Moving Beyond the Status Quo:
Alberta's "Working" Prescription for Health Care Reform
Conclusions
We began this Public Policy Source by suggesting that health care reform poses a real challenge for policy makers. Many experts contend that the status quo cannot be maintained over the long-term for several different reasons: costs are up, the appetite for more public funding seems insatiable, and increased public funding does not address the real problems. Our public opinion evidence indicates that in Alberta there is plenty of room for well-considered and economically rational changes. This is just as well because, if change is not anticipated, events will always come as a surprise—often a shocking one. Under such circumstances, governments are vulnerable and can do little but react rather than lead.
The obstacles to sensible change can easily be over-estimated. Some people are always going to view advocates of health care reform as having either ulterior motives or a hidden agenda. Of course private health care practitioners are interested in getting a fair return for their efforts, but so are doctors and nurses who currently operate under a publicly-funded and state-administered system. Talk of hidden agendas may appeal to conspiracy buffs and the politically paranoid, but such personal predispositions do little to address a challenge common to policy makers across the industrial world. Besides, the agenda is not hidden: the objective is to maintain sensible social programs, to reduce the perverse incentives that almost invariably accompany government intervention, and to leave more hard-earned dollars in taxpayers' pockets. What's more, there is ample evidence that voters in democracies everywhere support political parties that are fiscally prudent, limit spending, and cut taxes. The welfare state is on the defensive, not market-based health care reform.
Even so, it remains an open question whether even Alberta and Ontario will be able to move beyond the status quo on health care policy. The symbolic charge attached to health care alone makes any changes politically risky. Individual anxieties that surround illness and injury are inherent and add to the difficulties surrounding innovations of any kind. It is true that the strategy of long-range persuasion and "priming" the electorate worked well for the Klein government in other areas (Cooper and Kanji, 2000; Kanji and Cooper, 2001), but the agenda still remains regrettably dominated by advocates of hearsay and fear mongering.
Voters see health care as unlike other social programs. What the Alberta experience shows is that by controlling and minimizing the stresses on the existing health system through prudent measures such as "just-in-time" spending in major trouble spots, and by maintaining an acceptable level of accessibility, it is possible for a government to bring changes to the system, and to implement initially unpopular reforms, while still remaining politically viable. Indeed, the Klein government has shown it is possible for a government to grow in popularity and to improve the public's outlook toward the entire system. Yet doubts remain concerning the value of spending time, energy, and political capital in order to make small and incremental changes. But endless debate over public funding levels has solved nothing. It seems inevitable that eventually the economic rationality of a market-based health care system will prevail. Our data indicate that Albertans (and perhaps Canadians) are more willing to experiment along those lines than previously has been admitted by opponents of change or hoped for by advocates. The kind of spending the Klein government has so far put in place is one-time targeted funding, not continuing blanket public funding that commits governments to support the existing status quo or create a new program that is just as unacceptable. Such a spending program is flexible, which is always a plus, but it also requires innovation, imagination, and the courage to say "no" to continuing demands. No government, including the government of Ralph Klein, enjoys saying "no." In particular, when it comes to health care, spending cuts alone are not likely to effect significant structural reform; they were accepted, or at least tolerated, when governments had deficits to reduce, but at the first sign of surpluses demands for more public funding grew and intensified. Any government that fails to deliver what voters want is likely to be punished by them. The challenge, therefore, is for governments to walk the fine line that enables them to make changes to the system, but not at the cost of being voted out. It is clear that the Alberta government is an electoral success, but it is less clear that its changes to health care have constituted a policy success. As we have noted, not much has yet changed.
Second, the Alberta experience illustrates the fact that it is difficult to change the status quo (for all the reasons given above) by persuasion alone. For example, after tabling Bill 11, the Klein government temporarily deployed its so-called "truth" squads to try to counter the bill's critics by setting the record straight on what the proposed legislation was really intended to do. The result: more Albertans became opposed to the legislation, and there was plenty of critical attention in the media.
The other way to convince people that it is acceptable to experiment, to try alternatives that have not been tested, to anticipate a certain amount of difficulty and disappointment, is by example. After all, that is the purpose of political leadership—to lead by example. In the larger context, federalism is particularly well suited for these kinds of policy experiments—what a National Post editorial once called "competitive federalism" (December 3, 1999). In any event, it seems clear that the fears and anxieties surrounding even modest achievements such as Bill 11 will not be reduced by truth squads and shouting matches, but by "priming by example." A sure way to remove fear from the unknown is to show people in practice that changes to the old ways can actually be an improvement.
In one sense this has already happened, though not in Alberta. In the absence
of the modest changes introduced by the Klein government, it is highly
unlikely that Ontario Minister of Health Tony Clement and Ontario Premier
Mike Harris, let alone Senator Kirby, would ever have suggested that the
private sector could do a better job than the existing public system. Prior
to the Klein
reforms, the premier of Ontario would not have said: "there
can't be any sacred cows. You've got to look at everything. It doesn't
mean that you're going to do everything, but you have to be at least prepared
to look at everything" (National Post, April 27, 2001, p. A1). Nor would
Tony Clement have declared that "the logical argument here is if the private
sector can deliver better, cheaper, safer, more effective health care than
a public sector deliverer of that public health care, then we should at
least have a look at that" (National Post, April 28, 2001, p. A5). The
Klein government took the first step by opening the debate. The Harris
government took the second one by reaffirming the need for change and by
pointing to the private sector as the place to look for it. Perhaps at
long last the federal government, which guards the sacred CHA cow, will
take Senator Kirby's advice and put it out of its misery.
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