The

1
The Alberta Paradox The Regulation of Private
Health Insurance in Comparative Cross-Provincial
Perspective

• Gerard W. Boychuk
• Department of Political Science
• University of Waterloo
• Presented to the Institute for Advanced Policy
  Research, University of Calgary
• September 20th, 2006

2
The Paradox...

• Alberta is the testing ground of health care
  commercialization and nose-thumbing at the
  Canada Health Act and its role as a national
  Trojan Horse in pushing privatization has
  yielded impressive results elsewhere in the
  country... CUPE Innovation
  Exposed, Oct.2004
• "Alberta, of all the provinces in Canada, is the
  most hostile towards private clinics. We
  couldn't function in Alberta." Dr. Brian
  Day President Elect CMA Founder,
  Cambie Surgical Services Edmonton Journal, 18
  Sept.2005

3
The Paradox...

• political leadership in Alberta firmly committed
  to increasing private funding in health services
• Alberta regulation of private funding/financing
  options is relatively stringent
• more stringent that in several other Canadian
  provinces
• more stringent than required by CHA
• Why?

4
The Answer...

• relatively sophisticated political calculation
  based on a number of factors...
• electoral benefits are unclear
• public opinion in Alberta no more (and likely
  less) supportive than public opinion in other
  provinces
• Alberta government has contributed to an emphasis
  federal-provincial aspects of reform
• has undermined construction of a public consensus
  around reforms
• health care funding not as pressing a political
  problem as often made out
• strong fiscal capacity make acceptance of the
  status quo a more politically palatable option
• Alberta government views health care reform as
  key ideological battleground
• reticent to experiment if success is not
  guaranteed

5
Stringency of Regulation (Private
Provision/Funding/Insurance) in Alberta --
vis-a-vis Canada Health Act (CHA)

• CHA
• universal availability of public health insurance
  (on uniform terms and conditions) for all
  medically necessary hospital and physician
  services
• without financial barriers to access
• extra-billing on insured services
• user/facility fees on insured services (defined
  Marleau, 1995)
• penalties
• non-discretionary penalties for
  extra-billing/user fees
• discretionary penalties for other violations of
  five principles
• non-requirements
• no legal probitions on private provision of
  services
• no legal prohibitions on private insurance
• no reference to the status of physicians only
  the status of services (insured vs. non-insured)

6
Stringency of Regulation (Private
Provision/Funding/Insurance) in Alberta --
vis-a-vis Canada Health Act (CHA)

• limits on private income by opted-in physicians
• prohibits opted-in physicians from billing
  individual patients at rates above those payable
  by the public insurance program
• limits on public income by non-participating
  physicians
• expressly prohibits reimbursement of residents
  who have paid fees for services provided by a
  non-participating physician
• prohibitions on the private provision of
  services
• prohibits private facilities providing emergency
  care requiring medically-supervised stays of more
  than twelve hours
• prohibits physicians from performing major
  surgical services except in a public hospital
• CHA only requires that facility fees be covered
  by public plan if physician fee is covered by
  public plan
• bans third party insurance for services that are
  otherwise publicly-funded

7
Alberta in Cross-Provincial Comparative
Perspective
8
POTENTIAL FOR PRIVATE FUNDING OF MEDICAL SERVICES
OPTED OUT PHYSICIANS
None
High
Prohibit Opting-Out
Limits on Fees
Public Coverage Denied or Ban on Private Insurance
No Restrictions
Public Coverage Denied Ban on Private Insurance

• Newfoundland

• BC
• Alberta
• Quebec

• Saskatchewan
• PEI
• New Brunswick
• Manitoba

• Manitoba
• Nova Scotia

• Ontario

Public coverage denied. Ban on Private
Insurance
9
POTENTIAL FOR PRIVATE FUNDING OF MEDICAL SERVICES
OPTED-IN PHYSICIANS
None
High
Prohibit Direct Patient Billing
Ban Extra-Billing
Public Coverage Denied
No Restrictions (except no direct billing of
public plan)
Ban on Private Insurance

• Saskatchewan
• Manitoba
• Ontario
• Quebec
• Nova Scotia
• Newfoundland

• BC
• Alberta
• Saskatchewan
• Manitoba
• Ontario
• Quebec
• Nova Scotia
• Newfoundland

• PEI
• BC
• Alberta
• Manitoba
• Ontario
• Quebec

• New Brunswick
• All other provinces

• Allowed by CHA ?

