Alberta's hybrid public– private “third way”
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* Lisa Gregoire

## Winds of change

Last June's Supreme Court of Canada ruling, coupled with growing wait-time angst have prompted 3 provinces to open the door, at least part way, to the private delivery of health care. The Alberta government has announced it will allow physicians to work in both the public and private sector, while Quebec has pledged to provide hip and knee replacements and cataract operations within a timely 6 months — or it foots the tab at private clinics. British Columbia is also poised to plunge into the privatization fray according to its recent Throne Speech. Read on for the details of this evolving story.

The Alberta Government claims its new Health Policy Framework allowing patients to pay out-of-pocket for certain surgeries, and physicians to slide between the public and private systems will help save a sinking health care system. Critics say the proposals put a hole in the boat.

The Framework, released Feb. 28, finally fleshes out Premier Ralph Klein's vague promises of a “third way” to deliver health care. Under the proposal, which must still be passed by the legislature, patients would be able to circumvent the public system, purchase extra insurance and buy specific, privately offered surgeries.

![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/174/8/1076/F1.medium.gif)

[Figure1](http://www.cmaj.ca/content/174/8/1076/F1)

Figure. Alberta Health Minister Iris Evans says the third way is not 2–tiered health care. Photo by: Canapress

Health and Wellness Minister Iris Evans says this does not constitute 2–tiered health care.”These changes are about offering more health care options and reducing wait times, not about buying better care," she says.”No Albertan will be denied access to essential health services because they can't afford it. Physicians providing services in the private system may also be working in the public system, so the ability to purchase 'better'care is not an issue."

Alberta NDP Leader Brian Mason disagrees.”I call it full-blown two–tiered health care," he said.”It's not about a clash of ideology. It's not a reasoned debate. It's about greed and profit and a government that openly supports both."

Harvey Voogd, coordinator for the Friends Of Medicare lobby, was similarly blunt.”It fundamentally violates Canadians' and Albertans' sense of fairness and violates the Canada Health Act with queue-jumping," he says.”The only winner in this could be the provincial treasury, at the cost of people's pocketbooks." 

Both Prime Minister Stephen Harper and Federal Health Minister Tony Clement say they plan to examine the framework for compliance with the Canada Health Act.

The 10-point policy framework would off-load the cost of continuing care and pharmaceutical drugs to private citizens and expanded insurance plans; allow people to pay out-of-pocket for joint replacement and cataract surgery at private clinics; and allow physicians to practice in the public and private systems simultaneously.

The province hopes private joint and cataract clinics will take patients off long public waiting lists and help Alberta keep annual increases to health care spending in line with inflation.

"This year inflation was 2.1% and our [health care] spending increased over 7%,” says Evans. If this trend continues, “by the year 2030, health care will take over the entire provincial budget… The new Act gives us the legislative tools we need to allow for more flexibility in the public health system to meet emerging needs in a sustainable way."

Alberta now has a budget surplus of $7.4 billion.

Dr. Tzu Kuang Lee, president of the Alberta Medical Association, says members are split down the middle in supporting and opposing the government's plan. The AMA says the framework was vague and neglected to define care guarantees and a basket of core, insured services. "Without these 2 elements in the framework, discussion at this time is speculative,” Lee says.

At a Mar. 11 meeting, the AMA's Representive Forum, a province-wide governing body of more than 100 members, passed resolutions calling on the province to define core services and respect benchmarks, wait times and care guarantees. They also offered support for any initiative that gives timely access for patients to quality medical care that would put the patient first.

The economics of public-versus-private health care in Alberta have spurred a decade of fierce debate, public protest and media hype.

Dr. Ian MacDonald, chair of Ophthalmology at the University of Alberta, raised concerns recently about oversight, continuity of care and competition in private cataract clinics.

In the early 1990s, when Alberta was restructuring health care delivery, the Calgary region opted to contract most of its cataract surgery to private clinics. Edmonton, conversely, consolidated most of its cataract care in the public system. Wait times are now shorter in Edmonton than in Calgary, says MacDonald.

But wait times should not be the only driver of a system, he says. Government contracts with private clinics focus on the number of surgeries performed, leaving no mechanism for gauging success rates, patient satisfaction and follow-up, he adds.

Alberta Liberal Leader Kevin Taft says health care should not be left to the open marketplace.”If we think we're having trouble confronting costs, wait until we turn over more chunks of health care to the marketplace,” says Taft, author of *Clear Answers: the Economics and Politics of For-Profit Medicine*.

In April, the Alberta government plans to introduce a new Health Care Assurance Act, which would replace the Health Care Protection Act. The current legislation, once known as Bill 11, forbids privately–owned hospitals and alludes to the supremacy of the Canada Health Act. The new bill is expected to omit both.