Situation Critical

Ralph Klein made a mess of health care. Will his successor do any better?

By Gillian Steward

On that fateful Friday night at the end of March, when Premier Ralph Klein discovered he had fewer party members in his camp than he’d hoped, it became clear that his pet project was doomed as well. This time around it had been dubbed “the Third Way,” a bland and seemingly benign phrase designed to hide its real purpose. For the Third Way was simply Klein’s latest attempt to open up our public health-care system to those who see it as a wasted business opportunity. If he had succeeded in pushing the legislation through, enterprising surgeons could now recruit patients willing and able to pay the going rate (plus optional extras) for a hip or knee replacement. To raise revenue, regional health authorities would be marketing treatments and services not covered by Medicare.

Ralph Klein would have broken the back of our public health-care system and one of its foundational principles: all patients get the medical treatments and services they require, regardless of their capacity to pay for them. In Ralph’s world it would have been okay for people to pay their way to the front of the line. It would have been okay for others to wait while the surgeons operated on their well-to-do patients.

The Third Way was actually Klein’s third attempt to break the back of Medicare. In 1998 there was Bill 37, his first bid to establish private hospitals. But Klein pulled that bill in the face of stiff public opposition. In 2000 he set about establishing private hospitals yet again. Remember the televised fireside chat in which he said he was going to make it possible for people to bypass public hospitals if they needed hip and knee surgery? Despite polls showing that the majority of Albertans didn’t want what he wanted for them, Klein rammed Bill 11 through the Legislature. He got what he wanted, but he never did convince most Albertans that it was a good idea.

So why did Klein push for even more privatization with the Third Way? Why did he risk it when he knew that most Albertans don’t want private hospitals, private health insurance or two-tier medicine? Months after the demise of the Third Way there’s no clear answer to that question. But now that Premier Klein is on his way out, a bigger question looms: will the new leader of the Alberta Progressive Conservatives try to take us down the same path? Should Albertans simply write off the Conservatives and look to the Liberals or the NDs if they want a reliable public health-care system? Or was Ralph’s fixation simply that: a personal obsession that he couldn’t shake? Did his determination have more to do with proving himself right and others—such as the Liberals, NDs, Friends of Medicare and his pet peeve the Raging Grannies—wrong? Was it all about vengeance, petty revenge?

Richard Plain, a health economist, long-time political observer, card-carrying Conservative and a staunch supporter of public health care, is glad to see the end of the Klein era because there were so many “massive blunders” when it came to health-care policy. “Klein never seemed to get past Health Care 101,” he says with a chuckle.

When Premier Klein received far less support than he expected (a miserable 55 per cent) during that March leader- ship review, several factors had combined to sink his ship. Party members would likely have been kinder to him if he had simply set a firm retirement date—or if he hadn’t expelled Lyle Oberg from cabinet for speaking his mind. Another weighty factor was the confusion and anxiety surrounding the Third Way. Federal Conservatives were worried that it would make too many Canadians jittery about Stephen Harper’s plans for health care. Anxious constituents were calling their MLAs.

But still, one has to wonder if any of the contenders for the leadership of the Alberta Tories understand the antipathy that Klein created among many Albertans, and not just those of the left, with his attempts to gut Medicare. They certainly didn’t seem to get it when they appeared at a pancake breakfast during last summer’s Calgary Stampede. It had been organized by the Huang brothers, medical doctors and owners of what was once the Holy Cross Hospital—one of three inner-city public hospitals in Calgary that were closed by the Calgary Health Region (CHR) after the provincial government slashed health-care budgets early in its mandate. The Huangs’ company, Enterprise Universal Inc., bought the hospital for a mere $4.5-million, shortly after a $35-million renovation had been completed; a developer paid $12-million just for the city-owned parking lots next to the hospital.

The Huangs are big supporters of Ralph Klein and have donated generously to the Alberta PC party. John Huang was once a director of the Calgary-Varsity PC constituency association. The hospital building they own is now home to an extensive eye surgery clinic operated by Peter Huang, also chief of ophthalmology for the CHR. In addition, the building houses a clinic for ambulatory cancer patients, a chronic pain centre, a radiology clinic, beds for continuing care, and a pharmacy. In other words, it closely resembles a hospital (minus the expensive emergency department) but it is a privately owned, for-profit business, and the CHR must rent the space it uses.

Like a ghost of its former self, the building that once housed the much loved Holy Cross Hospital loomed over the candidates for the Tory leadership—Ed Stelmach, Dave Hancock, Jim Dinning, Ted Morton, Lyle Oberg—as they strolled about in their cowboy duds looking for votes. Eye surgeons fresh out of the operating theatre, still wearing greens, their masks untied so they hung around their necks like bandanas, seemed eager to chat with them. Elderly residents from the continuing care facility chowed down on pancakes as they listened to speeches.

