Four interrelated phenomena are at work in Canadian health care. First, in Canada as all over the world, there is growing momentum toward greater cost containment and imposition of tighter ceilings on health expenditures. Second is the demography of a falling birth rate and a greater number of elderly. Third, the failure of ratification by the provinces of the Canadian Meech Lake accord has created a constitutional structure that strongly favors provincial and not federal powers, and further guarantees widened regional and local disparities. Fourth, the economic union implicit in the United States-Canada free trade agreement of late 1988 will serve to weaken east-west ties within Canada in favor of north-south ties, and is likely to lead to taxation policy in Canada to favor the rich, with pressures toward privatization and restrictions on universal entitlement programs.