10
CHA

• Extra-billing
• 18. In order that a province may qualify for a
  full cash contribution referred to in section 5
  for a fiscal year, no payments may be permitted
  by the province for that fiscal year under the
  health care insurance plan of the province in
  respect of insured health services that have been
  subject to extra-billing by medical practitioners
  or dentists.1984, c. 6, s. 18.
• User charges
• 19. (1) In order that a province may qualify for
  a full cash contribution referred to in section 5
  for a fiscal year, user charges must not be
  permitted by the province for that fiscal year
  under the health care insurance plan of the
  province.

11
Alberta in Cross-Provincial Comparative
Perspective

• maximum allowance for private funding (using
  currently existing provincial practices)
• non-participating phyisicians
• billing rates unrestricted
• patient reimbursed (up to public rate schedule)
• private insurance coverage
• participating physicians
• direct patient billing at unrestricted rates
• private insurance coverage
• no patient reimbursement

12
Alberta in Comparative Perspective

• the Australian model (e.g. Emery)
• public subsidization of private insurance
  premiums
• waive public premiums for individuals who
  purchase private insurance
• coverage of physicians fee (non-participating,
  participating?) outside of the plan (up to fixed
  )
• facility fees in public facilities (up to fixed
  ) for private patients
• allowable for services provided to private
  patients (corrollary of Marleau stipulation)
• non-participating physicians
• issue is granting hospital privileges to
  non-participating physicians
• participating physicians
• if physician fee is not publicly reimbursed (e.g.
  New Brunswick)
• if patient is publicly reimubursed for physician
  fee??

13
Alberta in Cross-Provincial Comparative
Perspective

• maximum allowance for private funding (using
  currently existing provincial practices)
• non-participating phyisicians
• billing rates unrestricted
• patient reimbursed (up to public rate schedule)
• private insurance coverage
• participating physicians
• direct patient billing at unrestricted rates
• private insurance coverage
• no patient reimbursement

14
Alberta in Cross-Provincial Comparative
Perspective

• maximum allowance for private funding (using
  currently existing provincial practices)
• non-participating phyisicians
• billing rates unrestricted
• patient reimbursed (up to public rate schedule)
• private insurance coverage
• participating physicians
• direct patient billing at unrestricted rates
• private insurance coverage
• patient reimbursed (up to public rate schedule)

15
Albertas Proposed Reforms

• Mazankowski Report recommendations re health
  care financing
• Phyisicians should be able to work in public,
  private or not-for-proft systems and retain their
  privileges at public hospitals. (51)
• private insurance
• defined People would be able to choose to get
  both insured and non-insured health service at a
  private facility. They could pay for these
  services directly or through some form of private
  or supplementary insurance. The public system
  would continue to provide the full range of
  insured health services. (56)
• ...we do not recommend expanding private
  insurance for publicly funded services... (56)
• ...this approach would clearly contravene the
  Canada Health Act. (56)
• MSAs
• ...if people are are required to pay for some
  services once their medical savings account is
  exhausted, this may contravene the Canada Health
  Act. (58)
• variable premiums
• variable based on income and health service usage
• We believe our recommendations are consistent
  with the spirit and intent of the Canada Health
  Act.

