There's an ominous new meaning for two-tier medicine in Canada: rather than one system for rich people and one for the poor, it will be one system for rich provinces and one for the poor.
Ottawa has unilaterally declared a new health-care funding formula that eschews the old prescription of giving poorer provinces proportionately more health-care dollars than richer ones, substituting a per-capita formula that removes the built-in penalty for economic growth. The result is a health-care fight at the Victoria meeting of the country's first ministers that has become a proxy for the larger forces reshaping the balance of power in the country: a clash that pits the fast-growing, resource-rich West against the East.
Any doubt about this was quelled when Quebec Premier Jean Charest stepped to the microphone first thing Monday morning and talked about federalism's new truth.
"There's two realities in Canada," said the Premier. "There are the economies of oil, gas and potash and the others. That's the reality of Canada, and once we know that, we need, I think, to be able to make decisions accordingly."
What Mr. Charest means, we assume, is that the West is richer than the East thanks to access to valuable raw resources. And this, he believes, needs to be taken into account in areas such as health-care funding. The wealthy should subsidize the less fortunate so our provincial governments don't unwittingly create a two-tier health system of a different sort.
The Quebec Premier's lament certainly echoed past complaints from the poorer provinces. And it was no surprise that his position wasn't sympathetically embraced by Alison Redford.
Instead, the Alberta Premier again applauded a new federal "per capita" funding formula she says treats all Canadians equally. In other words, those living in her province don't receive proportionally less for health care than someone living in Nova Scotia or Quebec.
All the premiers were saying what you might expect about the prospect of a two-tier health system in Canada, one divided along economic lines. Whether it was host Premier Christy Clark or Ontario's Dalton McGuinty, the premiers insisted that every Canadian should have access to a comparable level of health care.
But "comparable" is a fairly vague term of measurement.
There isn't a truly equal level of health care in Canada even now. Wealthy provinces have hospitals and programs that poorer ones can only envy. Wait times for certain procedures can vary widely between jurisdictions. There is a reason for that. The health budgets of some eastern provinces eat up their entire equalization payment. That is not the case for provinces such as B.C. and Alberta, where the economies are growing and the governments can afford to pour dollars into their health care systems.
The question is: will Ottawa's new no-strings-attached funding proposal exacerbate the discrepancies in health care that already exist? And does Ottawa even care if it does?
Unless Stephen Harper and the Conservatives have an unexpected change of heart, it would seem this is going to be a problem the provinces are going to have to grapple with on their own. To that point, the sooner they begin sharing thoughts on how to start turning the health cost curve downward through innovation and best practices the better.
It will be savings made through these types of initiatives that will allow poorer provinces to stay in the health care game.
Moving ahead, it will be the provinces who make the health guarantees in Canada – not the federal government. It will be the provinces who will have to make themselves accountable to their citizens to deliver the same level of service across the country – not Ottawa. How they do that is something they're just starting to figure out now.
"We don't want 13 different health care systems in Canada," Ms. Clark said on Monday afternoon. "And we don't want different levels of care between provinces. Canadians expect the same care wherever they are."
The challenge of delivering on that just got a whole lot harder.