This article was originally published in Maclean's Magazine on July 25, 2005
Ralph Klein's Health Care Reforms Underwhelm
WHEN IT COMES to HEALTH CARE REFORM, Ralph KLEIN has always talked loudly while wielding a very small stick. The results never quite matched his fiery rhetoric. Last week, it was déjà vu all over again. Just six months after the premier delivered a much-hyped speech about finding a "third way" in health care - something between the survival-of-the-richest U.S. system and Canada's publicly funded monopoly - Klein unveiled his latest round of reforms. Critics and supporters alike found themselves underwhelmed.
Federal Health Minister Ujjal Dosanjh, who rarely passes up an opportunity to demonize the Alberta premier as the champion of privatization, sounded pleasantly surprised. Dosanjh said he found nothing objectionable in Klein's 12-point program. Meanwhile, those who advocate a far more vigorous role for the private sector in health care expressed dismay that they'd been misled, yet again. "What we needed was a visionary politician," groused Nadeem Esmail, senior health policy analyst at the Vancouver-based Fraser Institute. "What we got was a reaffirmation of the status quo."
There is much to admire in the list of initiatives unveiled by Klein and his health minister, Iris Evans. Among other things, Canada's richest province is moving to aggressively recruit primary physicians, extend drug coverage to more Albertans and set fixed limits on how long patients must wait before receiving specific surgeries and services. But the only truly controversial proposal is to allow patients to pay out of pocket for what the policy describes as "enhanced medical goods and services beyond what doctors decide is medically necessary." At a jam-packed news conference in Calgary, Klein seemed eager to highlight that initiative, pointing it out even before reporters asked him about it. "Uh, item eight," said the premier in his inimitable fashion, "calls for providing choices in paying for supplementary health services. This will be controversial itself. I don't know if this will violate the Canada Health Act or not. We don't think it will."
One could sense a stir in the room. This was, after all, the man who almost singlehandedly torpedoed federal Conservative Leader Stephen HARPER's chances of becoming prime minister when he mused, during last year's federal election, about introducing health care change that might contravene the Canada Health Act. (In the end, Klein did nothing more radical than throw hundreds of millions of dollars into the health portfolio.) "Isn't that two-tier health care?" demanded one scribe.
"I don't think it's two-tier," shrugged Klein, before conceding, "I guess it's subjective."
The jury is out on just how contentious "item eight" might prove to be. The only example of an "enhanced service" Klein and Evans could come up with was a surgical procedure known as Birmingham hip resurfacing, named for the English city where it was pioneered. It's far less invasive, but more expensive, than standard hip replacement. But it leaves patients with greater flexibility because less of the thigh bone is removed. Still in the experimental phase in Canada, the technique is considered best suited for active people under the age of 55, in large measure because it would allow for a full hip replacement operation if needed later in life. Under the Alberta proposal, anyone could have this procedure as long as they were willing to bear the costs themselves, either directly or through private insurance.
Most experts feel that "item eight" doesn't challenge the Canada Health Act because it applies to an enhanced, rather than a medically necessary service. But for some, it raises troubling questions all the same. Tom Noseworthy, director of the Centre for Health and Policy Studies at the University of Calgary, wonders what happens if doctors someday want the Birmingham procedure deemed a mandated operation, at least for certain patients. How likely is it the province will want to go along and bear the full cost? "What the government's done," says Noseworthy, a former ICU physician and hospital CEO, "is place a potentially necessary service into the private domain. And if they do that for all medical innovations coming on stream, it means only people who can afford to pay for them will benefit."
Another concern is queue-jumping. While Klein and Evans insisted patients who paid for enhanced services would not be fast-tracked, critics suggest that's very hard to police. Michael Rachlis, a Toronto-based physician and independent health policy analyst, points out that many doctors now work simultaneously in public hospitals and private clinics - so there is often an inherent financial incentive to do the more expensive procedures first.
All the same, both Rachlis and Noseworthy say the proposals announced last week are far less radical than Klein's previous sabre-rattling would have suggested. "I think the defenders of medicare in Alberta have been very successful in making their case," says Rachlis. "While I honestly believe Mr. Klein has been trying to make the health system more private, he's also a good reader of public opinion. So every time he's come to the brink of actually doing something, he's balked for very good political reasons."
In fact, Noseworthy suggests "item eight" may simply be Klein's final "thumbing of his nose at the feds" before his widely expected departure from public life, perhaps as early as this fall. If so, the heavy lifting on health reform will be left to a successor - or to other provinces. "The real boldness," says Noseworthy, "is in Quebec, where they have been playing fast and fancy with this stuff for a while, sometimes in complete and flagrant violation of the Canada Health Act." That trend could well accelerate, depending on how the Quebec government responds to the Supreme Court of Canada ruling last month which said that unless waiting lists in the province are dramatically reduced, private insurance plans must be allowed to fill the void.
But it's not just Quebec and Alberta that are wrestling with these issues. While the spotlight was on Klein last week, a private clinic in Toronto announced it would be offering cancer patients direct access to the new wave of high-priced drugs that the public system, in Ontario anyway, is unwilling to fund. These include medications such as the lauded breast cancer drug Herceptin, which can cost as much as $45,000 a year. It has been approved for direct use in some provinces, most recently B.C., but not in Ontario.
For all of that, Klein's latest pronouncements certainly left some feeling like they had lost a champion. The Fraser Institute's Esmail argues Klein said all the right things when he launched his "third way" initiative. "Many Canadians still believe there are only two ways to do health care - the Canadian way or the American," says Esmail. "But it's simply not true. Of the 30 most developed nations in the world, 28 of them, including Canada, have universal health care programs. Only the U.S. and Mexico do not. And of those 28 nations, fully 27 say that if you want to pay for your own services with your hard-earned dollars when the government program is unwilling or unable to meet your needs in a timely fashion, you can do so."
Canada, Esmail says, is the only exception, the recent rash of private clinics and opting-out arrangements notwithstanding. And he held out high hopes that Klein, who once led a successful crusade to eliminate Alberta's debt, could have taken a similarly "visionary approach" to revamping health care. Then again, Esmail cannot be entirely surprised that the premier proved not to be his man. With retirement in the offing, Klein's crusading days are clearly over.
Maclean's July 25, 2005