16
Albertas Proposed Reforms

• Health Policy Framework, February 2006
• Directions 6-9 relevant to issues of funding
• Direction 6 limiting publicly-funded health
  services
• excluding health services which are
  discretionary, are not of proven benefit, or are
  experimental in nature
• and leaving those services to be financed either
  by patients directly or through third-party
  insurance
• Direction 7 flexible funding options
• mentions co-payment, long-term care savings
  accounts, private insurance
• including non-emergency acute care (in addition
  to non-CHA services -- e.g prescription drugs,
  dental care)
• Alberta will closely examine...

17
Albertas Proposed Reforms

• Health Policy Framework, February 2006
• Directions 6-9 relevant to issues of funding
• Direction 9 paying for choice and access
• shift away from requiring physicians who wish to
  bill privately to opt out for all services
• no violation of CHA
• currently allowed in New Brunswick/PEI
• ...allowing both public and private providers to
  offer enhanced services and expedited acces to a
  limited range of non-emergency services at an
  appropriate charge.
• CHA compliance depends on implementation
• phyisicians cannot bill public plan directly and
  bill patients an additional charge
• facility fees cannot be charged if physician
  bills public plan directly

18
Albertas Proposed Reforms

• Health Policy Framework, February 2006
• Directions 6-9 relevant to issues of funding
• Direction 6 limiting publicly-funded health
  services
• excluding health services which are
  discretionary, are not of proven benefit, or are
  experimental in nature
• and leaving those services to be financed either
  by patients directly or through third-party
  insurance
• Direction 7 flexible funding options
• mentions co-payment, long-term care savings
  accounts, private insurance
• including non-emergency acute care (in addition
  to non-CHA services -- e.g prescription drugs,
  dental care)
• Alberta will closely examine...

19
Alberta in Cross-Provincial Comparative
Perspective

• MAIN POINTS...
• there is a lot of room under the CHA to expand
  the potential for private funding and private
  insurance of health services
• enforcement of the CHA is a political issue
• grey areas to be determined by federal
  interpretation
• enforcement more politically difficult where
  there are existing provincial precedents
• enforcement more politically difficult in respect
  to existing practices than in respect to proposed
  reforms
• federal government retains right to amend the CHA

20
The Answer...

• relatively sophisticated political calculation
  based on a number of factors...
• electoral benefits are unclear
• public opinion in Alberta no more (and likely
  less) supportive than public opinion in other
  provinces
• Alberta government has contributed to an emphasis
  federal-provincial aspects of reform
• has undermined construction of a public consensus
  around reforms
• health care funding not as pressing a political
  problem as often made out
• strong fiscal capacity make acceptance of the
  status quo a more politically palatable option
• Alberta government views health care reform as
  key ideological battleground
• reticent to experiment if success is not
  guaranteed

21
Alberta Public Opinion in Cross-Provincial
Perspective

• Alberta public opinion not more favourable to
  private funding/private insurance than other
  provinces (and probably less so)
• Compas, Pollara, Ipsos-Reid, Environics

22
Alberta Public Opinion in Cross-Provincial
Perspective

• support for private payment for quicker
  service/service enhancements
• support for private insurance
• support for different scenarios

23
Environics, National Issues Survey, June 2004.
24
Pollara, Health Care in Canada Survey, 2005.
25
Pollara, Health Care in Canada Survey, 2005.
26
Pollara, Health Care in Canada Survey, 2005.
27
Alberta Public Opinion in Cross-Provincial
Perspective

• support for private payment for quicker
  service/service enhancements
• support for private insurance
• support for different scenarios

28
Pollara, Health Care in Canada Survey, 2005.
29
Ipsos-Reid, CFNU, January 2006.
30
Pollara, Health Care in Canada Survey, 2005.
31
Ipsos-Reid, CFNU, January 2006.
32
Alberta Public Opinion in Cross-Provincial
Perspective

• support for private payment for quicker
  service/service enhancements
• support for private insurance
• support for different scenarios

33
Ipsos-Reid, CFNU, January 2006.
34
Ipsos-Reid, CMA, June 2006.
35
Ipsos-Reid, CMA, June 2006.
36
Alberta Public Opinion in Cross-Provincial
Perspective

