Saskatchewan, the birthplace of medicare, now spends more on health care than it collects from personal income taxes and the provincial sales tax.

Health care eats up $2.2-billion a year, or 40 per cent of Saskatchewan's budget. And still the province has some of the longest waiting lists in Canada.

Saskatchewan has three big demographic challenges in delivering health care: a large aboriginal population whose health indicators are generally worse than non-aboriginals; a declining population with a larger share of older citizens than provinces with growing populations; and vast rural areas with small populations hard to service efficiently.

No wonder, then, that health care has bedevilled successive Saskatchewan governments. Costs are rising faster than provincial revenue. Demands keep growing. And under former premier Roy Romanow, the province already took the politically controversial decision to close 50 hospitals in rural areas.

Those closures, however, did not ease the pressures for more spending. They irritated a lot of rural people already buffeted by declining real farm incomes and limited alternative employment.

When NDP Premier Lorne Calvert toured his province this summer, he received an earful from rural areas, including opposition to proposals for more rural hospital closures. Those proposals were part of a major report by Kenneth Fyke on health-care restructuring commissioned by Mr. Romanow.

Earlier this month, Mr. Calvert announced a new blueprint for health care, some of which followed the Fyke proposals. But his government balked in the face of rural opposition to closing any more hospitals. Closing 20 of them, said Mr. Calvert, would save only $14-million from the $2.2-billion budget. The savings weren't enough to justify following the Fyke recommendations.

Calling these rural institutions "hospitals" is a bit of a misnomer. Some of them have only half a dozen beds and limited equipment, making them more like glorified first-aid stations. But people in these areas feel deeply attached to their "hospitals," both as places they can go to quickly and as providers of a handful of well-paying jobs.

Having balked at closing more hospitals, Mr. Calvert bet heavily on primary-care teams spread across the province. The government hopes these teams of doctors, nurses and nurse practitioners (working under a reduced number of regional health authorities) and a 24-hour telephone service will deflect people from hospitals.

This kind of reform is all the rage across Canada. Ontario just signed a path-breaking agreement with the Ontario Medical Association to restructure primary care. Almost every report forwarded to provincial governments in the past five years has recommended this sort of change. The federal government is spending $800-million on primary-care projects across the country.

This is the biggest bet of all by governments trying to curtail increases in health-care costs. Reformers hope (pray?) that people will use these primary teams working in clinics rather than rushing to hospital emergency rooms. Telephone service, they hope (pray?), will keep parents at home dealing with kids' minor ailments.

Primary-care reform makes all kinds of sense for practical and financial reasons. But will it take the pressure off growing health-care budgets?

Check out other parts of Mr. Calvert's plan. He promises "funding increases" to provincial hospitals, including surgical centres to reduce waiting lists. He will unveil "programs to keep and attract key health providers," which must mean more money. He's offering $3-million more for training health-care providers and additional sums for health research.

More money, in other words, for the system -- money that Saskatchewan can barely find now. Primary-care reform is supposed to be part of the answer to where new money might be found. The rest will be squeezed from the system by the rational planner's dream -- better administration.

Throughout the Premier's plan are new methods for sharing information, assessing quality, managing better waiting lists. The inference is clear, at least in theory if not in practice: Better administration will save money while not sacrificing care. If this argument is wrong, the plan's underpinnings collapse, because the costs of medicare will keep rising. If the costs cannot be contained by better administration, Saskatchewan won't be able to pay them without deficits, higher taxes and/or cutting every other government service.

This, then, is Saskatchewan's big bet. It's the one being made by many provinces. It's the one the federal Liberals, portraying themselves as the guardians of medicare, are making, too.

It's probably a winning bet in the world of politics, but a loser in the real world of public finance.