Moving Beyond the Status Quo:
Alberta's "Working" Prescription for Health Care Reform
Is the Health Care Cow Sacred No More?
Public opinion analysts and advocates of the status quo in health care have long asserted that health care is too important or too fragile to change in any fundamental way. Some sentiments and anxieties may well be beyond refutation by evidence and reasonable argument, but the preceding analysis has shown that it is possible to make modest system-altering changes to health care in spite of the highly symbolic politics involved. Moreover, the Klein government has been able to make these changes in the system while at the same time improving popular perceptions about the system and thus retain its strong popular support.
There remains, however, an important question that health care experts agree needs to be answered to overcome the obstacles to reform: why bother? (Casebeer and Hannah, 1998). After all, there is a big difference between implementing minor changes or tinkering around the edges, and undertaking major and meaningful change. Bill 11 illustrates the problem. It is true that the Klein government was able to pass Bill 11 and not suffer at the polls, but the legislation was explicitly designed not to offend the Canada Health Act (CHA), which is arguably the greatest obstacle to a serious improvement in health care delivery. Thus, it remains debatable whether the legislation has made any difference at all. The question therefore arises: was it worth the effort?
Before its implementation, Bill 11 was subject to 47 hours of debate in the legislature—the longest discussion for any bill in provincial history. Sixty MLAs rose to consider its provisions, and representations were received from doctors, nurses, health authorities, the public, and other concerned parties (GOA, 05.10.00). Even after the Health Care Protection Act was proclaimed into law in the spring of 2000, a proposed set of new regulations that apply to the provision of surgical services was sent to a wide range of health care stakeholders for review and comment in two phases (GOA, 09.28.00). Then, following all the drafts, discussions, and amendments, it is still far from clear that the structure of health care delivery has been fundamentally changed. The foundation of the CHA has not yet been disturbed. Hostile federal politicians could say nothing more than that, perhaps, Bill 11 conflicted with the "spirit" of the CHA. Whatever that recondite term may mean, an appeal to the spirit of the law is a clear admission that the legislation does not violate the letter of the act. But if the CHA is part of the problem, then not violating both the spirit and, more importantly, the letter of the CHA simply avoids the real problem. Indeed, this issue has already arisen in the initial stages of Roy Romanow's nation-wide commission on health care.
If reform attempts amount to hardly any change at all and are likely only to get bogged down in arguments over levels of public funding, or to be portrayed as nothing but underhanded attempts to dismantle a piece of Canada's national heritage, then those interested in establishing market-based alternatives to the Canada Health Act have to ask: what is the point in attempting to change the status quo? Is it even possible, as Ontario Premier Mike Harris said, for Canadians to "think outside the box?" Our evidence has, in fact, demonstrated several good reasons to go on with further restructuring.
One reason identified in this study is that up to November 2000 most Albertans were satisfied with the amount of public money the Klein government devoted to health care. Of course, there are still those who favour even more public funding; as far as program spending priorities are concerned, health care remains high. But priorities are shifting. Not only has the demand for public funding shifted to other program areas such as education, but support for greater program spending in general has declined (see Kanji and Cooper, 2001). That is, Albertans have been persuaded of the advantages of affordable government. At the same time, the government has responded to an unprecedented budgetary surplus with what is presented as an increase in one-time, targeted spending, chiefly on health care and education, but also on infrastructure. This approach has been unquestionably popular, but fiscally conservative critics might well be concerned about whether it is desirable because the policy also implies continuing efforts to sustain the system from public funds.
Whether Ralph Klein remains faithful to the general objectives of fiscal conservatism and smaller government that animated his earlier mandates is still unknown. With respect to health care policy, however, our analysis shows that many Albertans believe that the current problems with health care are not just attributable to a lack of public funding (see figure 10). For instance, 69 percent of respondents to our most recent survey said the reason why people go to emergency rooms (ERs) with non-life threatening injuries is because they don't know where else to go. In fact, studies have shown that an increasing number of Canadians use ERs for primary care when primary care providers are unavailable (Weil, 1993). In a study of ER use at the Peter Lougheed Hospital in Calgary, only 32 percent of participants thought their conditions were emergencies. For 21 percent of participants, their usual source of care was closed, and 11 percent visited the ER because they thought they would need diagnostic services (Tink et al., 2000).
