An ill wind blows.

Cuts in health-care funding are seen as a threat to the quality and accessibility of a Medicare program that was the pride of the Canadian government in the 1960s

The debate on social programs is particularly steamy when it comes to health care. The provinces feel that Ottawa, having slashed their funding, has forced them to do the dirty work of closing hospitals and capping doctor's fees. Premiers resent the fact that Ottawa acts as judge and jury when the principles of Medicare and bent or broken even though it now contributes just a fraction of the money in the system. Now, Ottawa is talking about expanding health care to include the cost of prescription drugs and home care. The provinces say the basic health care system itself needs to be fixed first.

Provincial finance ministers want to see Ottawa use its new-found fiscal health to rebuild the huge reductions to health care before thinking of other places to spend money.

They feel even the government's recent guarantee of $12.5 billion in CHST (Canada Health and Social Transfer) transfers in the years to come won't make up for billions of dollars in cuts over the past few years.

While the increase, announced last year, marks a turnaround from a steady erosion of Ottawa's health spending over the previous four years, CHST transfers in 1997 were still about $7 billion lower than the CHST level in 1993-94.

Tom Kent was one of the architects of the social-safety net when he worked for former prime minister Lester Pearson in the 1960s. He couldn't agree more that Canada's health-care system needs a big boost. He says the federal government needs to give the provinces another $10 billion to save the Medicare system. That would merely go back to the payments Ottawa committed itself to make 30 years ago when it negotiated with the provinces to set up the Medicare system, he says.

In a paper published near the anniversary of Mr. Pearson's death in late December 1997, Mr. Kent bitterly attacks succeeding governments. He accuses them, including the current Liberal government, of "political betrayal" by which they have "destroyed, the financial basis on which their predecessors created (Medicare)."

Mr. Kent says the federal government has weakened its powers to preserve Medicare by cutting its financial contribution. Ottawa has also deliberately undermined the system envisioned by Mr. Pearson as a force to bind Canadians together.

He says today's politicians should consider extending the Medicare system -- the political leaders who set it up envisaged eventual coverage for drug costs as well as dental and eye care. But, he adds that the government shouldn't tack on plans covering drugs and home care without rebuilding the financial sharing between federal and provincial governments.

"The provinces cannot be asked to accept new programs -- pharmacare or any other, however desirable, however shared -- while the federal government retains its present degree of downloading of existing programs.

"The maintenance and improvement of Medicare depend on a reinjection of federal funds. And, not in trivial amounts."

A few months earlier, in August 1997, a Saskatchewan health advisory group said Canada may be moving into the danger zone on the division between public and private spending on health care.

Figures from Health Canada show that public spending on health care dropped below 70% of total expenditures in 1996, and that actual spending on Medicare has decreased for the first time.

Steven Lewis, head of Saskatchewan's Health Services Utilization and Research Commission, says that puts Ottawa's share of health spending at the low end among developed countries with public health-care systems.

"... below what percentage does the public Sector have to fall before we see really serious erosion of Medicare?" Mr. Lewis says. "In most [developed] countries, the split is between 70% and 80% and now we are creeping below 70% ... To get to 50% would be alarming."

Patients are paying more of the cost of health care themselves than they used to. Doctors charge a $10 or $15 fee to fill out a medical form or do a phone consultation. Some laboratory tests are not covered by Medicare. Many drug prescriptions and home care costs must be picked up by patients. Practically every hospital , in the country is seeking donations from the public for expansion or new equipment.

The public expenditures that have fallen include everything from hospital operating budgets and doctors' services to local public-health programs and workers' compensation costs. At the same time, private costs range from payments for semi-private hospital rooms to over-the-counter medications.

Most Canadians, in fact, do not think private health-care is the answer to problems in the current system. According to a 1997 study by the Canadian Medical Association, only 35% of 250 participants (across the country) believed that problems with Medicare mean that "there will have to be an increase in private funding in health care." That was down from 44% who thought private care was necessary in May 1996.

More than 60% of the participants in the CMA's study believed that private funding is not the way to improve health care in Canada, up from 54% a year earlier. Rather than back a two-tiered health care system, the CMA, wants more money from the government to fund the current system properly.

Continued cutbacks will likely lead to further decline in the quality of our health care. Ontario, for example, moved too far, too fast with its restructuring of hospitals, according to a study by the University of Western Ontario's business school.

The 1997 report found various examples of a decline in hospital services: less nursing time per patient; high employee stress; slow recording of patient data; reduced patient supervision; less appetizing food; and lower levels of cleanliness.

Politicians in two of the hardest hit provinces are having a change of heart.

By November 1997, the Ontario government decided it needed a complete re-evaluation of every aspect of health care in the province.

In late 1996, the Alberta government also decided to inject $97 million into healthcare services as part of a plan to restore most of the money cut from the system by Premier Ralph Klein's administration. Expenditures are scheduled to increase by another $170 million between 1997 and April 2000, making up almost entirely the cuts imposed by the government since Mr. Klein became premier in 1992.

SUGGESTED ACTIVITIES:

1. In 1997, a National Forum on Health report defended the current federal role in setting and enforcing national standards for Medicare, and rejected the idea that the provinces and territories should join in setting standards. "With the best of intentions, such an arrangement would probably tend toward an increasingly minimalist interpretation of national principles as the provinces experience various economic circumstances, priorities, and political preferences," the draft report says. Explain why you agree or disagree with this conclusion.

2. As beds in psychiatric institutions and hospital wards continue to disappear in Toronto, people with diagnosed mental illnesses have turned to hostels where overworked staff have little time or professional training to deal with the serious psychiatric disorders. One report estimated that at least 600 people with serious mental illnesses are living in the city's hostels -- more than the inventory of beds in the city's two main psychiatric institutions. Who is responsible for these people, and what should be done to improve services to them?

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About 13% of Britons have private health insurance, but the rest rely on the health service or pay out of pocket for private treatment.

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According to a Southam NewsCompas poll in 1997, 82% of Canadians surveyed favour more spending on emergency health services, and 83% advocate higher funding for health care for children.

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The Canada Health Act -- the federal law that sets standards for Medicare -- is based on the five principles of universality, accessibility, comprehensiveness, portability, and public administration.