Moving Beyond the Status Quo:
Alberta's "Working" Prescription for Health Care Reform

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The Politics of Health Care

Despite the problems with the current health care system, attempts to change it frequently meet resistance. Certainly, changing health care is not a straightforward matter of being fiscally responsible and using common sense; the highly emotional context of symbolic politics, which requires a strategic approach in addition to administrative competence, must be considered as well. To be sure, deficit reduction required considerable political skill, but several additional factors contribute to the distinctiveness of health care reform.

The health care system is said to symbolize a citizen's sense of "Canadian-ness." According to one authority, "Canadians value medicare not just because they need it, but because it brings them together as a national community" (Gray, 1996). Indeed, some zealous supporters of the current system have compared it to building the transcontinental railway. At a time when few national sources of attachment are said to exist for Canadians, medicare is often considered to be the most compelling symbol of the country—even more than the flag (Environics, 1996). The relatively widespread acceptance of this notion, despite its reliance on highly questionable economics, is testimony to its overall importance.

The apparent significance of the health care system to Canadians has been an integral component of recent election campaigns. The slightest hint of changing the current system seems to threaten serious and adverse electoral consequences. During the 2000 federal election, for example, one of the Liberals' criticisms of the Canadian Alliance was that they were "enemies of medicare," who, if elected, would exchange a virtuous "universal" health care system for a vicious "American-style, two-tiered" system. This imagery of good and evil proved remarkably difficult to overcome (despite Stockwell Day's use of visual props during the leaders' debate), and may partly explain why the Alliance failed to make significant electoral gains in Ontario. When it comes to reforming health care, public perceptions are exceedingly important and there is a significant downside risk that challenging conventional perceptions will have detrimental results. This may explain the timidity of politicians, though it does not address the real issues.

Notwithstanding the sensitivity of health care, according to the 1999 and 2000 Alberta Advantage Surveys, most Albertans (85%) agree that the health care system needs to be fixed. For some, however, the problem is more personal than for others. Figure 1 shows that those who are less satisfied with their own personal health are more likely to agree on the need to fix the system. This is hardly surprising, because even though healthy people might be anxious about someday being sick and needing access to timely and reliable health services, such anxieties are understandably higher among those who are less healthy.

Attitudes toward spending cuts to health care budgets are ambivalent. Just before former premier Don Getty retired from office, 94 percent of Albertans said they supported spending cuts (Whyte, 1994). The realization that the deficit had to be controlled, said Premier Klein's labour minister, "gave (Albertans) the anaesthetic to take the temporary pain of the cutbacks" (Koch, 1994). Indeed, we have shown that in the early '90s, most people agreed that spending reductions were the best way to eliminate the deficit and reduce the debt (see Kanji and Cooper, 2001). But when it comes to health care, most people (more than 90 percent of Albertans according to the 1999 and 2000 AAS) believe that "proper health care comes before spending cuts." This is why, we suspect, that even though most people (97 percent of Albertans according to the 1999 and 2000 AAS) agree that "efficiency and proper health care can go hand in hand," opposition to fewer doctors and nurses, hospitals, health services, and longer waiting times continues to mount, and most people make the assumption that public funding is needed to build hospitals or pay staff. Furthermore, figure 2 reveals that such opposition is even greater among those who have had recent experience with health care services, and the major concerns appear to be over inadequate staffing and extended waiting times.

Factors other than personal experience may also influence perceptions. Some claim that anecdotal reports and misrepresentation of issues in the media and by the "friends" and "foes" of medicare are to blame for the lack of public confidence in the system (Jacobs and Shapiro, 1997; Rachlis et al., 2001; Roos and Brow- nell, 1998), especially when personal experience is lacking (Shapiro et al., 2000; Pescosolido et al., 1999). Others have shown that the public is inadequately informed about the health care system, and so argue that citizens have not received enough unbiased information to have a meaningful debate (Bernstein and Stevens, 1999). We may expect, therefore, that people's levels of knowledge and their experiences with the system both affect their views.

Moreover, health care differs from other social programs in that the provinces are bound by the principles of the Canada Health Act, which also influences perceptions, as do politically-motivated statements coming from successive federal health ministers indicating that Ottawa is determined to defend the elusive "spirit" of the Canada Health Act. Even though economic analyses show that Alberta and Ontario both could reform their health care systems and save money even if their contraventions of the Canada Health Act resulted in the extinction of federal money to these two provinces (Zelder, 2000b), and despite what a prominent group of Alberta academics and economists recently advocated—namely, that Alberta should indeed reject federal money for health care in order to free itself from Ottawa's dictates ³—our data indicate that Albertans are not yet ready to forego federal administrative control, although nearly two in every three Albertans (65%) believe that the provinces should have more say in how money is spent on health care.

A final constraint on introducing changes in health care policies follows from the ease with which sensible proposals for reform can so easily and so effectively be side-tracked by emotionally-charged rhetoric that awakens deep-seated fears. For example, when Ontario Premier Mike Harris said it was time to talk seriously about reforming health care, opposition leader Dalton McGuinty immediately responded by accusing the premier of undermining the Canada Health Act. McGuinty clearly hoped to polarize the electorate and effectively prevent serious and prudent discussions of any real alternatives.

Our data show that a growing majority of Albertans (now nearly 60%) agree that "if people are willing to pay the price they should be able to use private medical clinics." Support for this principle is highest (at 64%) among those who are satisfied with their personal financial situation. The fear, anxiety, and resentment associated with this particular cleavage are used by opponents of market-based alternatives to prevent serious change, or even the prudent discussion of change.

Table 1 reports the results of a regression analysis. Regression analysis is a statistical technique that allows us to compare a number of independent factors to explain what is causing changes in something else. In this case, regression analysis enables us to discover how different personal and political factors work to detract from overall satisfaction with the health care system. In this instance, regression analysis illustrates which of these potential constraints has the most powerful effects. Table 1 indicates that more or less all of the factors just discussed detract from overall satisfaction with health care. Support for maintaining a federal presence, poor personal health, and low levels of financial satisfaction seem to be particularly limiting initiatives, whereas direct experience with the system, though significant, does not seem to have as powerful an effect.⁴  What this means, then, is that any serious attempt at health care reform must find strategic ways of keeping these obstacles at bay.

Table 1: Regression Analysis—The Influence of Personal and Political Factors on Health Care Satisfaction (Beta coefficients)

3 The text of "The Alberta Agenda," an open letter to Premier Klein by Stephen Harper, Tom Flanagan, Ted Morton, Rainer Knopff, Ted Boessenkool, and Andy Crooks was published on January 24, 2001. It is available at www.thereport.ca, or The National Post, 26 January, 2001, p. A14.

4 This may indicate that there may be some overlap between the indicators measuring "level of personal health satisfaction" and "extent of indirect experience."

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