• Alberta public opinion not more favourable to
  private funding/private insurance than other
  provinces (and probably less so) WHY?
• public perceptions of the quality of public
  health services
• levels of spending on public health services
• governments strategic approach to reform

37
Alberta Public Opinion in Cross-Provincial
Perspective

• Alberta public opinion not more favourable to
  private funding/private insurance than other
  provinces (and probably less so) WHY?
• public perceptions of the quality of public
  health services and govt performance in health
  care
• levels of spending on public health services
• governments strategic approach to reform

38
Ipsos-Reid, Health Care System Report Card,
August 2005.
39
Ipsos-Reid, Health Care System Report Card,
August 2005.
40
Alberta Public Opinion in Cross-Provincial
Perspective

• Alberta public opinion not more favourable to
  private funding/private insurance than other
  provinces (and probably less so) WHY?
• public perceptions of the quality of public
  health services and govt performance in health
  care
• levels of spending on public health services
• governments strategic approach to reform

41
Source Canada Institutes for Health Information,
Statistics Canada
42
Alberta Public Opinion in Cross-Provincial
Perspective

• Alberta public opinion not more favourable to
  private funding/private insurance than other
  provinces (and probably less so) WHY?
• public perceptions of the quality of public
  health services
• levels of spending on public health services
• governments strategic approach to reform

43
The Alberta Govts Strategic Approach to Reform

• It is my preference that provincial/territorial
  Ministers themselves be given an opportunity to
  interpret and apply the criteria of the Canada
  Health Act to their respective health care
  insurance plans. Minister Jake
  Epp National Health and Welfare
  Canada 1985
• Theres nothing that says you have to stay in
  the Canada Health Act. Premier Ralph
  Klein June 2004
• It may violate the Canada Health
  Act. Premier Ralph Klein March 2006
  (on Alberta health reform proposals)

44
The Alberta Govts Strategic Approach to Reform,
2006 Perceptions that Reforms Violate CHA

• The Alberta government strongly supports these
  CHA principles and views them as fundamental to
  the future evolution of the health system in this
  province. Health Policy Framework 2006
• It may violate the Canada Health
  Act. Premier Ralph Klein quoted in
  Klein Willing to Defy Ottawa, Globe and
  Mail, 2 March 2006
• The province's Health Minister, Iris Evans
  said...that she isn't sure whether the plan would
  violate federal laws. Globe and Mail,
  1 March 2006
• Alberta Report characterized as crossing the
  Rubicon of health care and breaching the
  firewall Don Martin, National Post, 2 March
  2006
• marks the beginning of the end of medicare as
  practiced today in Canada the end of the Canada
  Health Act, at least as conventionally
  interpreted the end of the worlds only fully
  publicly funded health-care delivery system the
  end of the guarantee that only need, and never
  wealth, will determine who gets served
  first. John Ibbotson, Globe and Mail, 5
  March, 2006
• Mr. Klein...said those who opposed the
  province's plan had confused the public about
  what it would mean. Globe and Mail, 21
  April 2006

45
The Alberta Govts Strategic Approach to Reform,
2006 Perceptions that Significant Reforms Must
Violate CHA

• The minister Alberta Health Minister Iris
  Evans said a Supreme Court of Canada ruling last
  spring opened the door to broadening the use of
  private insurance for primary health-care
  treatments... Calgary Herald, 14 Sept.
  2005
• It's impossible to know whether Evans is leading
  the charge for a private, parallel health-care
  system, finally free of the constraints of the
  Canada Health Act, or for more modest reforms.
  Are we talking about a major realignment of
  services -- as if the Canada Health Act didn't
  exist -- where only public service is limited to
  expensive hospital treatment? Or some
  tinkering? Sheila Pratt Edmonton
  Journal, 25 Sept. 2005

