As political debate and its consequent media coverage slowly recede from the "all terror, all the time" focus, health care is re-emerging on the public policy radar screen.

The Romanow commission on medicare is gearing up and the Kirby Senate committee - to which yours truly testified last week in Toronto - is continuing its consultations. Provincial health minister Tony Clement just gave us a peak at the mood of 450,000 Ontarians - over a 10% response rate to his summer survey - and we're not pleased at our minimal input and lack of control when it comes health care reform. And locally, the hospital infrastructure issue is back in play at city hall and the idea of a regional health authority is also in the mix.

While a regional health authority (RHA) structure - employed in every other province - would help in some areas of coordination, service apportionment and human resource planning, folks are dreaming if they believe such a structure would mean an end to deficits, waiting lists, and cancelled surgeries.

For the most part, RHAs simply replicate unwieldy provincial health bureaucracies at the local level. From B.C. to New Brunswick, many of these RHAs are running deficits, just like the Ottawa Hospital, not to mention a few dozen others across the province.

In an eerily similar parallel to the primary care reform fervour we see today, regionalization was the medicare fad of the late 1980s and early 1990s. But regionalization represents a minor supply-side solution to more fundamental issues of inexhaustible patient demands and expectations, flawed economics, perverse incentives and multiple external pressures that have driven our health care system to a state of crisis.

This situation is chronicled in a 109-page study that I authored and released for the CTF in September entitled: The Patient, The Condition, The Treatment (see www.www.taxpayer.com).
Although this study received acclaim former head of the OMA, a former Donner prize winning author and the Alberta Minister of Health, and although it was circulated widely among national and local journalists, sadly, only a handful of them (and I mean just one fist) have actually bothered devote some time and read it. Nonetheless, let's look at the big picture.

Our national - and local - health care debate has been dominated by the usual public policy surrogates who have diminished complex issues by referring to facile U.S. vs. Canada or farcical left vs. right ideological disputes. These surrogates have also created a climate where invective rhetoric, sloppy logic and personal character attacks await anyone or any group that proposes something new. Toronto-based psychiatrist Dr. David Gratzer labels this the more money (spendthrifts) vs. better management (magicians) paradigm. The RHA-will-cure-all proponents fall into the hocus-pocus category.

Still, Canadians yearn for an ideas-based discussion about all possible options for reform. Collectively, we know that we will spend some $95 billion - or 9.3% of GDP - for health care this year. And with health costs consuming 62% or $20 billion of all provincial budget increases over the last three years, it is clear that health care is a taxpayer issue.

But before the debate can move forward, we must agree on several key points of reference or assumptions. First, health care is in a state of crisis. Second, health care is a shared jurisdiction between Ottawa and the provinces. Third, the Canada Health Act is not the Bible. Fourth, it is impossible to measure health systems by numbers alone. And fifth, quality and excellence must be the primary focus for reform, not cost containment, which merely shifts resources and doesn't address structural issue.

The development of health care policy in Canada over the past century reveals that we can handle exhaustive and sometimes painful debate. We owe it to ourselves, not to mention our kids, to mirror and build on this history by objectively considering all options for reform. The logical starting point is with a review of the Canada Health Act (CHA), since it is the de-facto standard by which reform options are judged.

Increasingly, scholars and medical practitioners are converging around one dominant school of thought about this Act: it constrains provincial initiatives and its core principles are often in conflict with each other. Meanwhile, public opinion reveals a thirst for fundamental changes, even if these changes contravene some of the Act's existing principles.

The Act has also fuelled the fight between Ottawa and the provinces over funding levels. While some jurisdictional tension is inherent and necessary in our federal system, it has clearly reached a counterproductive level.

In the provincial capitals, health ministers - regardless of partisan stripe - have all stated that health spending increases that double or even triple annual revenue growth are unsustainable. Yet in budget after budget, they continue to ramp up the health care envelope.

But as this spending continues unabated, today's tax cuts vs. social investments debates will quickly give way to tomorrow's spending cuts vs. spending cuts debates. Legislatures will be forced to choose between MRIs and textbooks or worse still heart surgeries vs. cancer tumour resections. Provinces will need only two ministries: finance to collect the money, and health to spend it. Indeed, health care will consume 50% or more of the budgets of seven provinces by 2018.

At the root of this problem is medicare itself and its flawed economics. Its present, pay-as-you-go funding configuration is unsustainable. In this context, it is similar to an illegal pyramid scheme. Today's tax collections fund tomorrow's surgeries, but in a decade, the demand for surgeries may well outstrip our ability to pay.

Funding flows from taxpayers though a variety of intermediaries - governments, insurers, etc. - and insulates patients from the financial ramifications of their consumption decisions. As a result, we are left with a patchwork system of perverse incentives for patients, doctors, bureaucrats and politicians. This perversion serves to drive up costs and vaccinates the system against innovative options that could improve quality and health outcomes.

Worse still, a "gang of four" pressures will only complicate this situation. Demographics point to an aging population and aging health practitioners. Technological advances - while welcome - usually improve upon existing technology instead of replacing it. Furthermore, advances in rational drug design, genetic mapping and artificial blood, bring exciting hope and promise, but they come with a hefty price tag. Pharmaceuticals now consume more resources (ie: dollars) than physician billings. In the last decade alone drug costs to provincial health plans have skyrocketed by 87% (inflation adjusted). Finally, patient demands for "right here, right now" services will magnify exponentially.

Health care reform is complex and there are no magic bullet solutions - be they regionalization, primary care or user fees - to fix the system. However, key principles do exist that should be employed both in legislation and in restructuring service delivery.

At the legislative level, a modernization of the Canada Health Act is long overdue. Its five current principles should be replaced by the following six principles: public governance; universality; quality; accountability; choice; and sustainability.

At the structural level, guiding principles for reform should include: more individual accountability and responsibility (this could include forms of co-payment as employed in every other OECD country); intergenerational fairness (pre-funding of health care is key which could include health care savings allowances or lifetime accounts); and an embrace of innovative approaches (including flexible and workable public-private partnerships in capital construction, service provision and technology renewal).

Regionalization while somewhat attractive for Ottawa's current woes, is akin to putting a tiny band-aid on a gaping flesh wound. We can and must do better.

The principal and laudable aim of medicare was to provide health services without hindrance. Now, the greatest hindrance to reform is the intransigence of those who refuse to accept that the problem with health care is the system itself.