They are scrambling to figure out how to move forward after Finance Minister Jim Flaherty took them by surprise last month when he handed them a 10-year funding package for health care with no policy strings attached.
Health Minister Leona Aglukkaq is now touring the country to see how her provincial counterparts want to proceed, with the official aim of stitching together a new accord that would set national standards and hold provincial governments to account for their spending.
And provincial premiers are preparing to hash out a some sort of plan when they meet in Victoria on Jan. 15 to 17.
But a no-accord approach is a distinct possibility, say provincial and federal officials.
"It's a possibility that we have no codified accord," said one federal source, who spoke on the condition of anonymity.
That's because the new funding arrangements for 2014 to 2024 were presented without negotiation, pleasing some of the Western provinces but upsetting the rest of the country. Now the federal government has signalled that it will be taking a back seat in setting health care policy.
Prime Minister Stephen Harper was asked this past week in a radio interview whether Ottawa is, in effect, telling the provinces to take full responsibility for health care.
"Well, that's partly what we're saying," Harper said during an appearance on the Rutherford Show, an Alberta-wide radio call-in program.
"Look, most provinces are already projecting reductions in their own growth rates and health-care spending. But the provinces themselves, I think, are going to have to look seriously at what needs to be done to make the system more cost effective."
Flaherty's fiat cements financing until 2024. It gives provinces some fiscal certainty about their levels of funding. But it also comes with no mechanism to ensure national standards or service improvements.
At the same time, the new 10-year funding arrangement will be allocated to the provinces based purely on a per-capita basis, eliminating any consideration for poorer provinces, fragile tax bases or higher costs in remote areas.
That means the distribution of the funding will swing heavily in favour of richer provinces west of Manitoba, to the detriment of Manitoba and east.
The equalization formula is also up for negotiation soon, so there is no guarantee poorer provinces will see additional federal cash to make up for the health redistribution.
The concern is that without national standards, have-not provinces will see their health care systems deteriorate, as the health services in richer provinces flourish.
"Is it appropriate that the federal government just washes its hands of the country's most important social program?" asked one provincial official, who was not authorized to speak publicly.
Some of those have-not provinces are contemplating a co-ordinated push back against the unilateralist nature of Flaherty's funding.
They would argue that Harper promised a collaborative approach to health care during the last federal election campaign, and has also committed to reducing wait times and improving accountability and health care services more generally.
But they are far from united heading into their meeting in Victoria. And it's not clear Harper would have any obligation or incentive to listen to them anyway.
"There's not a hell of a lot the provinces can do about it," said University of Regina professor Greg Marchildon, who was the executive director of Roy Romanow's royal commission to reform health care a decade ago.
"They can complain publicly but they cannot force the federal government to come to the table and negotiate."
The provinces will have a difficult time forging a national accord as long as one of the key players — the federal government — is absent from those discussions, Marchildon said. And Harper has shown little inclination to join in.
"There can't be an accord unless there's an agreement to have a meeting," he said. "The federal government does not want a meeting so there can't be an accord."
The provinces could decide to take matters into their own hands and all go their separate ways on health care. Or they could decide to work together in some areas without the federal government, using the Council of the Federation as a secretariat.
Health care has not always been directed through a federal-provincial accord. That practice started in about 1999 with social-union talks that morphed into the more formal 10-year accord of 2004.
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