46
Ipsos-Reid, CFNU, January 2006.
47
Ipsos-Reid, CFNU, January 2006.
48
The Paradox...

• Alberta is the testing ground of health care
  commercialization and nose-thumbing at the
  Canada Health Act and its role as a national
  Trojan Horse in pushing privatization has
  yielded impressive results elsewhere in the
  country... CUPE Innovation
  Exposed, Oct.2004
• "Alberta, of all the provinces in Canada, is the
  most hostile towards private clinics. We
  couldn't function in Alberta." Dr. Brian
  Day President Elect CMA Founder,
  Cambie Surgical Services Edmonton Journal, 18
  Sept.2005

49
The Paradox...

• Alberta is the testing ground of health care
  commercialization and nose-thumbing at the
  Canada Health Act and its role as a national
  Trojan Horse in pushing privatization has
  yielded impressive results elsewhere in the
  country... CUPE Innovation
  Exposed, Oct.2004
• "Alberta, of all the provinces in Canada, is the
  most hostile towards private clinics. We
  couldn't function in Alberta." Dr. Brian
  Day President Elect CMA Founder,
  Cambie Surgical Services Edmonton Journal, 18
  Sept.2005

50
Alberta Public Opinion in Cross-Provincial
Perspective

• MAIN POINTS...
• Alberta public opinion less favourably predispoed
  toward private funding/private insurance than is
  the case generally in other provinces
• the Alberta governments strategic approach to
  reform probably contributes significantly to this
  outcome
• undermines the political construction of a public
  consensus in favour of reform

51
The Answer...

• relatively sophisticated political calculation
  based on a number of factors...
• electoral benefits are unclear
• public opinion in Alberta no more (and likely
  less) supportive than public opinion in other
  provinces
• Alberta government has contributed to an emphasis
  on federal-provincial aspects of reform
• has undermined construction of a public consensus
  around reforms
• health care funding not as pressing a political
  problem as often made out
• strong fiscal capacity make acceptance of the
  status quo a more politically palatable option
• Alberta government views health care reform as
  key ideological battleground
• reticent to experiment if success is not
  guaranteed

52
The Alberta Govts Strategic Approach to Reform

• WHY??
• recast provincial health reform as an issue
  relating to federal intrusion into a field of
  provincial jurisdiction
• rallying the base
• not an appropriate strategy for a broader
  electoral appeal
• blame avoidance for failing to undertake health
  care reforms which are not broadly politically
  popular
• Both Prime Minister Stephen Harper and federal
  Health Minister Tony Clement had expressed
  concern in recent weeks that Alberta's proposed
  reforms, which Premier Ralph Klein had dubbed the
  Third Way, could violate the Canada Health Act --
  something Ottawa could address by withholding
  transfer payments. Mr. Klein took the federal
  government to task yesterday, saying it offered
  no alternatives. Globe Mail, 21 April
  2006

53
The Answer...

• relatively sophisticated political calculation
  based on a number of factors...
• electoral benefits are unclear
• public opinion in Alberta no more (and likely
  less) supportive than public opinion in other
  provinces
• Alberta government has contributed to an emphasis
  federal-provincial aspects of reform
• has undermined construction of a public consensus
  around reforms
• health care funding not as pressing a political
  problem as often made out
• strong fiscal capacity make acceptance of the
  status quo a more politically palatable option
• Alberta government views health care reform as
  key ideological battleground
• reticent to experiment if success is not
  guaranteed

54
Alberta Health Expenditures

• crowding out argument
• Spending on health is crowing out other
  important areas like eduction, infrastructure,
  social services or security. If health spending
  trends dont change, by 2008 we could be spending
  half of the provinces program budget on health.
  We do not believe that is acceptable. Maz
  ankowsi Report, 2001 4

55
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56
Source Canada Institutes for Health Information,
Statistics Canada
57
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58
Source Canada Institutes for Health Information,
Statistics Canada
59
Source Canada Institutes for Health Information,
Statistics Canada
60
Source Canada Institutes for Health Information,
Statistics Canada
61
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62
Alberta Health Expenditures

• crowding out argument
• questionable logic
• undue focus on health care expenditures (vs. tax
  relief, debt reduction)
• empirical evidence??

