The path of least resistance

In the first concussed reaction to Ralph Klein's health care bombshell, a lot of silly things were written, not all of them in The Globe and Mail. Alberta's proposed Health Policy Framework, it was suggested, spelled the end of medicare, if not of Canada itself. Its 18 vaguely worded pages amounted, it was said, to a direct challenge to federal authority, a flagrant violation of the Canada Health Act. Immediately the cry went up for the Prime Minister to Do Something. "The ball is clearly in the Prime Minister's court now," the Premier of Ontario, Dalton McGuinty, ventured. The Globe's John Ibbitson went him one better, conjuring images of Mr. Klein as a kind of Lex Luthor bent on dismantling public health care as we know it. "Only one thing -- one person -- can stop him," he announced, sounding a little like a '40s radio serial. "That person is Stephen Harper." Actually I can think of several people who can stop him. Jennifer Huygen, for example: the 17-year-old legislature page in whose general direction the Alberta Premier is alleged to have heaved an opposition health care paper -- at 80 pages, rather heftier than the Premier's own proposal. It's unlikely the incident will imperil Mr. Klein's chances in next month's party leadership review, but that people are even mentioning it shows that, as retirement approaches, King Ralph is not quite the lord of all he surveys. Indeed, one reason the Premier has been so hesitant to move on this file over the years has been the continual misgivings within his caucus. Besides his own party, the Premier will need to keep a watchful eye on public opinion. It is by no means a given that Albertans will support the plan, particularly in its two most contentious provisions: allowing people to pay for faster service with respect to certain treatments, and allowing doctors to work in both the public and private systems -- or more exactly, requiring them to work a certain number of hours in the public system as a condition of operating privately. Now, these proposals may be many things, but the one thing they cannot be is a "violation" of the Canada Health Act. Health care is a provincial responsibility under the constitution. Ottawa has no power to regulate it. As federal legislation, the Act does not and cannot bind the provincial governments. Rather, it sets out conditions on federal transfers to the provinces, ostensibly for health care (though in fact they go into general revenues) -- the famous "five principles" of universality, accessibility, comprehensiveness, portability and public administration. At that, it's not at all clear that what Alberta is proposing would offend against even these, though much else that goes on in provincial health care systems across the country does. Though some provinces prohibit the practice, the Canada Health Act itself says nothing about doctors charging patients out of pocket for treatment -- provided they pay the whole shot. It merely prohibits -- or rather, excludes as a condition of federal transfers -- charging for services that are also publicly insured: that is, topping up the public plan with additional fees. That's as it should be. Only the most doctrinaire would forbid people from spending their own money to obtain care if they wish -- which, after all, they can always do by going to the States. But only the most purblind would allow those with means to buy their way to the front of the line for public care, which is what mingling public and private payments amounts to. A trickier question is whether allowing doctors to work both sides of the street would fall afoul of the act. There's a danger that doctors could informally tie services together -- pay for the deluxe cast privately, and get your leg set faster on the public dime -- to say nothing of the perverse incentives for doctors to drag their heels in their (obligatory) public practice as an inducement to their better-heeled patients to visit them privately. But that's more a question of policy than it is of law. Even if Mr. Harper were inclined to invoke the Canada Health Act's penalties, the most he could do is to deduct a dollar in transfers for each dollar charged privately -- chicken feed, given Alberta's swollen surpluses. If Mr. Klein is to be stopped, it will be by persuasion, not by threats. Here's hoping he's listening. Free marketers may think he's their hero, but in fact what Mr. Klein is doing is a cop-out. There is ample room to reform the public health care system on market-oriented lines, within the envelope of public finance -- and within the Canada Health Act: as should be clear by now, it is not the "straitjacket" conservatives imagined it to be. But that's hard work. It means imposing on providers not just market freedoms, but market disciplines. It requires people to work within budget constraints, to wring efficiencies out of the system, to do more with less. How much easier just to tack on a parallel private system, and let health care swallow several more percentage points of GDP. This is my fear: that private insurance and user fees, once the "third rail" of Canadian politics, will become, post-Chaoulli, the path of least resistance; that we will end up with an unreformed public system, which increasing numbers of the well-to-do will use only to subsidize their escape to the private sector; that we will have, not a Third Way, but the worst of both worlds.