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While health care is consistently identified as the No. 1 concern of Canadians in opinion polls, the issue rarely arises on the campaign trail.

Debates among the leaders – and questions from reporters on the campaign trail – will be dominated by talk of the economy, foreign policy, defence and the environment, but health care will barely merit more than a few jingoistic platitudes.

This seeming paradox, which has been the norm for decades, is easy enough to explain.

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"I never had a conversation about health care that didn't lose me votes," Joey Smallwood, the legendary premier of Newfoundland and wily politician, is purported to have said.

In other words, talking about health care tends to be a lose-lose for politicians.

Why is that?

First, Canadians love medicare. Despite the fact that it is a public insurance program – and not a particularly well-designed or well-managed one – the public romanticizes and mythologizes medicare to the point where ridiculous statements such as "medicare is what defines us as Canadians" get bandied about, and Tommy Douglas is elevated to deity. Any politician worth her or his salt knows better than to challenge idolatry.

What that means, practically speaking, is that there is no political incentive to challenge the status quo – on the contrary, it's best to perpetuate it.

So, when politicians do talk about health care, they don't promise change, they promise more money.

Another key reason that there is little debate about health care is that there are few fundamental differences in the policies of the major parties, especially on paper.

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All of them – Conservatives, New Democrats, Liberals, Greens, Bloc Québécois – support universal, publicly funded health insurance. All of them believe Ottawa should transfer significant amounts of federal tax dollars to the provinces for health care.

And all of the parties conveniently ignore that Canada has the least universal, most expensive, and least cost-efficient universal health system in the world, and that the provinces have almost no accountability for the federal money they receive.

There are some differences among the parties, of course, but they are largely philosophical, and revolve around interpretations of the constitutional divisions of power – not very good fodder for sound bites.

The Conservatives (at least under Stephen Harper) believe health is strictly a provincial responsibility and Ottawa should transfer money with no strings attached. The separatist Bloc has the same position.

The New Democrats, Liberals and Greens believe that Ottawa's role should be to create a semblance of a national health plan and show moral leadership (for lack of a better term).

But to do so they need to, among other things, earmark money, to demand it be spent on specific programs. But the leaders don't want to say so out loud because no federal leader wants to pick a fight with the provinces during an election.

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NDP Leader Thomas Mulcair has made a number of health-care promises aimed at specific demographic groups – such as home care and long-term care for seniors and a mental health plan for teens – but has been fuzzy on the details and an overall plan.

Similarly, both the Liberals and the NDP promise to renew the health accord by holding talks with the premiers, but offer no hard numbers. (To refresh memories, in 2004, the Liberals unveiled the health care "fix for a generation," which principally involved increasing health transfers to the provinces by 6 per cent a year for 10 years. The Conservatives extended the 6-per-cent escalator to 2017; after that it will be tied to inflation, and no less than 3 per cent per annum.)

Pharmacare – providing affordable access to prescription drugs for all Canadians – is another hot topic in health circles, but not on the hustings. The Greens have a firm plan to implement pharmacare, saying it will save up to $11-billion annually, but promising a national plan is easy when you have little chance of winning power. Other parties are more circumspect about a topic whose details really matter.

In fact, that's the overriding reason health care is difficult to discuss on the campaign trail: It's a sprawling, complex topic, with many potential pitfalls.

Health care is not one issue, it's 1,000 issues. The politician who wades too deeply into the morass risks bleeding support, suffering the proverbial death by a thousand cuts.

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