63
Source Canada Institutes for Health Information,
Statistics Canada
64
Correlation Between Health Expenditures and Other
Expenditure, Alberta, 1990-2005
Column B No Lag No Lag Column B Lagged Column B Lagged Column B Lagged Column B Lagged Health Lagged Health Lagged Health Lagged Health Lagged
General Category Specific Expenditure/Revenue Category Annual Increase Rate of Change (Annual Increase) Annual Increase Annual Increase Rate of Change (Annual Increase) Rate of Change (Annual Increase) Annual Increase Annual Increase Rate of Change (Annual Increase) Rate of Change (Annual Increase)
Other Expenditure Lag 1 yr. Lag 2 yr. Lag 1 yr. Lag 2 yr. Lag 1 yr. Lag 2 yr. Lag 1 yr. Lag 2 yr.
Other Expenditure Total Education 0.14 (0.02) 0.22 (0.05) 0.09 (0.01) 0.16 (0.03) -0.03 (-0.00) 0.14 (0.02) -0.23 (-0.05) -0.32 (-0.10) -0.16 (-0.03) -0.27 (-0.07)
Other Expenditure Elementary/Secondary Education -0.13 (-0.02) 0.15 (0.02) -0.12 (-0.01) 0.13 (0.02) -0.10 (-0.01) 0.17 (0.03) -0.43 (-0.19) -0.33 (0.11) -0.24 (-0.06) -0.14 (-0.02)
Other Expenditure PSE 0.48 (0.23) 0.24 (0.06) 0.32 (0.10) 0.11 (0.01) 0.01 (0.00) 0.05 (0.00) 0.26 (0.07) -0.14 (-0.02) 0.03 (0.00) -0.34 (-0.11)
Other Expenditure Debt Reduction 0.33 (0.11) 0.49 (0.24) -0.13 (-0.02) -0.54 (-0.29) -0.10 (-0.01) -0.46 (-0.21) 0.13 (0.02) -0.66 (-0.43) 0.43 (0.19) -0.78 (-0.62)
()R2
65
Correlation Between Health Expenditures and
Revenues, Alberta, 1990-2005
Column B No Lag No Lag Column B Lagged Column B Lagged Column B Lagged Column B Lagged Health Lagged Health Lagged Health Lagged Health Lagged
General Category Specific Expenditure/Revenue Category Annual Increase Rate of Change (Annual Increase) Annual Increase Annual Increase Rate of Change (Annual Increase) Rate of Change (Annual Increase) Annual Increase Annual Increase Rate of Change (Annual Increase) Rate of Change (Annual Increase)
Lag 1 yr. Lag 2 yr. Lag 1 yr. Lag 2 yr. Lag 1 yr. Lag 2 yr. Lag 1 yr. Lag 2 yr.
Revenue Own Source Revenue 0.20 (0.04) 0.21 (0.04) -0.09 (-0.01) -0.09 (-0.01) -0.18 (-0.03) -0.21 (-0.04) 0.09 (0.01) -0.11 (-0.01) 0.13 (0.02) -0.08 (-0.01)
Revenue Investment Income 0.38 (0.15) 0.36 (0.13) 0.00 (0.00) -0.05 (-0.00) -0.24 (-0.06) -0.19 (-0.04) 0.20 (0.04) -0.10 (-0.01) 0.19 (0.03) -0.17 (-0.03)
Revenue Income Tax -0.13 (-0.02) 0.04 (0.00) -0.21 (-0.04) -0.49 (-0.24) 0.31 (0.09) -0.09 (-0.01) -0.34 (-0.12) 0.25 (0.06) -0.20 (-0.04) 0.24 (0.06)
Revenue Personal Income Tax -0.23 (-0.04) -0.25 (-0.06) -0.23 (-0.05) -0.16 (-0.02) -0.01 (-0.00) 0.39 (0.16) 0.07 (0.01) 0.45 (0.20) 0.07 (0.00) 0.40 (0.16)
Revenue Corporate Income Tax 0.07 (0.01) 0.24 (0.06) 0.06 (0.00) -0.28 (-0.08) 0.39 (0.15) -0.45 (-0.20) -0.46 (-0.21) -0.21 (-0.04) -0.27 (-0.07) -0.18 (0.03)
()R2
66
Alberta Health Expenditures

