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

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Prevailing Attitudes Toward Change

Attempts at health care reform are further hampered by what appears to be a general resistance to structural changes to the system. Despite the problems with the current health care system, Albertans, and Canadians more generally, seem almost instinctively to equate changes to the system with attempts to dismantle it. Even so, Albertans have arguably experienced some of the most assertive efforts to incorporate private health care into the current system, and attitudes toward Bill 11 illustrate the relevance of this point. Provisions of this act allow the provincial Regional Health Authorities (RHAs) to contract with a private health service provider (either for profit or not-for-profit) for the provision of specified surgical services. The impact of this bill, according to its opponents, has been to increase scepticism about health care in the province. Evidence from the Alberta Advantage Surveys, however, indicates that Albertans have been almost equally divided. Figure 3 shows that opposition toward Bill 11 is much more evident among those who oppose other policies of the Klein government, such as the creation of the Regional Health Authorities. Thus, opposition toward restructuring the current system remains significant.

Currently, less than 30 percent of health care expenditures in Canada come from private sources such as insurance premiums and out-of-pocket expenses for services deemed medically unnecessary. This ratio of public-to-private expenditures is roughly equivalent to that in the average industrialized nation (GOC, 2000b). Many health experts consider that one way to maintain Canada's health care system is to increase private funding. For example, Albert Schumacher, president of the Medical Association of Ontario, argues that allowing Canadians to pay for some medical services might be necessary to revamp the "crumbling and ineffective" existing health care system. Furthermore, recent indications from Ontario suggest that Harris government may be poised to follow the Alberta model (Kondro, 2001).

Despite the latest overture made by Roy Romanow, currently heading the federal Commission on the Future of Health Care in Canada, that "rational men and rational women should look rationally at the options which might fit and… those which might not fit the Canadian system" (National Post, May 2, 2001, p. A1), the difficulty until now has been in simply having any reasonable, prudent, or unemotional discussion of health care. Some political leaders are no doubt persuaded that arguments in favour of introducing private health care as a way to deal with the significant and widely-acknowledged existing problems are sound. Even so, the anxieties of the public require an almost Solomonic statesmanship to move towards the objective of market-based alternatives and greater privatization.

Notwithstanding these difficulties, it bears repeating that the literature on medical economics indicates that introducing market-based, private-sector hospitals would, indeed, help improve health care delivery. Although studies have not shown a clear performance difference between for-profit and non-profit hospitals, clear and significant differences between private and public hospital performance has been shown to exist as a result of inefficiencies and lack of incentives in public hospitals (Zelder, 2000a). It would seem, therefore, that what is required for strategically-ordered change is less a matter of economic argument or the great postponer, "more research," than of political courage and skill at persuading or priming the electorate. Albertans, at least, have reason to be optimistic: the Klein government has undertaken initially unpopular, but economically sound, changes before.

For instance, the consolidation of 200 separate hospital boards across the province into 17 new Regional Health Authorities was initially opposed by both doctors and by other front-line health care providers. Often their reasons were self- serving (Cooper and Kanji, 2000), but given the generalized resistance to change, the government did well to persuade the public that any streamlining of the administration was desirable. Our data indicate that, despite initial criticism, support for the creation of Regional Health Authorities has remained between 50 and 60 percent over the last five years or so (between 1995-2000). Moreover, most Albertans, including those who support the creation of RHAs (see figure 4), agree that administrators who serve on these boards should be made more accountable through democratic elections. Partly as a result of public opinion on this issue, the government announced that by October 2001, 126 out of 189 regional health authority members across the province will be elected during municipal elections (GOA, 04.20.01).

Even so, the crucial point to bear in mind is that when we calculate the regression coefficients to indicate the relative weight of these political considerations, it turns out that policies designed and intended to improve—and in any event alter—the health system detract from overall satisfaction with health care (table 2). In particular, the negative impact of Bill 11 has been more than double that of any other factor. This analysis indicates that just as traditions are hard to break, it is also difficult to alter the fundamental structure of the health care system without arousing an adverse reaction.

Because most politicians are in the business of being re-elected and because reforming health care threatens to make them unpopular, it is not difficult to see why the process of health care reform remains stalled. But given the existing system's highly precarious future, it is worthwhile to determine what factors might mitigate those negative effects and provide politicians with the flexibility to make sensible reforms.

Table 2: Regression Analysis—The Impact of Various Personal/Political Factors and System-Altering Policies on Health Care Satisfaction (Beta coefficients)

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