Sarah Palin's prophecy is a fact of life in Ontario.

It was Palin, the former U.S. vice-presidential candidate and governor of Alaska, who conjured up the Orwellian spectre of "death panels" -- faceless groups of bureaucrats who'd make tough decisions on who gets what medical care under socialized medicine.

In this province, a patient whose application for out-of-province care is turned down can appeal to the Health Services Appeals and Review Board (HSARB).

But, according to lawyer Perry Brodkin, almost all those appeals are rejected.

Part of the problem, he says, is that patients try to represent themselves at the hearings -- and find themselves up against a battery of high-priced OHIP (Ontario Health Insurance Plan) and ministry lawyers.

And high legal costs mean it's only worthwhile hiring a lawyer if the procedure is expensive.

"When we're talking $25,000 only, the legal fees are going to be pretty close to that.

"If your appeal is granted, you get nothing. If your appeal is denied, you pay the $25,000 (for the procedure) plus all the legal fees," he said.

Either way, you're out of pocket.

So who makes up these panels?

Well, of HSARB's 43-person board, 31 are lawyers. One is a chartered accountant, one is a mortgage underwriter, and the rest are a mix of educators and consultants. The position pays $398 a day.

So much for the little guy.

When it comes to drugs, there are three hurdles a new medication must clear to be paid for by the provincial government.

First it must be approved for safety by Health Canada.

Then a cross-country agency in Ottawa -- the Canadian Agency for Drug Technologies and Health, made up of health specialists and patient reps -- make a recommendation to the provinces.

Because each province is structured differently, almost every province does another review.

Then the Committee to Evaluate Drugs, made up of physicians, pharmacists, health economists and patient reps, make recommendations to Dianne McArthur, executive officer of Ontario Public Drug

Programs, who oversees the $4.4-billion program.

"We have to have some very difficult conversations around the relative improvement in treatment versus the cost that is associated with that incremental improvement in care," McArthur said in an interview.