Gerard W. Boychuk Department of Political Science University of Waterloo

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 19th, 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) • 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 (insured vs. non-insured) services

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. 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

11. 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 • 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??

12. 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

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 • patient reimbursed (up to public rate schedule)

14. Alberta’s Proposed Reforms • Mazankowski Report

15. Alberta in Cross-Provincial Comparative Perspective • MAIN POINT... • there is a lot of room under the CHA to expand the potential for private funding and private insurance of health services

16. 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

17. Alberta Public Opinion in Cross-Provincial Perspective • support for private payment for quicker service/service enhancements • support for private insurance • support for different scenarios

18. Pollara, Health Care in Canada Survey, 2005.

19. Pollara, Health Care in Canada Survey, 2005.

20. Pollara, Health Care in Canada Survey, 2005.

21. Alberta Public Opinion in Cross-Provincial Perspective • support for private payment for quicker service/service enhancements • support for private insurance • support for different scenarios

22. Pollara, Health Care in Canada Survey, 2005.

23. Ipsos-Reid, CFNU, January 2006.

24. Pollara, Health Care in Canada Survey, 2005.

25. Ipsos-Reid, CFNU, January 2006.

26. Alberta Public Opinion in Cross-Provincial Perspective • support for private payment for quicker service/service enhancements • support for private insurance • support for different scenarios

27. Ipsos-Reid, CFNU, January 2006.

28. Ipsos-Reid, CMA, June 2006.

29. Ipsos-Reid, CMA, June 2006.

30. 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 • government’s strategic approach to reform

31. 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 gov’t performance in health care • levels of spending on public health services • government’s strategic approach to reform

32. Ipsos-Reid, Health Care System Report Card, August 2005.

33. Ipsos-Reid, Health Care System Report Card, August 2005.

34. 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 gov’t performance in health care • levels of spending on public health services • government’s strategic approach to reform

35. Source: Canada Institutes for Health Information, Statistics Canada

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 • government’s strategic approach to reform

37. The Alberta Govt’s 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 • “There’s 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)

38. The Alberta Govt’s Strategic Approach to Reform • “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

39. Ipsos-Reid, CFNU, January 2006.

40. Ipsos-Reid, CFNU, January 2006.

41. 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

42. The Alberta Govt’s 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

43. 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 don’t change, by 2008 we could be spending half of the province’s program budget on health. We do not believe that is acceptable.” Mazankowsi Report, 2001: 4

45. Source: Canada Institutes for Health Information, Statistics Canada

47. Source: Canada Institutes for Health Information, Statistics Canada

48. Source: Canada Institutes for Health Information, Statistics Canada

49. Source: Canada Institutes for Health Information, Statistics Canada