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How the Alberta election could further define the private sector’s role in health care

For nearly a decade, Ron Clark has been operating a mobile chapel at truck stops across Alberta to provide chapel services for truckers.

At 75, he’s hopeful he can continue to do that for many years — but his health is always on his mind.

That’s because Clark was diagnosed with cancer close to 10 years ago. With a provincial election looming, it’s the issue that most concerns him. 

“I think it’s important for everybody — you need health care to be available and on a regular basis. That is reasonable,” Clark said.

For years now, the symptoms of a provincial health-care system gasping for breath have become difficult to ignore, from rural emergency room closures, to ambulance shortages, to overwhelmed hospitals. Health care has emerged as the top issue on the minds of Alberta voters as an election looms, polling suggests

Zoom out for the big picture across Canada, and many of the same issues emerge. That has led some provincial governments to consider an increased role for private health-care clinics, such as in Ontario.

Privatization has existed for decades in Canada, and in Alberta there are various publicly funded, privately-delivered options.

A man looks at the camera.
Ron Clark said he feels like he fell through the cracks when it came to doctors suggesting he get a colonoscopy for his colon cancer. His wife waited two years to get an operation, while a friend of his has waited years for a knee replacement. For those reasons, health care is his top election issue. (Elise Stolte/CBC)

In this crucial moment, there’s consensus that some kind of change is required to ward off pressure on the system. In Alberta, both the United Conservative Party and New Democratic Party have broadly pledged to protect public health care. 

But the debate truly lies at the boundaries of the system, where the division between public and private pay is blurred. Whoever wins the provincial election will be a key participant in a national debate that will define what happens next to one of Canada’s most cherished symbols of identity.

So do solutions to Alberta’s health-care crisis involve an increased role for the private sector? Are such moves likely to be effective? And what does each party leader believe?

A quick refresher

As election season kicks off in Alberta, it’s likely you’ll be hearing a lot about introducing more privatization into health services. 

The NDP has already tried to make political hay from UCP Leader Danielle Smith’s plan to establish health spending accounts, while the UCP has held fast to a recent pledge that it plans to protect public health care. Both sides have elements to unpack, which we’ll get to.

But it’s easy to get confused, because there are a lot of things at play here. 

So before we sort through the political spin, let’s take a look at what the discussion consists of in Canada right now, specifically discussing the two elements at play here: privately delivered, publicly funded health care, and privately paid health care.

Federal laws in Canada dictate that charges for “medically necessary” services, provided in a hospital or by a doctor, can’t be charged back to a patient. 

Health Minister Jean-Yves Duclos
Federal Health Minister Jean-Yves Duclos recently warned provinces against letting private health-care providers charge patients for medically necessary services, lest their funding be clawed back. (Sean Kilpatrick/The Canadian Press)

Alberta already has publicly funded health-care arrangements with private corporations. They provide health-care services to patients without charging them. The arrangements were put in place to address surgical backlogs, according to the province, and privatized community lab services have been established in a stated effort to cut costs.

Some of those developments have come with their fair share of criticism from public health advocates. They worry about profit motivations for private companies, which have limited transparency. On the other hand, proponents of such an arrangement would argue that that same business structure can drive efficiencies.

But what’s really the crux of the issue here is what’s referred to as “private pay.” Some services, such as chiropractic services, are not deemed medically necessary and as such are not covered in Alberta. Patients have to pay for those themselves, or through private insurance.

Grey areas emerge

On private pay, things become more complicated, and here’s where the crucial question comes into play: What is medically necessary care?

As mentioned above, provinces that allow private health-care providers to charge patients for medically necessary services have dollars clawed back by the federal government. The feds this year have already taken back $13.8 million from Alberta.

Such moves don’t make much sense from a policy context, said Fiona Clement, a professor who specializes in health policy in the department of community health sciences at the University of Calgary. 

A woman smiles at the camera.
Fiona Clement is an assistant professor at the University of Calgary’s Cumming School of Medicine who specializes in health policy and health economics. (Riley Brandt/University of Calgary)

For instance, hypothetically having a patient pay for a family physician visit would see a dollar-for-dollar clawback from the federal transfer, Clement noted, in essence rejecting federal dollars in favour of Albertans paying out of their own pockets.

Still, grey areas are emerging that are pushing the boundaries. Some primary care clinics in Alberta and elsewhere have started to charge membership fees, and in return clients receive certain guarantees such as getting appointments within 24 hours. 

Though the guarantees aren’t technically health-care services, it is a monetization of health-care access beyond what’s currently covered by the system, Clement said.

“It’s really pushing the boundaries of what’s allowable in that space,” she said.

On health spending accounts

Perhaps the one element that has become a flashpoint in the health-care debate in the Alberta election so far has been the UCP leader’s proposal to create health spending accounts. Smith said they would cover things such as massages, chiropractic work, optometry and dentistry, and other services not covered by the health-care system.

The NDP leader has often suggested health spending accounts represent the first step toward further privatization of health-care services in the province. Rachel Notley specifically references a 2021 policy paper written by Smith, in which she argues the government should pledge to match up to $375 per person for health spending accounts and challenge individuals and employers to do the same.

A woman speaks at a podium.
Alberta Premier Danielle Smith announces a public health guarantee in Sherwood Park on April 11. Smith’s plan to create health savings accounts is being studied by the province. (Jason Franson/The Canadian Press)

The benefit, Smith contended, was Albertans could use their account to pay for services that are uncovered and largely preventative, which would mean less pressure on the hospital system and better chronic care management. 

