In Canada, the struggle around medicare never goes away.

To the general populace, universal public health insurance is an unalloyed asset. Politicians who criticize it openly do so at their peril.

But beneath the surface, the pressure to eat away at medicare is relentless.

Sometimes, that pressure comes from health-care providers trying to make money. Sometimes it comes from governments trying to save money.

But in the end, medicare puts every government to the test. Prime Minister Justin Trudeau will find that his Liberal regime is no exception.

The most recent flashpoints are in Quebec and Saskatchewan. Both provinces have instituted reforms that push their health systems toward two-tier medicine.

Quebec’s reforms in particular could end up violating the Canada Health Act, a federal statute that prohibits physicians from charging extra fees for medically necessary services.

That province has long allowed physicians to extra-bill patients for “medication and anesthesia agents.” The idea, presumably, was that doctors couldn’t charge patients out-of-pocket for, say, looking at a sore finger. But they could charge for the cost of a bandage.

This deft distinction was designed to get around the Canada Health Act’s requirement that medically necessary physician and hospital services must be supplied free of charge.

As the Montreal Gazette has reported, some Quebec physicians interpreted this loophole in a remarkably broad fashion.

Some doctors performing colonoscopies in private clinics, for instance, charged $600 in medication fees — this on top of the amount they received from Quebec medicare.

Instead of banning such practices, however, Quebec’s Liberal government decided to further embed them in the province’s medicare system.

Bill 20, passed last November by the National Assembly, accepts the principle that physicians can charge ancillary fees but gives Quebec’s government the power to regulate what those fees will be.

So far Premier Philippe Couillard’s government has not yet produced a list of permissible extra-billing charges.

When it does, Trudeau’s federal government will be on the spot. Will it enforce the Canada Health Act’s ban on extra billing by withholding federal health monies from Quebec as the law demands?

Or, like so many federal governments before, will it ignore the problem and pretend that nothing happened?

Saskatchewan presents Ottawa with a murkier problem. In November, Premier Brad Wall’s government passed a law allowing private MRI clinics to operate in the province, charge whatever fee they choose and bill patients directly for the service.

The interesting wrinkle is that for each private scan, these clinics would have to offer one MRI free of charge to patients waiting in the public system.

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Wall says the net effect will be to reduce wait times overall. The Saskatchewan Medical Association, which opposes the move, is skeptical.

Writing on the University of Manitoba’s EvidenceNetwork website, Dr. Ryan Meili of Canadian Doctors for Medicare notes that Alberta’s embrace of private imaging clinics didn’t solve wait time problems there.

Meili notes that although Alberta has the second highest number of diagnostic imaging scanners per person in Canada, it also suffers the longest wait times.

He points out that the real effect of private-pay imaging clinics is to give those with money an advantage in obtaining necessary surgery.

In the past, Ottawa has chosen not to get involved in the diagnostic imaging controversy, saying nothing when Alberta, British Columbia, Nova Scotia and Quebec went the private-pay route.

Stephen Harper’s strategy for dealing with medicare was to ignore Ottawa’s enforcement role and, when the opportunity presented itself, scale back federal funding.

That the provinces are responding by moving more into two-tier care is the logical result.

Trudeau’s strategy is unclear. Except for a pledge — not yet kept — to devote an extra $3 billion to home care, he said little in the election campaign about health.

Any ideas he may have about his promised health-care accord with the provinces have yet to be revealed.

I don’t recall him saying anything about the Canada Health Act.

Still, he can’t avoid medicare for ever. No prime minister can. It may not dominate the front pages. But as far as most Canadians are concerned, it is still the country’s number one political story.

Thomas Walkom’s column appears Wednesday, Thursday and Sunday.

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