Alberta ignores vocal opposition, presses ahead with law to expand role of private clinics

Richard Cairney

CMAJ 2000;162:1606-7

Not that the demonstrations did any good. Bill 11, the Health Care Protection Act, was expected to become law by mid-May after Premier Ralph Klein invoked closure on debate in the legislature May 1. The bill, which expands the role of private-sector clinics within the public system, not only drew fire from opponents across the country but also divided physicians and had protesters describing Klein as "a fascist."

Critics say the bill brings Canada closer to a two-tiered health care system, sets a precedent under the North American Free Trade Agreement that would allow American health care firms to set up in Canada, and does nothing to address the underlying problems that are causing long waiting lists for surgery. The bill's vociferous opponents said the bill would, in effect, allow the formation of private hospitals. And they accused Klein of playing loose with language: the legislation refers to approved surgical facilities, but critics say these are, in fact, hospitals.

Bill 11 (www2.gov.ab.ca/healthfacts/index.cfm?PnM=Legislation) proposes a new regulatory structure for private surgical facilities. The province's 17 regional health authorities will have to follow the new rules when establishing contracts for private surgical services. The bill also expands the role of private-sector clinics, allowing them to perform more complicated procedures that require overnight stays. At present, only relatively minor day procedures, such as cataract surgery, are permitted.

The bill would prohibit queue jumping and charging patients extra for enhanced services; the private firms would charge the province itself for any extra costs. And the act would allow such contracts to exist only if they improve access to health services or if they are cheaper than in the public system. Surgeons are allowed to work in the public and private sectors but would be paid the same fees in either system.

Opposition has come from groups as diverse as the Consumers' Association of Canada, Alberta's Catholic hospitals, the Raging Grannies, unions, municipal governments, grass-roots organizations like Alberta's Friends of Medicare (www.savemedicare.org), the Canadian Health Coalition (www.healthcoalition.ca) and the Alberta Medical Association (www.amda.ab.ca).

Dr. David Bond, president of the 6000-member AMA, says the province needs to focus on providing the public health system with adequate resources. He argues that contracting for services doesn't make sense when a shortage of medical staff is at the heart of surgical waiting lists.

"We are saying that we don't believe this bill actually protects anything and that it does not get to the root of the problems we have in terms of providing services to our patients," says Bond. Those problems, he adds, have more to do with a lack of infrastructure: nurses, physicians, operating rooms. And the bill focuses only on one small area — facilities outside of the hospital.

Many of the bill's critics, including the AMA, are worried about conflicts of interest. In particular, some opponents point to the strong connections between government-appointed members of the Calgary Regional Health Authority board, the region's medical staff and the ownership of private surgical facilities. Bill 11 makes no mention of conflict of interest, the premier says, because each of the province's health regions has its own conflict guidelines.

Bond says this isn't good enough. "This is a provincial health plan. Why should we have 17 different rules in 17 different regions? If you are an Albertan and you are covered by Alberta Health and Wellness, you get the same service and support whether you are in Edmonton or Lethbridge or Calgary."

Bond also argues that there's no way of knowing whether the surgical contracts are cheaper. With Bill 11, the surgical contracts will not be protected under the province's freedom-of-information legislation. This means that anyone can request the financial details. However, it is impossible to "price out" services in a public hospital because of confidentiality rules, meaning that it is also impossible to compare prices within the 2 systems. "If we don't know what lab services cost in the public system, how the heck are we supposed to make a decision about whether it costs less to have it done in the private system?" Bond wonders.

Although he makes a strong case, some members of the AMA disagree with the association's opposition to the bill. Dr. Dennis Modry, head of the AMA's section of cardiovascular and thoracic surgeons and a longtime critic of medicare, says the province's 20 cardiovascular and thoracic surgeons disagree with the AMA and may quit the association over the issue.

"With respect to Bill 11, we applaud the way in which the provincial government is looking for new, creative and innovative solutions to improving our health care system, in response to the federal health minister's challenge to the provinces to develop new ways of improving health care within the constraints of the Canada Health Act," Modry said in a statement issued shortly after the AMA criticized the bill.

However, such public expressions of support for Bill 11 have been few and far between. In Edmonton and Calgary, public rallies against the bill drew thousands of people, who flocked to hear speeches by Shirley Douglas; her father, the late Saskatchewan premier Tommy Douglas, is considered the father of Canada's medicare program. Her son, actor Kiefer Sutherland, also appeared at the rallies to fight the bill.

Actor Kiefer Sutherland addresses Bill 11 protesters during mid-April protest in Calgary (Photo courtesy of Canapress photos)

In an interview with CMAJ, Sutherland said the federal and provincial governments seem to have abdicated responsibility for health care by cutting funding. "We have to take responsibility for the welfare of others," he said. "We have evolved to a level of society, I hope, where that is true. We have a health care system in this country that exemplifies that and I've watched it slowly, over the last 20 years, be stripped down to the bare minimum and to the point where people are now saying it doesn't work. Well of course it doesn't work — it's not being funded properly. I have a huge problem with politicians who have been going against the wishes of their constituents and have been bloodletting the system for 20 years and now say it doesn't work and that we have to go private."

Protesters rally at legislature in Edmonton

The rallies in Alberta's 2 largest cities were followed by growing protests at the provincial legislature in Edmonton. Although for the most part peaceful, Edmonton police showed up in force to monitor the impromptu rallies. As politicians debated the bill inside, some protesters entered the building through a ground-floor window, another window was smashed and a police van had a tire slashed. More legislature gatherings were held in early May. Elsewhere, the Raging Grannies — a vocal group of social activists — held a funeral for Bill 11 outside the office of Health Minister Halvar Jonson.

Despite the vocal opposition, Klein was determined to pass the bill — even if it meant invoking closure to end the debate. Bond said the AMA wouldn't have a problem with that, as long as a few key amendments were made first.

"The split isn't quite as big within the profession [as it is among the public]," he said. "As soon as the word private is in there, and contracting out, people have concerns. Contracting is an integral part of the system, and we do it now for all sorts of services. I am sure the minister of health wants regulations over private clinics because there aren't many now. But we are hoping that what this will do is make sure these facilities meet the standards that are set for everything else. More importantly, we want to be assured the money that goes to these facilities is being spent in reasonable, rational ways."

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