Two-Tier is Here

In Alberta, the door was already open to user-pay health care. Bill 11 kicked it wide open...

By: Gillian Steward

CALGARY: The great federal election debate this year has focused on whether the Alliance favours "two-tier" health care and to what extent Liberals have encouraged user-pay health services.
  In Alberta we are already grappling with a public/private health care model that will likely expand into other provinces if the Canadian Alliance forms the next government. Alliance Leader Stockwell Day and his first lieutenant Jason Kenney have already endorsed it. The Liberal government has done precious little to stop it.
 

Klein and Day have intentionally blurred the line between private and public health care

  Is it two-tier medicine? Not if you define two-tier as a publicly funded system operating along side a private system in which patients pay for all medical services, goods and amenities out of their own pockets.
  But if you define two-tier as a system in which some patients in the public system get faster or better treatment because they can afford to pay extra then it has already arrived in Alberta.
  What the Alberta government has done, with the support of Stockwell Day who was a key cabinet minister at the time, is blur the line between public and private health care. In Alberta we don't have two separate systems but we do have medical entrepreneurs in for-profit clinics using the public funded system as a base from which they can offer patients services and goods that are not covered by Alberta Health Care.
  In the language of the Alliance it's called "giving consumers a choice" rather than two-tier. Here's how it works in Calgary which has gone further down this road than any other region in the province.
  The Alberta government has delegated its responsibility to provide all aspects of publicly funded health care in Calgary to The Calgary Regional Health Authority (CRHA). The CRHA has delegated some of its responsibility to provide surgical services and diagnostic services to private, for-profit clinics operating at arm's length from the CRHA.
 

Public health care patients become captives of entrepreneurs who want to sell them all sorts of things

  For example, all cataract surgery (about 6,000 procedures a year) is done in private clinics. The CRHA contracts with each private clinic to provide a specified number of cataract surgeries each year. The CRHA pays the clinic a facility fee for each procedure, and the doctors in the clinic bill Alberta Health for their professional fees. The patient simply brings an Alberta Health Care card just like she does when she visits any other doctor.
  But unlike most doctor's offices these clinics also provide non-insured services such as laser vision correction, and extras such as a video of your cataract surgery - if you can afford to pay for them. Critics of this type of privatization, such as Friends of Medicare, fear that doctors will pressure patients into paying for services/goods that are not necessary but add to the clinic's profit margin.
  "Public health care patients become captives of entrepreneurs who want to sell them all sorts of things," says Wendy Armstrong of Edmonton, who has authored two reports on the growth of private clinics for consumer rights groups
  Besides cataract surgery the CRHA also contracts with private clinics to provide therapeutic abortions, dermatology, podiatry and plastic surgery.
  While there are no contracts for surgery that requires over night stays, the Alberta government has a legislative framework in place that allows for this thanks to the new Health Care Protection Act also known as Bill 11.
  So it is possible that within the next two years the CRHA will contract with private, for-profit corporations to provide hip and knee replacements, surgery now done only in public hospitals. And as with the eye clinics these private, for-profit hospitals could offer another tier of service other than the "medically necessary" procedures covered by Alberta Health Care.
  "Bill 11 didn't open the door to privatization, it was already happening," says Armstrong. "Bill 11 kicked the door wide open because it allows for private hospitals."
  There are also privately owned Magnetic Resonance Imaging (MRI) clinics in Calgary. The CRHA has contracted with them to provide MRIs in an effort to reduce the length of time patients have to wait to get an MRI in a public hospital. But if a patient wants to skip the waiting altogether he/she can pay for the MRI, get a diagnosis and likely get the treatment they need faster than the people waiting for the publicly-funded MRIs.
  The Alberta government argues that contracting out reduces costs and waiting lists. But there is little evidence of this. The financial details of the contracts are not public so it is impossible to know if the services provided by the private clinics cost more, the same or less than if they had been provided in the completely public system.
  Health Minister Gary Mar will only say of this year's contracts that he was satisfied the surgery was being done at a "cost saving or comparable cost."
  There is plenty of evidence from other jurisdictions, however, that contracting to private, for-profit clinics and hospitals costs taxpayers and consumers more money in the long run. Private operators have to build in profit, handsome executive salaries and costs such as advertising and investor relations. And unlike the public system where resources, such as expensive technology are shared, private clinics are more likely to over load themselves with the latest equipment in order to attract customers/patients.
  Experience in the US also shows that contracts with private, for-profit operators create ample opportunities for fraud.
  In 1999 The New England Journal of Medicine stated: "For decades... no peer reviewed study has found that for-profit hospitals are less expensive (than not-for profit hospitals)... "
  Do we have two-tier medicine in Alberta?
  "You bet we do," says Wendy Armstrong. "The dilemma now is how to bring it back to one-tier."

Gillian Steward is a Calgary-based journalist and former managing editor of The Calgary Herald. She co-authored with Kevin Taft Clear Answers: The Economics and Politics of For-Profit Medicine.

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