This article argues that the debate over the future of Medicare has been dominated by financial considerations at the expense of an examination of the place of supervisory institutions in the health care system. Supervisory institutions will be of central importance to the future of Medicare because any future system will include some national standards, which, to be effective, must be interpreted, applied and enforced by institutions of some kind. This article focuses on two specific institutional questions: the dismal record of federal enforcement of the existing national standards of the Canada Health Act, and the pressing need for dispute-settlement machinery under the Social Union Framework signed by Ottawa and nine provinces in 1999. The article also examines the compliance of Alberta’s Bill 11 with the Canada Health Act.

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