The technology and expertise exists today to provide almost any medical service imaginable in the home. Yet, the greatest danger to the sick and elderly receiving homecare is the most mundane: falling down and suffering a broken hip or fractured skull that will send them to hospital or a nursing home.

Federal Health Minister Allan Rock, who this week proposed the creation of a national homecare program, faces a similar dilemma. He has the will and the support for the plan but, as he tries to make it a reality, there are a number of obstacles along the way that could prove debilitating and, ultimately, fatal.

In creating new social programs, money is often the issue. A national homecare program would not be that expensive -- about $3-billion annually. The provinces now spend $2.1-billion a year, with much of that money already coming from Ottawa in the form of transfers.

Nationwide, homecare budgets amount to only 4 per cent of public spending on health. But the per capita variations from province to province are dramatic, ranging from $34 in Prince Edward Island to $94 in New Brunswick.

A study conducted by the Home Care Evaluation and Research Centre at the University of Toronto estimated that an additional $700-million annually would allow all provinces to have the same spending levels as Ontario, whose homecare services are considered among the best.

For its part, the Health Education Action Lobby estimates that an additional $1.5-billion a year is needed to create a national homecare program. Mr. Rock is proposing a 50-50 cost-sharing arrangement with the provinces, meaning he would need somewhere between $500-million and $750-million. With three million caregivers in Canada, and their ranks growing daily, the program would likely pay immediate political dividends.

And if he puts that kind of money on the table, the majority of provinces will rally quickly to the idea. The starting point for a national program, however, is establishing national standards. Because existing homecare services vary wildly from province to province, this definitional work is the biggest potential pitfall in the short term. And doubly so because there are major philosophical differences about the role of homecare. The Western provinces have embraced a social-entry model, meaning homecare is principally a social service, a means of delaying the need for institutional care. In the east, the medical model -- using homecare as a substitute for acute care after people have fallen ill -- tends to dominate.

This is important because, in creating standards, Ottawa and the provinces will have to decide what is in and what is not in the basket. Paying for nursing care and occupational-health therapists is an easy decision.

Some provinces consider services such as respite care for family caregivers and building modification to remove hazards as essentials, while others see them as frills. More problematic still for Mr. Rock's plan is the question of means testing. Homecare is the only part of the broader health system that is not universal. Provinces not only routinely establish income-cutoff levels for eligibility, almost all jurisdictions charge fees for homecare services. The only exception is Ontario.

If homecare is going to be incorporated into the Canada Health Act -- a move many provinces would vociferously oppose -- universality and portability would be ensured. More important, it would mean homecare would be a guaranteed service, not a discretionary one.

What will move these discussions along is compelling new data about the cost-effectiveness of homecare.

A recent study found that caring for the frail elderly at home instead of in nursing homes, regardless of the severity of their condition, saves about $8,000 a year per person. Another study found that sending people home from hospital after surgery can save about $800 per case. Multiplied by hundreds of thousands, this can amount to big savings.

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