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

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Perceptions of the State of Health Care

Cross-national studies indicate that historically Canadians have been satisfied with their health care system (Blendon, et al., 1990). In 1998, however, public confidence in Canada's health care system dropped to 20 percent from 56 percent where it stood a decade earlier (Donelan, et al., 1999). Published discussions by academics, press releases by interested parties, and media horror stories have undoubtedly increased anxieties among the general public. A synthesis of survey results by the Conference Board of Canada (CBOC, 2000a) shows that since 1993, concerns about health care have been steadily rising, and health care is now identified as the top national issue. Concerns about health care seem to be prompted by the belief held by almost 80 percent of Canadians that the health care system is in crisis (Angus Reid, 2000). Further, surveys commissioned by the Canadian Medical Association found that among Canadians, Albertans were most likely to cite health care as the most important issue leaders should address (CMA, 1999).

In spite of the political minefield surrounding health care reform, the Klein government has gone to great lengths to change the system—even though conventional wisdom said it would be "political suicide" (Farnsworth, 1995) to implement even the modest reforms of Bill 11. Contentious as these changes have been, Ralph Klein has not paid the price politically.

During the 2001 provincial election, both opposition parties tried to use Bill 11 as a means of mobilizing votes against the Tories. The results speak for themselves: popular support for the government increased, as did the size of the cohort on the government side of the Legislative Assembly. We have documented the reasons for the success of the Klein government elsewhere (Cooper and Kanji, 2000, ch. 5; Virani, Kanji and Cooper, 2000). What is important for our purposes here, however, is not simply to note the general political success of the Klein government, but to emphasize that electoral success has been accompanied by improvements in the general outlook of the Alberta public toward health care. Figure 5, for example, shows that compared to earlier years, Albertans in 2000 were significantly less likely to argue that the province had become a worse place for those who are ill. Indeed, over the past four years or so, the percentage of citizens indicating that Alberta has become a better place for those who are sick has improved by 17 percent.

Figure 6 shows that general satisfaction with the health care system has also improved: today, 3 in every 5 Albertans (62%) are satisfied with health care, which is a striking 14 percent increase from 1999. Within this group, the percentage of Albertans who are very satisfied with health care has increased by an astounding 16 percent. Comparatively speaking, Albertans today are as satisfied with health care as they are with other social programs, such as education and welfare (see Kanji and Cooper, 2001).

Theoretically, there are many ways of improving the economics of the health care system. The practical difficulty, however, is to find a "working prescription" for implementing politically risky structural reforms that at the same time improves general perceptions of health care and so maintains the political support necessary for change. The prescription metaphor suggests as well that, just as with medications administered to individuals, where the same pharmaceutical may have quite varied effects in different individuals diagnosed with the same ailment, something similar is true with policy prescriptions for the body politic. The treatment that worked in Alberta may not work elsewhere; the dosage may have to be adjusted to suit different needs and different political cultures. Even with all these qualifications, the Alberta example shows that it is possible to make incremental reforms to health care, improve overall satisfaction with the system, and at the same time avoid paying a heavy political price.

By claiming to use one-time targeted expenditures rather than giving in to demands for increases in long-term commitments of public funds, the Alberta government implemented an effective strategy that dampens or buffers the inevitable dislocation and associated transaction costs that come with any large administrative change. The objective of the strategy is to direct public resources to areas considered to be politically the most sensitive—to improve accessibility and to improve quality—but without falsely or unduly raising expectations, or spending over budget. The appropriate analogy in this case may be that of a "just-in-time" system of funding from public revenues.

For example, in April 2001, Health Minister Gary Mar announced a strategy aimed at doubling the number of MRI machines by providing one-time funding to regional health authorities to contract with private MRI providers (GOA, 04.09.01). Moreover, the government allocated additional money to upgrade and renovate existing facilities, including a new Children's Hospital in Calgary (GOA, 06.05.00). Whether the money actually hits the target is another matter, but as of November 2000, reaction to the government's strategy of "targeted spending" has been positive. Figure 7 shows that 2 in every 3 Albertans (67%) are satisfied with how much the government has spent on programs such as health care, and about a third (32%) said they are not at all satisfied. The downside risk is equally obvious: "targeted reinvestment" or "just-in-time" spending can easily become general long-term program funding, which introduces yet another kind of status quo. Fiscal conservatives have reason to be concerned that what the government calls reinvestment may in fact turn out to be the first step on a return to uncontrolled and unfocussed spending.

While it is one thing simply to inject more dollars into the current system, it is quite another to make sure they are used in the right way. Thus, a second element in the strategy of the Alberta government has been to ensure that new spending is seen to be used effectively. And, in fact, the public opinion evidence indicates that there have been marked improvements in perceived accessibility of services. Figure 8, for instance, shows a significant increase in the number of Albertans who disagree that the availability of health services has deteriorated.

Moreover, as figure 9 illustrates, improving perceptions of availability has an enormous effect on perceptions of quality.

Perhaps the most important political effect is that, as of November 2000, all of these changes have been made without adding to anxieties over whether future public revenues will be able to sustain the system. However, as noted above, it remains an open question as to whether the recent round of spending is the beginning or the end of fiscal conservatism as that term has come to be understood during the first two Klein administrations.

Two other significant findings emerge from the regression analysis reported in table 3. The first is that even after controlling for various socio- demographic factors, all three of these policy initiatives work to reduce the negative effects associated with health care politics and system-altering policies such as Bill 11. In particular, the system of "just-in-time" spending and improvements to accessibility appear to be the two most powerful positive influences on satisfaction with health care. This finding is consistent with the conclusions drawn from the 1999 Alberta Health Summit⁵ and the Alberta Health Surveys (Northcott and Northcott, 2000), namely, that perceived problems with "accessibility and availability of services" best explain the lack of confidence with the health care system.

Table 3: Regression Analysis—The Determinants of
Satisfaction with the Health Care System (Beta coefficients)

Table 4 provides additional support for this interpretation. It shows that perceptions of accessibility are driven mostly by factors such as improved access to doctors, timely surgery, and shorter waiting times in emergency rooms. Thus, it is not surprising that the Alberta government has recently attempted to target these areas (GOA, 12.01.00; 01.17.01). Even the Alberta Medical Association ratified an agreement with the government designed to "keep Alberta competitive in attracting and keeping doctors" (GOA, 02.27.01).

Table 4: Regression Analysis—
The Determinants of Accessibility to Health Care Services (Beta coefficients)

In much the same way, the regression results reported in table 5 show that overall evaluations of quality pertain more to some aspects of the system than to others. What matters most is how people appraise the care they receive in their communities and in hospitals, and not so much the quality of care they receive at home—although better home care also works to improve the perception of the overall quality of care. By directing resources toward important areas of public perception, the Alberta government appears to have derived the biggest bang for its buck.

Table 5: Regression Analysis—
The Determinants of the Quality of Health Care Received (Beta coefficients)

5 Health Summit '99: Summary of Delegate Recommendations. Calgary, February 25-7, 1999.

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