• MAIN POINTS...
• crowding out
• alternative interpretation growth in provincial
  fiscal capacity has been shared between tax
  relief, debt reduction, and health care
• crowding out hypothesis must have some
  empirical content
• initial indicators -- does not appear to be the
  case
• strong economic growth makes health funding
  status quo more politically palatable
• it is politically easier to divided a growing pie
  than a shrinking one
• so long as budgets of other services are keeping
  pace with inflation and population growth,
  disproportionate growth in health care is not
  politically problematic

67
The Answer...

• relatively sophisticated political calculation
  based on a number of factors...
• electoral benefits are unclear
• public opinion in Alberta no more (and likely
  less) supportive than public opinion in other
  provinces
• Alberta government has contributed to an emphasis
  federal-provincial aspects of reform
• has undermined construction of a public consensus
  around reforms
• health care funding not as pressing a political
  problem as often made out
• strong fiscal capacity make acceptance of the
  status quo a more politically palatable option
• Alberta government views health care reform as
  key ideological battleground
• reticent to experiment if success is not
  guaranteed

68
Health Care as Ideological Battleground

• highly directive approach to opening up the
  health care system to private insurance
• RFIs/RFPs
• actuarial review
• proposal to approve a single private insurer
• alternative view
• Some MLAs argued that Evans should simply
  announce a list of services that will be
  pay-for-priority and see which insurers come in
  to take up the challenge. Edmonton
  Journal, 14 September 2005
• Alberta's tepid decision to keep on studying
  the issue is the furthest thing from anarchy.
  It's time to stop making excuses and loosen up
  the rules. Editorial, Calgary Herald,
  15 Sept. 2005
• these analyses ignore the perceived political
  costs of failure

69
Conclusions

• ...the second Third Option?
• Option 1 Status Quo
• Option 2 Violation of CHA
• Option 3 Aggressive Redefinition of
  Public/Private Role in Health Funding within CHA

70
Conclusions

• maximum redefinition allowed under CHA
• remove legal restrictions on private provision of
  privately funded services
• e.g. public monopoly of emergency services and
  major surgery
• provide public subsidization of private insurance
  premiums
• waive public premiums for individuals who
  purchase private insurance
• provide coverage of physicians fee
  (non-participating, participating?) outside of
  the plan (up to fixed )
• facility fees in public facilities (up to fixed
  ) for private patients
• allowable for services provided to private
  patients
• non-participating physicians
• grant hospital privileges to non-participating
  physicians
• participating physicians
• if physician fee is not publicly reimbursed (e.g.
  New Brunswick)
• if patient is publicly reimubursed for physician
  fee??

71
Conclusions

• political strategy
• make legislative changes and allow private
  providers/insurers to react through the market
  (rather than through government directed
  consultations)
• emphasize that reforms are in keeping with CHA
• emphasize elements of reform already existing in
  other provinces
• undertake reforms and allow federal government to
  challenge
• use dispute resolution mechanism to full extent
• political pressure on federal government will be
  higher in the case of existing (rather than
  hypothetical) practices

72
Conclusions

• failure to achieve health financing reforms is
  not the result of external constraints (e.g. CHA)
  but determined by domestic politics
• failure to achieve reform of health financing in
  Alberta is not paradoxical result of deliberate
  political calculation
• health reform in Alberta hs been the political
  means rather than the policy ends
• rather than allowing experimentation,
  federal-provincial entaglement in health care has
  contributed to sclerosis (through blame avoidance)

73
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