The Calgary Regional Health Authority (CRHA) has successfully reduced ER load somewhat through media campaigns designed to educate the public on the appropriate use of emergency services, and has also proposed the creation of alternative services such as diagnostic and treatment centers and after-hours care to ease the pressure on emergency rooms (CRHA, January 2001). Given that 72 percent of our respondents agree that "people with non-life threatening emergencies should be redirected to their community clinic," such initiatives are likely to be well-received by Albertans, and we suspect by Canadians more generally. Of course, these kinds of improvements do not address the dysfunctional basis of the CHA, though they do prime electorates on the desirability of change per se, and indicate that it can be done.
Other evidence indicates more basic changes may be possible as well. For example, "personal responsibility for appropriate use of health resources and health choices" was one of the core health care values that emerged from discussions with Canadians through the National Forum on Health (GOC, 2000b). Our study suggests that most Albertans consider that this "core value" has not been upheld by the existing system. Sixty-one percent of respondents said that too many people see health care as being a "right" and not a "privilege," and 57 percent said the reason people turn to the health system for almost everything is because they have no financial incentive not to. Such evidence indicates clearly enough that the public agrees with claims made by health care experts that the chief defect of our collectivist health care system is that there are no disincentives for abuse (Ramsay, 1998; Gratzer, 1999). The positive news, however, is that evidence from the AAS indicates that intermediate measures that will ease the transition to a more economically rational system are likely to be acceptable.
The chief political difficulty is how to manage the transition. To simplify somewhat: if the problem is that the existing collectivist system is unworkable, and the solution is to introduce market incentives through private sector involvement (which means both that private facilities can supply medical services and private individuals can pay for them), then the question is: how to get from here to there? Supporters of the existing system are bound to invoke the usual range of symbolic defenses. This tactic, as we have indicated, makes matters worse both by postponing and preventing improvements in the system, and by preventing any serious consideration of genuine change.
On the other side of this issue, advocates of economically sensible changes are fully aware that the persuasiveness of reason and common sense is often limited, especially when opponents are on the defensive and can rely on the traditional, though economically irrelevant, symbols of "nationhood," or "compassion," or other high- sounding things.
On other policy issues, however, the Klein government was able to prevail in the face of symbolically powerful criticism. In the mid-1990s, Ralph Klein was accused of wrecking the educational system, destroying a "caring" society by reducing the number of recipients of social welfare, and so on. One of the reasons for its earlier successes stemmed from the Alberta government's ability to prime the electorate by getting the message out not only with respect to what the problem was, but how to deal with it. Because of the high political risks surrounding changes to health care, the willingness of Albertans to change course is much more sensitive. To determine the flexibility of Albertans on this issue, the 2000 AAS asked respondents whether they supported various measures for health care reform. As expected, the symbolic importance of "universal" health care was strongly confirmed, as were several non-controversial options—such as changing the emphasis of the health care system to focus more on the prevention of disease, increasing the amount of community-based care, or redirecting people with non-life threatening emergencies to their community clinics in order to relieve the access bottleneck. All of these proposals are amenable to market-based alternatives, though they have not, as yet, been proposed.
The most significant finding, however, was that a sizeable majority (79%) of respondents to our survey agree that "there should be penalties for those who abuse the system." Health Minister Gary Mar has proposed that people who take greater health risks should pay higher premiums than those who do not. Forty percent of respondents to our survey agreed with the minister's proposal, which suggests that Canadians are willing to entertain significant departures from existing practices. It also suggests that, with a certain amount of government priming, further changes can be made.
We also asked respondents whether they agreed with the statement that "too many people see health care as a 'right' and not a 'privilege.'" Among those who agreed, nearly half (44%) wanted to encourage the creation of private clinics, while fully 85 percent thought there should be penalties for abuse of the system. There is obviously room for more fine-grained analysis of the data, but in general, it appears that respondents widely agree with health economists and other policy experts who say that major problems within the system have nothing to do with the question of public versus private funding, administration, and delivery. The fact is, there exists a broad spectrum of acceptable options for health care reform—whatever respondents think is wrong with other aspects of the system. For some of these alternatives, such as a focus on disease prevention, market-based programs such as immunization travel clinics are obvious options. What is important in this context, however, is not the details of any particular proposal but the discovery that any change in the current system is likely to introduce a sense that experimentation is acceptable and that Canadians can "think outside the box" after all. Looked at in the broader national perspective, Bill 11 was probably worth the trouble. It did little to change the basis of health care delivery in Alberta, but it may well have given Premier Harris the encouragement he needed to take the next step. Indeed, it seems likely that, in the absence of the modest changes introduced by Bill 11, Premier Harris would have been more reluctant to introduce changes in Canada's largest province. Recent comments by Liberal Senator Michael Kirby (National Post, July 3, 2001, A1) indicate, mirabile dictu, that even the federal government may at last be willing to consider changing the system.
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