The 2004 Health Accord expired last  week, not with a bang, but a whimper. While there was protest from some corners, it didn’t make a noticeable dent on the front pages.

A few columnists came out to bury the Accord (certainly, praise was not in order), citing its failure to move forward on virtually every marker of progress, and bemoaning its entrenchment of status-quo mediocrity in our health care system.

They weren’t wrong – the Health Accord was supposed to be “a fix for a generation” that created national goals and standards Instead, Canada made only modest improvements and lags behind other high-income countries in overall performance, according to the Health Council of Canada, the body created to monitor the Accord’s progress.

All of that misses the big picture. The real questions are: Do we still want the changes the Health Accord was supposed to deliver, and do we care about national standards? If so, what’s the way forward, and whose responsibility is it?

The Health Accord was supposed to reduce wait times, establish a pharmaceutical strategy, improve access to primary care, invest in innovation and increase capacity for home care and community care. It’s difficult to believe that Canadians wouldn’t want these things – or that they wouldn’t want the same standard of care as their neighbours in the province next door.

Canadians consistently rank health care as their number one or two concern in survey after survey.  They also say that the federal government has some responsibility for it. Wrapping ourselves in the flag, we take pride in our national health care system, and have an unspoken acceptance of its value to the fabric of Canada.

The issue of who takes responsibility is far murkier. The current federal government has continually, albeit quietly, moved away from health care. It never features prominently in budgets or throne speeches.

The prevailing message for years was that health care is the responsibility of the provinces alone. The feds changed tack recently after much criticism from health care professionals and advocates, replacing Leona Aglukkaq with Rona Ambrose as Health Minister, and declaring that they were open to collaboration and consultation to move forward together.

While the voice on the Hill may be somewhat louder, the strategy hasn’t changed on the ground. They shuttered the Health Council of Canada, and changed the health transfer formula, tying it to economic growth, and using a per capita formula that will result in big reductions in the transfers to all provinces (with the exception of Alberta).

And what about the provinces? Although the federal government is often painted as the villain in this story, it’s fair to mention that there were no premiers clamoring to demand the negotiation of a new Accord.

There are a few good reasons for this. Arguing for transfers is a shell game. If provinces push for a renewed Health Accord with dollars attached, they likely fear reprisal in the form of a reduction in other federal transfers. For many, it wasn’t worth spending the political capital to engage in the fight for another Accord – and no one could adequately defend its record. What’s more, the key ingredient missing from the Accord was accountability. A strengthened Accord would mean that the provinces would be more strictly responsible to the federal government – hardly desirable.

So we are left at an impasse on health care. It’s clear that the Accord didn’t work. And there doesn’t seem to be any appetite for another one from the federal government or the provinces. No one thinks that continuing to pour money into the health care system will achieve meaningful results.

Yet the public narrative on health care is that we want better value for money. We want to keep people out of expensive acute care, and support seniors in their homes and communities as long as possible. We want faster access to elective surgeries, and 24/7 access to a doctor who knows our medical histories.

There are clear pockets of success that point the way – islands of innovation in a sea of failure. Elective knee and hip surgery wait times were reduced from 11 months to just nine  weeks at the Alberta Bone and Joint Institute. An e-consulting program in Ottawa reduced the need for specialist visits by 43%. The ARTIC MOVE ON program in Ontario is keeping seniors mobile when they land in hospital, preventing the quick deterioration that often leads to institutionalization.

This is the kind of change the Accord was supposed to bring about, but it’s not happening for all Canadians. Change is not impossible, but it’s piecemeal, and it’s being driven by small, motivated groups. In the current context, your quality of care may increasingly depend on the province you live in, and which projects they’ve prioritized.

So what does the way forward look like? There are three possibilities:

1) Status quo. The provinces will get their diminished transfers, and will continue to invest as they see fit without national coordination of goals or standards while the federal government continues to divest itself of responsibility for health care.

2) Interprovincial agreements. Provinces and territories will agree (whether in small groups or all together) that certain standards should be maintained, perhaps targeting specific areas of care such as wait times or primary care access.

3) A new federal-provincial agreement. Essentially a Health Accord, but presumably without the large-scale investment attached to the original Accord. This likely only becomes a possibility if there’s a change of government in 2015. Whether such an agreement would incorporate true accountability for results or just function as window dressing would remain to be seen.

We’re currently on track for option one, even though we constantly hear that the status quo is not good enough for our health care system. If we care about national standards, it’s likely not good enough for the leadership of the system either. But in the current political environment, it’s unclear if anyone will stand up for the vision of a national health care system.