Moving Beyond the Status Quo:
Alberta's "Working" Prescription for Health Care Reform
Introduction
Health care reform poses a major challenge for policy makers worldwide as demands on health care increase and the population changes (GOC, 2000b). The problem is especially acute in Canada, where per capita health care expenditures are the third highest among G-7 countries (CIHI, 2001) and health care spending consumes one-third of provincial program expenditures (GOC, 1999). The experts warn that without reform, the current publicly-funded system cannot be sustained over the long-term without either significantly compromising other program areas or raising taxes (CBOC, 2000b; GOS, 2001).1 Not surprisingly, therefore, many governments are in the midst of re-examining their policy priorities and placing health care reform at the top of their political agendas. In a recent Speech from the Throne, the Harris government in Ontario announced: "responsible choices and tough decisions are needed not merely to sustain, but quite literally to save Canada's health care system," and Premier Harris added that his government would "look to the private sector" to run the province's hospitals (National Post, April 28, 2001, p. A4). Several other provincial leaders have also called for serious discussion with Ottawa over health care reform.
As imaginative as the proposals of the Harris government are, nowhere in Canada has health care restructuring been more evident than in Alberta under the leadership of Premier Ralph Klein. In 1993, the premier stated: "we can no longer afford to solve problems by spending money," and followed his words with actions leading to major changes in health care delivery, starting with a reduction of some $500 million in public funds. Budget cuts were followed by large-scale changes that involved hospital closures and consolidation, regionalization, and the introduction of the controversial Bill 11—officially the "Health Care Protection Act"—which permitted selected surgical services to be contracted out to private facilities (Cooper and Kanji, 2000, pp. 113-19). After they were introduced, these changes were widely seen to be the Achilles heel of the Klein government's popularity.
The difficulty of health care reform, even for a government as popular as Ralph Klein's, arises from the notion that health care in Canada is something of a sacred cow. That is, the symbolic importance of health care in the endless discussion of Canada's distinctiveness from the United States has added to the difficulty of engaging in a moderate and sensible consideration of reform of the system. This is why demands for more public funding have so prominent a role in political discussions of the future of health care in this country. Indeed, widespread public concern about the health care system apparently still forces the hand of governments to increase public funding, even though it is clear that alone more money can neither improve health nor result in the most visible improvement in the system—a decline in waiting times for treatment (Evans, Barer and Marmor, 1994; Zelder, 2000b).2
The importance of health care reform is apparent from recent newspaper headlines, and from federal and provincial election campaigns. However, the volatility of public perceptions on health care reform and the perceived threat of adverse political repercussions has led many politicians to avoid discussing how to change the system, let alone actually trying to do so. Instead, governments happily fund one costly study after another on the future of medicare—from the National Forum on Health launched in 1994, to the most recent $15 million "Commission on the Future of Health Care in Canada" led by Roy Romanow. In practice, however, the dedication of governments to follow through on even the modest recommendations of these studies is much weaker than their enthusiasm to appoint commissions and commissioners (Boessenkool and Harper, 2001). It would be surprising indeed to expect Roy Romanow, a former NDP premier of a province that understands itself as the seed-bed of medicare, to engage in a serious re-examination of the principles of the Canada Health Act.
This Public Policy Source provides empirical insight into what is widely held to be one of the main sources of resistance to changes in health care: the unwillingness of the public seriously to entertain the possibility of moving beyond the status quo. A sound understanding of public views and attitudes is vital for the development of policy in health care, and past experience has taught political leaders that almost any attempt to change the status quo is likely to arouse intense public concern. Moreover, advocates of the status quo, or those who want to reinforce it by providing more public funds but no structural changes, typically add to such fears. Accordingly, the entirely predictable response to Premier Harris' remarks was that his proposals would invariably lead to "American-style, two-tier health care," as the Ontario NDP leader, Howard Hampton, immediately charged (National Post, Apr. 28, 2001, p. A4).
Debate about health care reform has been effectively derailed by denouncing, rather than discussing, market alternatives and private funding. The small changes made by the Klein government in an effort to integrate private health clinics into the existing system sparked negative and critical advertising campaigns, petitions, and efforts by lobby groups against the initiative. Undoubtedly, the words, "American-style, two-tiered health care" are intended to provoke deep anxieties among Canadians, and the symbolic importance of health care reduces the persuasiveness of economically compelling arguments in favour of markets and private sector solutions to Canada's health care woes.
None of this is to suggest, of course, that popular reforms always make the best policies. But because there are significant political constraints involved, a lot rides on having the correct strategy. In this Public Policy Source we show that:
It is possible for governments to make initially unpopular reforms to health care, but subsequently improve perceptions toward the system and not suffer politically as a result.
Many citizens associate the current problems in health care with factors other than allegedly inadequate public funds. Indeed, there is evidence to show that Albertans' priorities regarding public spending have begun to shift and that many citizens are satisfied with current levels of government health care spending.
There are politically workable ways of moving beyond the status quo that do not incur the blanket resistance thrown up by concerns and anxieties relating to the symbolism of "two-tiered, American-style" health care. Some of these alternatives, such as a focus on disease prevention, are clearly amenable to market-based initiatives, and are at least as popular as a state-controlled and state-directed monopoly.
1 For a dissenting voice, see Lewis (2000).
2 At the federal level, a new health accord was signed by the First Ministers on September 11, 2000, that will include the allocation of over $23 billion over the next five years for health and other social programs to the provinces and territories. Provincial governments have been allocating most new program funding for health care (62%) (CBOC, 2000a).
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