We apply a 5.0% quality discount to Ontario’s healthcare transfer, based on four measurable quality deficits: economic costs from wait times (Canada’s median wait from GP referral to treatment is 28.6 weeks versus 4 to 6 weeks in the US), a diagnostic imaging access gap (Canada has 10.8 MRI units per million versus approximately 40 in the US), a cancer survival deficit (2 to 3 percentage points lower five-year survival for breast, prostate, and colon cancers), and broader unmeasured degradation from delayed specialist access (47% of Canadians wait two or more months for a specialist versus 6% of Americans).