“It has to shift the burden of payment away from taxpayers and toward private individuals, their employers and their insurance companies,” Smith wrote. 

Once people get used to the concept of paying out of pocket for more things themselves, she wrote, then the conversation could be changed on health care. 

She went on to state that the entire budget for general practitioners should be paid from health spending accounts, adding co-payments could be considered, with deductibles based on income.

Such suggestions that annual visits to primary care doctors not be paid for by government would be within the bounds of what would be considered “medically necessary” care, according to Clement, the U of C health policy expert, and would result in clawbacks from the federal government.

In recent weeks, Smith has declined to say specifically whether she continues to hold those perspectives, and the UCP has pushed back against characterizations that further privatization is in play.

In April, the UCP made a “public health-care guarantee,” which states that no Albertan will have to pay out-of-pocket to see a family doctor or to get medical treatment. 

“Rest assured you will never use a credit card to pay for a public health care service. You will only ever need your Alberta health care card,” Smith said at the time.

When asked April 24 about what her personal philosophy was when it came to public health care, Smith pointed to an agreement signed by Alberta with Ottawa worth $24 billion over 10 years, which would uphold the principles of the Canada Health Act.

“I believe actions speak louder than anything,” she said.

Concerns surround private pay

Privatization might improve the health outcomes of people who are already affluent, said Brian Rowe, a professor in the School of Public Health at the University of Alberta, whose research has focused on privatization in Canada.

“But it won’t help Indigenous people, it won’t help racialized Canadians, poor Canadians, people who need access to health care for mental health and addictions,” he said. 

“We’re one of many, many studies that have looked at this, and there’s virtually no evidence that privatization will be the solution.”

The evidence is clear that financial barriers of any kind to medically necessary care stops or slows people from seeking that care, said Clement.

“We do know that systems that have universal health care, with no or very minimal financial barriers to access, have better health outcomes as a society,” she said.

  • WATCH | Talking to Albertans about what issues are most important to them this provincial election:

Calgarians weigh in on their experiences and suggestions for the future of health care

Wait times, funding, and pay for health care staff among issues discussed by Albertans.

Perspectives on private delivery are mixed

So what about private delivery, which already exists in the province?

Some believe private clinics are a tool. Ontario’s health minister said such methods represent an opportunity for “innovation and opportunity” in the health system when eyeing the issue of solving long wait times. 

But perspectives are mixed.

Janice MacKinnon is a professor of public policy at the University of Saskatchewan and a former provincial finance minister. Her recommendations were utilized by the UCP under former premier Jason Kenney. 

She said the key to running private clinics that strengthen the public system is to have contracts that work to the advantage of the government, not the company providing the procedures. 

“You can use [private clinics for] simple day procedures: the cataracts, knees, joints. Moving those procedures out of hospitals actually frees up more space in the hospitals for what they should be used for,” she said.

A woman speaks at a podium.
Janice MacKinnon, pictured during her time as chair of the Blue Ribbon Panel on Alberta’s Finances, speaks to the media in 2019. (Jeff McIntosh/The Canadian Press)

Dr. Fredrykka Rinaldi, head of the Alberta Medical Association, said publicly funded and privately operated options have some merits — if the processes are transparent — but believes economic status should not affect health-care access.

“If we look at any of the statistics … if we just look at socioeconomic status, we know that peoples’ health outcomes fare less well,” Rinaldi said.

Others believe such moves take resources away from the public system and increase inequity, and the supposed benefits — saving taxpayers money and reducing wait times — aren’t borne out by the data.

What the parties say

So what’s to be done, if all involved agree business can’t continue as usual? 

When asked on Tuesday whether an NDP government would ever consider utilizing additional private health-care services to handle backlogs, Notley said in certain brief windows there might be settings where that would be possible.

“But generally, we also know the research shows, and more importantly, experience shows that the most cost-effective means of delivering public health, as well as the means that gives the best care for patients, is actually through public delivery,” she said.

During its time in government, the NDP was persistent in that point of view, at one point rejecting an Alberta Health Services plan to contract out laundry services. 

In the 2019 campaign, then-candidate Kenney used puns to lambaste the move: “Putting taxpayers through the wringer just to maintain a government-run monopoly on laundry is just plain dirty, and certainly won’t leave taxpayers feeling April fresh.”

Rachel Notley speaks at a podium.
When asked Tuesday if there was any privatization an NDP government would roll back, including membership fees charged at private clinics, NDP Leader Rachel Notley said the party would ‘work hard to try to limit the opportunity for that.’ (Mike Symington/CBC)

In a statement, Dave Prisco, director of communications with the UCP, said its utilization of chartered surgical facilities was targeted at bringing down wait times so Albertans can access care when and where they need, for free.

“UCP Leader Danielle Smith has signed the public health guarantee, which commits that no Albertan will have to pay to see their family doctor or to get the medical treatment they need,” he wrote.

He did not specifically respond to a question requesting more information around whether additional publicly funded, privately delivered services would be considered under a re-elected UCP government.

If more private delivery systems are introduced in health care, robust tracking and reporting mechanisms will be needed to ensure resource allocation, equity of access, and value for money, said Clement, the health policy expert at the University of Calgary. 

Though she noted there aren’t any easy answers here, Clement suggested Canada look to other comparative nations.

“There are other places we could look to to achieve better health outcomes, and pay less than we do. We can do better,” she said.