Even a premier as popular as Ralph Klein could never convince most Albertans that privatization of health care was a good idea. So it seemed more than a little odd that those who want to replace Klein would make a public appearance in front of one of the most flagrant symbols of his disastrous policies. So eager were they to collect votes and give quotes to a passel of news media, it looked as if they just didn’t make the connection: they didn’t seem to understand that Calgarians are in dire need of more hospital beds and emergency room services because the Holy Cross, the Grace (which was also sold off) and the General (which was blown up) were eliminated from the public system when the Conservatives were sitting on the government side of the Legislature. This doesn’t bode well for Albertans looking for leaders who thoroughly understand the complications of health-care policy— leaders prepared to make sure we don’t sell off our public health-care system bit by bit to the highest bidders.

The top candidates for the leadership of the Alberta PCs, one of whom will be the next premier for at least a few months, can be divided into three camps when it comes to health-care policy. Lyle Oberg and Ted Morton, who want more privatization, sound very much like Ralph Klein; Jim Dinning is putting all his eggs squarely in the public health-care basket, but his record indicates some of the eggs may not stay there; Ed Stelmach, Mark Norris and Dave Hancock don’t have much to say about health care but are unlikely to challenge the legitimacy of the Canada Health Act, as Ralph Klein was wont to do.

According to Oberg, a former cabinet minister and medical doctor, Albertans should be allowed to pay out of pocket for some surgeries if they want to skip the line in the public system. He also says physicians and surgeons should be allowed to work in both public and private systems, although they might have to commit to spending 75 per cent of their time in the public system. Ted Morton also believes patients should be allowed to pay if they want faster service. Both candidates maintain that that this will shorten waiting lists in the public system and free up resources there—a canard that is often bandied about by privateers but has been proven false by many reputable academic researchers. Even Prime Minister Stephen Harper warned Ralph Klein that his Third Way would not be acceptable to the federal government if it meant doctors would be working in both the public and private systems, because such a move would create a shortage of medical staff in the public system. Why Oberg and Morton still insist on such a policy is somewhat mystifying, especially since both are targeting rural party members, and it is rural people who will suffer most if doctors are lured to private clinics in the large urban centres. Morton, a political scientist at the University of Calgary, also wants more public money to be funnelled into private health-care facilities. This too is an odd position for someone as right-wing as Morton. Shouldn’t he be advocating for tight controls and transparency of public funding rather than public subsidization of private medi-businesses?

Jim Dinning has done an about-face when it comes to health-care policy. As provincial treasurer he initiated the deep budget cuts that led to hospital closures, downsizing and layoffs. After he left government and was appointed chair of the Calgary Health Region, he became a vocal supporter of Bill 11, Premier Klein’s successful bid to allow for overnight patient stays in private surgical clinics, a move that paved the way for private hospitals. Now Dinning says private health care “scares” Albertans. “I agree with Albertans that we don’t need to go down a private parallel route or the private insurance route for essential services… they want quality health care delivered fast to all Albertans in a publicly funded health-care system,” he told the editorial board at the Edmonton Journal earlier this year.

For Dinning there are three priorities that must be attended to: primary health care (finding the elusive family doctor), electronic health records and new models for chronic care. He doesn’t want to embark on any “grand plans” but would rather focus on improving the public system. He also believes that we can blend public and privately delivered services within the publicly funded system “as long as high standards of quality are met and as long as people don’t need to shell out of their pockets for essential health services.” He doesn’t mention whether these privately delivered services should be as cost-effective as services delivered within the public system. Last year the CHR announced that it had contracted the privately owned Health Resource Centre in Calgary to provide 2,500 hip and knee surgeries, an arrangement that would cost 10 per cent more than if the surgeries had been performed within a public hospital.

Jim Dinning has done an about-face when it comes to health-care policy. As provincial treasurer he initiated the deep budget cuts that led to hospital closures, downsizing and layoffs.

Dinning is quite familiar with private, for-profit healthcare providers, since he is a director of AgeCare Investments, a company which operates several assisted-living and long-term care facilities, and has contracts with the CHR to provide those services. One of the principals of AgeCare is Dr. Kabir Jivraj, who was chief medical officer and vice-president of the CHR at the same time Dinning was chair of the board. During his tenure with the CHR, Jivraj also owned surgical clinics that were awarded contracts by the CHR, an arrangement that was criticized inside and outside the organization as a conflict of interest. Mark Scharf, who used to manage those contracts on behalf of the CHR, has since left the CHR to take an administrative position with AgeCare. Earlier this year, AgeCare was acquired by Northern Property Real Estate Investment Trust (NPREIT) of Ontario. NPREIT intends to act only as a financier and landlord for AgeCare and was drawn to the company because of its contracts with the public sector.

