Windows were smashed and tires on police vehicles were slashed during several days and nights of intense protests in front of the Alberta Legislature earlier this year. There's nothing like the threat of privatizing healthcare to turn mild-mannered Canadians into an angry mob.
Protesters in Edmonton this past spring were opposing Bill 11, a piece of legislation that allows private clinics to be paid with public dollars to keep patients overnight for operations and other medical procedures. But in the end, the bitterly fought legislation that some say opens the door of Canadian healthcare to American companies--through the North American Free Trade Agreement--became law in late September.
"This legislation protects Alberta's publicly funded health system and sets out the strongest rules in the country," Health and Wellness Minister Gary Mar said the day the law was enacted.
For Premier Ralph Klein, the third time was the charm for the proposal. The politician who had privatized liquor stores and the motor-vehicle registry had tried twice in 1998 to expand the role of private medical clinics with similar legislation. But public outcry forced him to scrap a proposal that would have given the health minister power to approve "alternative treatment" facilities.
Albertans had viewed that proposal and Bill 11 as legislation that would allow private, for-profit hospitals. Demonstrations this past spring with as many as 2,500 protesters failed to stop Klein, though he would later acknowledge it was a "tough battle."
More privatization. Some see the law, formerly called the Health Care Protection Act, as the end of universal healthcare and a welcome mat for private U.S. companies--something most Canadians don't endorse.
The act allows private companies to bid on contracts for publicly funded medical procedures that require an overnight stay. Those procedures must first be approved by the College of Physicians and Surgeons of Alberta, the doctors' regulatory body.
Larry Ohlhauser, M.D., registrar of the college, says the organization has not yet decided what procedures can be performed in private clinics. However, there are what he called "absolute no's," which include any procedures done to the skull, chest or to a child younger than 18 months.
The Alberta government stressed to an anxious public that Bill 11 would be an extension of what the western province already had done. The only difference, the government says, is that overnight stays would be permitted. It is unlikely any overnight-stay clinics will open before the next provincial election.
Thirty-six private clinics were paid $9 million (figures are in Canadian dollars) out of a $5.8 billion budget to do--among other publicly funded day procedures--vasectomies, ear tubes and knee arthroscopies for the fiscal 2000-2001 year. Bill 11, according to the government, would be an extension of what has been done for about 15 years.
`A climate for infraction.' Even Federal Health Minister Allan Rock has acknowledged that "Bill 11 is not an infraction of the Canada Health Act in itself." That act, among other things, bans extra billing, which means a doctor can't charge a patient for a medical service already covered under public health insurance, known in Canada as medicare. However, he acknowledged that the new law "could be creating a climate for infraction."
Consequently, the federal government is spending $4 million per year on extra staff to monitor the Alberta health system and crack down on any infringements of the Canada Health Act. Infringements would include charging patients for medical procedures above the negotiated fee agreed upon by government and medical associations.
Hugh Scully, M.D., former president of the Canadian Medical Association, says that before any government looks to expand the role of the private market, a key question should first be answered: "Has the public system capacity been used as well as it could be?"
Last year, federal and provincial governments spent an estimated $86 billion on the healthcare system. Of that, private healthcare spending accounted for $26.2 billion, or about 30% of the total. Drugs, dental care, vision care and insurance cost Canadians, on average, $850 last year, according to Health Care in Canada, a report compiled by the Canadian Institute for Health Information, a government-funded clearinghouse of health figures.
Spending vs. care. Overall, spending on the healthcare system has increased to 9.2% of gross domestic product in 1997. Canada ranks fourth after the U.S., Germany and France in its spending among the G-7 industrialized countries. In terms of total health expenditures, Canadians spent $2,175 (U.S.) per capita, compared with the $4,095 (U.S.) in America in 1997, according to Organization for Economic Cooperation and Development figures.
This move toward private care comes during a time of big government surpluses and tax cuts. In September, Canadian Prime Minister Jean Chretien and provincial and territorial premiers struck a health agreement in which the federal government will provide an additional $21.2 billion for healthcare services during the next five years.
In return, the provinces agreed to issue report cards prepared by third parties on the performance of their health systems.
Klein has called Bill 11 "one of the strongest pieces of legislation in Canada to protect the health system." Backing down, he says, would have sent a message that "it's too risky to attempt meaningful and positive reform of the health system."
