Textes d'opinion

COMMENT / A healthy starting point: Alberta proposals on medicare are courageous but don’t go far enough

Alberta’s advisory council on health deserves congratulations for having the courage to expose and confront some fundamental and politically sensitive structural flaws and myths that have afflicted Canada’s 40-year experiment with provincially run health care and health insurance monopolies. Chaired by former deputy prime minister Don Mazankowski, the council was to provide strategic advice on the preservation and future enhancement of health services for Albertans and on the sustainability of the publicly funded and administered health system.

One of the most incriminating sections of the report is its description of the current economic and legislative organization of the provincial health system: “Alberta’s health system, like the other systems across the country, operates as an unregulated monopoly. Government provides insurance and forbids, by law, the provision of private insurance for these services. Government prevents, by law, people from obtaining insured services outside the public system except where there are contracts with the public system. It’s a command and control system… People have no choice but to get the health services they need from the publicly insured system and wait their turn in line.”

The council’s critical description of the current health system continues: “In almost every other public and private area, monopolies are simply not accepted. Canadians and Albertans understand and support competition, and we’re reluctant to accept a situation where we have only one choice… In education, people have choices. Parents can choose which school they want their children to attend – public or private. There’s no competition and no incentive to provide the most efficient and effective services available. The old command-and-control central planning approach doesn’t work.”

In spite of the conclusion that the status quo is unsustainable and the dismal picture of the present health system it painted, the advisory council is reluctant to go for the ultimate reform. Instead, it chose the middle ground: maintaining a virtual government monopoly in financing health services but utilizing outsourcing and contracting of privately delivered services. This quasi-internal market approach certainly deserves a trial. So does a market of parallel public and private services and insurance.

Unfortunately, the council stopped short of exposing and recommending repeal of the coercive and prohibitory provisions in provincial and federal health legislation. These provisions have either discouraged or prevented the restoration of a parallel sector of private health-care and health-insurance services, separately or in partnership with the provincial medicare plans.

This long overdue legislative reform would not only assure universal and timely access to quality health services but would restore a full measure of individual freedom and responsibility, market competition, and freedom of choice in health-care matters. These are the crucial health-system advantages that the pluralistic and outperforming systems of Europe and other OECD countries enjoy but that are denied to Canadians. The absence of these advantages has been a major factor in the downgrading of Canada’s health-system performance to 30th place by the World Health Organization.

An environment of health system freedom and personal choice has been strongly supported by public opinion surveys of Canadians over the past four years. This tolerant health system environment would be restored by the necessary but unfinished legislative reforms mentioned above. Now it is up to our forward-looking provincial and federal politicians to undertake this reform project with some urgency.

Otherwise, it will be left to the slow but ongoing court challenge now under way in Montreal. The case involves a patient who suffered for a year on waiting lists before having hip surgery. His individual freedom was infringed by provisions in Quebec health and hospital legislation that prevented him from purchasing private medical and surgical services in hospital and private health insurance, both of which he was willing to pay for. The case is now awaiting a Court of Appeal’s judgment and will likely end up in the Supreme Court.

A bolder recommendation by the Alberta council toward a parallel public and private system of funding and delivery of health care and health insurance would have been more in line with the proposals made in Universal Private Choice: Medicare Plus, a research study recently published by the Montreal Economic Institute and available in French and English on our Web site. It proposes a concept of health care with quality, access and choice for all Canadians.

Our proposals would allow for a voluntary shift from the predominance of health-care financing and monopoly control by government as insurer, payer and provider, toward a pluralistic approach of financing, insuring, and providing, mainly controlled by the patient.

Now is the time for Canadians to keep their minds open to new approaches in health system reform and carefully weigh proposals as they unfold. The Alberta proposals clear the air, improve the language of debate and are important steps in the eventual modernization and liberalization of Canada’s deteriorating health system.

Michel Kelly-Gagnon est président de l’IEDM, Dr. J. Edwin Coffey est chercheur associé à l’IEDM et co-auteur de Universal Private Choice: Medicare Plus.

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