Wendy Armstrong, an Edmonton-based health policy analyst who has authored several studies for the Alberta chapter of the Consumers’ Association of Canada, warns that this increased reliance on the private sector to provide financial and management services in health care raises a disturbing question: “What long-term debt have they taken over? And will that be paid for with public funds?” Jim Dinning is also a director of Partnerships British Columbia, an organization established by the BC government to facilitate private financing and ownership of provincial infrastructure. On the health-care front, Partnerships BC has spearheaded an agreement between the private sector and the public sector for the construction of a 300-bed hospital and cancer centre in Abbotsford. Under the agreement, the private partner finances, designs, builds and maintains the hospital and cancer centre and provides facility management services such as housekeeping, food, laundry and linen services over a 30-year period. The public sector (the government treasury) will pay for clinical services—the cost of nurses, doctors, pharmaceuticals, medical equipment, surgeries and other treatments. This is the same model used by private companies who provide long-term care beds to regional health authorities. One can only wonder if this is what Dinning has in mind for hospitals and cancer centres in Alberta.

It is this continuing-care model—in which private corporations own the buildings and charge for housekeeping services while the public treasury funds direct patient care—that worries Carol Wodak. She is an experienced advocate for continuing-care patients and has watched as funding for patient care has moved from the health-care envelope to housing and seniors programs. “I think it is a mistake to believe that the established Tory program for continuing care is simply to spend as little public money as possible. What they have achieved over the last 20 years is to distance long-term care from the provision of health care; what started as ‘auxiliary hospitals’ and ‘nursing homes,’ regulated as hospitals and funded under public health care, are now part of a social housing program, with increasingly limited services provided and paid for from health-care funding,” says Wodak, whose mother recently died after several years as a patient in a long-term care facility. In practice, adds Wodak, these policies leave seriously ill and disabled citizens without essential health care, while at the same time they have to pay escalating rates for their rooms, meals and housekeeping services.

Early in the leadership campaign, Wodak was heartened by the fact that Mark Norris, a former Edmonton MLA who was defeated by the Liberals in the last election, had at least mentioned continuing care in his platform. But then Norris told a Rotary Club meeting that he not only favoured expanding seniors’ benefits, but would also like to see funding for seniors’ long-term care facilities provided by the Seniors ministry rather than split between Seniors and Health. “He just doesn’t get it,” a discouraged Wodak wrote in an e-mail.

Bev McKay, another experienced advocate for long-term care patients and one of the founders of a website (www. continuingcarewatch.com) designed as a public forum for patients and their families, is also pessimistic. She believes that until there is greater public recognition of the dreadful conditions that many long-term care patients endure (confirmed by a 2005 Auditor General’s report), things will not improve. McKay, who lives just outside Cochrane, also wants the government to be much more open and transparent about the millions of dollars it is pouring into long-term care. “Where exactly is the money going?” she asks. “Is it going into administrative budgets or is it being used for hands-on patient care? No one seems to know.” For the soft- spoken McKay, all politicians come up short on this issue. “Neither the NDs, Liberals or Conservatives seem to get it,” she says, echoing Carol Wodak’s sentiments.

Wendy Armstrong says it’s difficult to judge how a pre- election platform might affect policies after a candidate is elected—the candidate’s level of interest in health-care policy, as well as his overall knowledge and understanding of the issues, is a much better indicator of future performance. It’s also important, says Armstrong, to ask whether the MLAs, party members and Albertans at large will have influence over the premier in regard to health care, or whether it will continue to be a one-man show as it was with Premier Klein.

Pessimism aside, what questions concerning health-care policy should Albertans be putting to the PC leadership candidates—as well as politicians from the opposition parties, since we are likely to have a provincial election within a year? How can Albertans be reassured that we have left the Klein Care era once and for all?

Richard Plain, the health economist, is supporting Jim Dinning’s candidacy because he believes Dinning holds the most promise when it come to health-care policy. But he also has some suggestions for questions that need to be posed to all the candidates. “I think it’s important to ask each candidate what guidelines he or she will use to deal with health-care spending. It is a financially sustainable system as long as we control it. But how is that to be done?” The other questions involve the Klein government’s plan to permit pharmacists to diagnose patients and then prescribe medication. “What is this really all about?” says Plain. “It seems to be another way of delisting a service normally delivered by a doctor and covered by Medicare. Will patients have to pay pharmacists for this service? And should pharmacists who work for large multinationals like Wal-Mart and Rexall be permitted to diagnose and prescribe costly pharmaceuticals?”

Wendy Armstrong thinks the Tory leadership candidates should take a look at the Liberals’ health-care policy. “The most detailed health-care policy is to be found on the Liberal website,” she says. “It provides the basis for good questions to be put to the PC leadership candidates.” Armstrong would also like to know if any of the leadership candidates are commit- ted to having opposition MLAs included in the Standing Committee on Health and other legislative committees. “But the big question in my mind is: who are they going to listen to once they get elected?” she says. Armstrong would like them to listen to ordinary Albertans seeking “bread and butter” medical care, instead of lobby groups and powerful vested interests.

With the departure of Premier Klein and the subsequent leadership race and general election, it seems Albertans do have an opportunity to participate in the reframing of the province’s health-care policy. Whether the new Tory leader and a new government will continue to encourage that kind of participation, or instead shut people out as Ralph Klein did, remains to be seen.

Gillian Steward was the publisher of Alberta Views.

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