Christine Burdett of the Friends of Medicare, a group that led nightly protests at the Legislature in the spring, says the law won't reduce waiting lists or save money.
But now that it's become law, Alberta New Democrat leader Raj Pannu says his political party "will be there to argue the case for strengthening our public hospitals, rather than throwing money away on costly privatization experiments."
Healthcare, for a price. Recently, Canada has seen more entrepreneurs dabbling in private healthcare, even though some critics argue that it violates the Canada Health Act.
Private magnetic resonance imaging centers have opened across the country to serve a public more than happy to pay as much as $875 rather than face what can be months-long waits at publicly funded hospitals.
At least 14 private MRI scanners have been installed in Alberta, British Columbia and Quebec over the past few years. In Edmonton, there are three MRI private clinics, and price wars have broken out. A scan can be had for the bargain price of $475.
Entrepreneurs in those provinces contend no law has been violated, because public health insurance plans don't cover MRIs done in private clinics. Nevertheless, the clinics have sparked a federal review.
There seems to be little doubt that an entrepreneurial shift is taking hold in Canadian healthcare. A Toronto firm has launched what is believed to be Canada's only Web site that allows patients to get sick notes, prescription renewals and medical advice through the Internet--for a price.
And an Edmonton-based private company provides up-to-date lists of reputable surgeons and physicians outside of Canada, information on treatment costs and help deciding where to go for medical care--for those willing to pay an initial $500 fee.
`There's no going back.' Toronto lawyer Barry Appleton, who specializes in international trade law, says Bill 11 opens the door to for-profit U.S. companies not just in Alberta but in the entire country. By making these changes, "it's a one-way street--there's no going back," Appleton says. "Once the door is open, market forces will start pushing in other places. The fact is, it's not about public opinion, it's a question of law."
Appleton says "no one would have cared about NAFTA if it was 10 years ago, but now Canada looks like a good market. The whole Canadian market is like one, good-sized U.S. state. We're very appetizing."
The Alberta government contends that NAFTA is not a real threat to the healthcare system and backed up that claim with a legal opinion citing the so-called "carve-out" section of the NAFTA agreement, which shields health services from a requirement to open them up to foreign investment. The trade agreement shields health services that are provided for a "public purpose."
"The identity of whom or what owns, operates or funds health services is not a consideration in determining whether health services are provided for a public purpose," according to the review done by Edmonton international business lawyer Shawna Vogel, who has served on a Canada-U.S. NAFTA trade dispute panel.
Protecting national care. But other lawyers say the new law violates the Canada Health Act. They include Steven Shrybman, an international trade lawyer who wrote an opinion on Bill 11 on behalf of the Canadian Union of Public Employees, the country's largest union representing 150,000 healthcare workers.
"The province's legal advisers agree with us that Canada's NAFTA reservations around health are medicare's lifeline. They then argue that a dispute resolution panel won't rule that private-sector participation shreds that reservation," Shrybman says. "Well, it doesn't take a crystal ball to tell you they're wrong. In light of the strong evidence that the Americans would push to end the reservation, they're taking a huge gamble with the future of the country's healthcare."
What is certain is that other provinces are watching Alberta's experiment with private healthcare and may follow suit, as politicians and bureaucrats look for new ways to finance healthcare while observing federal laws. If the Canada Health Act is violated, the federal government can penalize provinces by withholding funds.
But it appears many Canadians are against the new law. Only 39% of Albertans backed the legislation, the lowest level of support in Canada, according to an Angus Reid poll of 1,500 Canadians conducted in March.
"Canadians' healthcare is being slowly killed by governments too willing to promote or too weak to oppose the privatization of medicare," says Maude Barlow, chairwoman of the Council of Canadians, a citizens' rights group. "The proposed law in Alberta is nothing less than an invitation to for-profit companies--including U.S. corporations--to undermine the public health system from within."
Shirley Douglas, spokeswoman for the Canadian Health Coalition, a medicare advocacy group, and daughter of medicare's founding father, Tommy Douglas, says Bill 11 makes Canada's healthcare system too vulnerable to free enterprise.
"For sure, American companies will be here, there's no doubt they'll be here," Douglas says. "That's why I've been so upset about Bill 11. The premier of Alberta has the future of all the people in Canada in his hands. I think Canada is up for sale."