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During a quiet moment, one of the people at the very centre of yesterday's health-care negotiations among the premiers expressed this concern: "What worries me," he said, "is that Paul Martin doesn't have an exit strategy. So if it falls apart, then what's going to happen to Jean Charest?"

We are all working on the assumption that this week's meeting of the Council of the Federation, will result in a communiqué obscuring differences among the provinces and demanding that Ottawa pony up money for health care, no strings attached.

We all assume that this will lead to a great deal of chest expansion from Ottawa, but that both sides will reach a compromise at the September first ministers conference. But what if we're wrong?

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What if Health Minister Ujjal Dosanjh's stiff-necked determination to exorcise "creeping privatization" from the health-care system runs up against Alberta Premier Ralph Klein's vocal musings about freedom of choice?

Yesterday, Mr. Klein raised a question virtually no politician in Canada ever dares broach: Why, he asked reporters rhetorically, are you free to piss away money at a casino, but you can't use it to get your mother the hip replacement she so desperately needs?

Such questions are intolerable, because they expose the underlying totalitarianism of the public health-care system. Mr. Klein will need to stifle himself; that sort of loose talk could wreck the necessary compromise.

If that compromise does founder, we're in trouble. The Canadian brand of federalism will have shown itself inadequate to the needs of the country, jeopardizing the federalist cause in Quebec.

One of the most baffling aspects of Paul Martin's prime ministership is his indifference to the fate of the Liberal Party of Quebec. Mr. Martin and Jean Charest have known each other since Mr. Charest was environment minister and Mr. Martin environment critic in the days of Brian Mulroney.

Last summer, the two had several relaxed and productive conversations at Mr. Martin's farm in the Eastern Townships.

But by last Saturday, when the two spoke briefly, Mr. Charest's private comments to Mr. Martin had become identical to his public position: Quebec considers the federal government's conditions for increased health-care funding intolerable. Recent exchanges by their respective staffs have been similarly frosty, leaving someone to wonder whether Mr. Martin lacks "the Quebec reflex."

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At root is the evolution of Mr. Martin's definition of federalism. Most observers believed that the Prime Minister was far more sympathetic to provincial concerns than was Jean Chrétien, that he wanted to end the chronic warfare over funding and the interminable federal intrusions into provincial jurisdictions.

That seemed to suggest that he sympathized with the version of federalism embraced by every Liberal Quebec premier since Jean Lesage: that Quebec and Ottawa should each respect, and stay out of, each other's jurisdiction.

Instead, Mr. Martin fought the June election on promises to further federalize the public health-care system by imposing conditions on additional funding, while also getting Ottawa back into the game of urban redevelopment.

To make things worse, Ontario Premier Dalton McGuinty has eroded the Quebec-Ontario solidarity forged by Lucien Bouchard and Mike Harris, leaving Alberta as Quebec's sole, uncertain ally.

This is why we need to hope that the premiers and the Prime Minister eventually find a way to blunt the edges of their differences. Whatever the long-term prospects for medicare, the short-term prognosis is dire without a major infusion of federal funds.

And if they fail, then the resurgent sovereigntists in Quebec will have powerful ammunition with which to assault the federalist cause, and we could be looking at a referendum in 2010.

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"I'm a federalist, you know," Mr. Charest said yesterday. But Quebec federalism "requires that the areas of jurisdiction be respected." It sounded almost plaintive. jibbitson@globeandmail.ca

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About the Author
Writer-at-large

John Ibbitson started at The Globe in 1999 and has been Queen's Park columnist and Ottawa political affairs correspondent.Most recently, he was a correspondent and columnist in Washington, where he wrote Open and Shut: Why America has Barack Obama and Canada has Stephen Harper. He returned to Ottawa as bureau chief in 2009. More

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