Chicken little? Why the healthcare sky does not have to fall

If the healthcare sky is falling, it is because we have not yet grasped the opportunity to do better. Here we comment on three points in Chappell and Hollander's lead article. First, rather than looking to new federal-provincial mechanisms, which do not currently appear on the political agenda, we propose that federal and provincial governments honour their current commitments, including an extension of the 2004 First Ministers' agreement, set to expire in 2013-2014, that flows federal healthcare dollars to the provinces. Second, we concur that small things (e.g., transportation and medication management) matter in big health systems. Access to a full range of services in integrated systems of care permits cost-effective "downward substitution" instead of more costly, and often inappropriate "upward substitution" to hospital and institutional care. Finally, given the current political climate of fiscal constraint, it is helpful to consider the lessons of successful local initiatives such as supportive housing, which can integrate care "from the ground up" including essential primary and preventive care. Rather than seeing an aging population as the harbinger of healthcare doom, we suggest seeing it as a motivator to rethink, refresh and innovate.