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With hospitals stretched by the Omicron variant of COVID-19, and constituents wondering if the health care system is strong enough, provincial premiers did what they do: They called on Ottawa to give them more money.

At this point, we may want to conclude this runaround isn’t getting us anywhere.

So let’s stick primary responsibility for fixing health care systems where it belongs – with provincial governments and premiers who have constitutional responsibility for health care.

The question of who pays is a lot less important to us Canadians than it is to our politicians. Yet the latest pandemic conference call between Prime Minister Justin Trudeau and provincial premiers was the scene not only of pandemic requests for supplies of rapid tests and approvals of medications, but for dramatic increases to federal health transfers, more than $28-billion a year.

Premiers have been doing this for years, and there is plenty of reason for them to do it now, when the pandemic has people wondering if their health care systems need to be beefed up, not just now, but over the longer term. The call for federal cash is a way to deflect the basic question of political accountability: What are you going to do about it?

The point here is not to let the prime minister off the hook for his promises to fund health care, or the fact that they are made in a way that makes the accountability problem worse. It is that only provincial governments can actually answer for the way health care works.

Canada’s health care system ‘stretched too thin,’ health minister says, as hospitals grapple with Omicron wave

After this week’s first ministers’ call, a spokesperson for Ontario Premier Doug Ford issued a statement citing a “gap” in federal funding of billions of dollars that could be used to improve health care – as if provincial authorities can’t improve the system until the feds cough up more dough.

But of course they can. They can raise funds in almost all the same ways that Ottawa can, from the same taxpayer. And they can decide what needs to be funded and what doesn’t.

Only provinces, not Ottawa, can make choices about how the health care system works, to make it more efficient or provide better care.

Only provinces can answer the kinds of questions they face in a pandemic: Why are hospitals in Quebec, a province of nine million, in crisis when there are 2,500 patients with COVID in hospitals, only half of whom are being treating primarily for the virus? Why does Canada’s richest province, Alberta, have so many fewer ICU beds than one of the poorest U.S. states, Alabama? The real questions will always be about provincial choices. There’s a need for accountability.

In some provinces, voters are asking those questions. Nova Scotia Premier Tim Houston won power in August with a campaign focused on a promise to improve health care. Other premiers – and their opponents – should take note.

Which doesn’t mean Mr. Trudeau is off the hook.

Health care is often a major concern for Canadian voters, so he likes to promise better outcomes by earmarking funds for specific things. In the last campaign, he promised $6-billion for surgery backlogs, $3.2-billion for family care, $1.1-billion for virtual care, and so on. But he can’t really guarantee outcomes or even that the additional money will go to those things.

The provinces insist Ottawa should just give them a lump sum and stop telling them how to spend it – which, in theory, it should.

But the feds have done that in the past and never got any credit. In 2004, then-prime minister Paul Martin signed a “fix for a generation” arrangement for health care funding with premiers that didn’t bring lasting peace. The 1979 transfer of tax points in which Ottawa ceded taxation room to the provinces was forgotten. So federal politicians such as Mr. Trudeau campaign as if they are premiers. And that makes the accountability problem worse.

So we should absolutely expect Mr. Trudeau to live up to the dollar value of his health care promises, which the Liberals pegged at about $20-billion in additional spending over five years. We should expect premiers to insist it come with few strings attached.

And if the provinces do spend more, they can tell voters Ottawa isn’t keeping up its share. But that’s an issue of who levies taxes. When it comes to improving health care, it’s up to premiers to tell us what they are going to do.

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