handle the overflow of lined-up families. In London, Ont., it’s a plea to retired pediatric staff to come back to work.

Across the country, emergency room doctors and nurses are worried about the worst possible outcomes. The pandemic, and its aftereffects, are not going to be tidied up quickly. A COVID-19 disaster is now unfolding in China. Within a matter of weeks, it could be something new that preoccupies our overburdened health care systems.

It’s certainly not that cash from the federal government that will solve all of this, but a plan to work together, and a promise of increased and stable funding from Ottawa, are part of the answer.

The federal government argues that the premiers are being dogmatic in their demand for much more in Canada Health Transfer billions with no strings attached – and a massive boost in health care transfers only helps provinces enact tax cuts, send out cheques to help with inflation or pay off debt.

The provinces and territories tout their first-hand knowledge of actually running health care systems, and emphasize that different parts of the country face unique circumstances, such as older or more geographically dispersed populations. The premiers insist that a First Ministers’ conference – an actual meeting with the Prime Minister – is the only thing that will actually move the needle.

In year-end interviews, Mr. Trudeau said he won’t sit down the premiers until the broad outlines of a deal are sketched. And his government also argues that provinces are relatively flush with cash. Yes, there are provincial surpluses this fiscal year. But Canada is an incredibly decentralized country and most of the public debt – including past spending on health care – is held by provinces. You can understand why the provinces and territories wouldn’t want to add to this bill at the same time Ottawa brags about its debt-to-GDP ratio.

(The Organization for Economic Co-operation and Development said subnational outstanding gross debt is relatively limited compared with central government debt, accounting for 9.8 per cent of total public debt in 2020 amongst the 75 countries sampled. Canada, however, is an outlier – with 53.6 per cent of public debt held by subnational governments.)

That doesn’t mean the united premiers are blameless, either. They are playing fast and loose with the numbers regarding health care funding. They have primary responsibility for health care, which means primary responsibility for its failures. Given the economic volatility likely to present itself in 2023, Ottawa has a responsibility to be fiscally responsible.

And any money to be used in important recruitment and retainment measures for health care workers could quickly end up as a staffing arms race between provinces. Perhaps if the federal government inserts any conditions, it has to be concerned with the level of aggression and tactics allowed for luring staff from other provinces.

The pandemic-fuelled health care challenges of today make the health care negotiations of the past look like a trifle. But going back nearly two decades, then-Manitoba premier Gary Doer said then-prime minister Paul Martin’s 2004 decision to make health care discussions public forced a solution.

“It wasn’t like the Treaty of Utrecht. We got it done in 48 hours,” Mr. Doer said in an interview last month.

“It was really important for us to have a full day in open televised discussion,” he added. “Why should we have a televised committee on XYZ but not on the most important item in Canada?”

Mr. Legault, in characteristic frankness, has said the current Prime Minister has been hesitant to convene what will be a closely watched meeting with premiers on the subject of health care out of fear that the discussions would not end positively. “He doesn’t want a failure,” Mr. Legault said.

A complete failure on a funding deal for health care isn’t really an option. But Mr. Trudeau certainly wants to avoid a political defeat. Another part of health care history is that Mr. Martin faced so much pressure for his health care talks to be successful he was forced to concede vast amounts of cash to the provinces and territories. (On the plus side, it also led to a decade of stable health care funding and some improvements in wait times).

Mr. Trudeau’s best chance to win, or at least to not lose, politically is probably akin to what he has done on child care or carbon pricing – to allow for individual, semi-private deals with each of the provinces.

But a full public airing of where the provinces, territories and Ottawa stand when it comes to health care funding and expectations early in 2023 could serve as a catalyst for action. We’re at that desperate point, a few months away from a federal budget no less, where Canadians expect their politicians to move beyond their impasse and do something.