Health care policy in an aging Canada: The Alberta ‘experiment’

HEALTH CARE POLICY IN AN AGING CANADA: The Alberta ‘Experiment’

SUSAN A. MCDANIEL* University of Alberta

ABSTRACT: Tensions and contradictions abound in health care policy in Canada in the 1990s with Canadian public health care, the envy of many observers throughout the world and the pride of Canadians, on the brink of destruction. Challenged by a number offorces, most notably public policy shifts, insistent rhetoric holds that drastic cuts are inevitable, that universal health care is a luxury no longer affordable, and that the health care funding crunch is related to population aging and the large and looming demands for health care by the elderly. Realities, however, contrast with this rhetoric. Nowhere in Canada has health care undergone as radical a change as in the Province of Alberta in the period since 1993. In this article, health care policy changes in Alberta are examined as an ‘experiment’ in Canadian health care restructuring using a socio-historical political economy approach, consistent with critical gerontology. Aging and the aged are found to be centrally involved and implicated in health care changes, but in ways dtrerent than those predicted in Canada prior to contemporary health care restructuring.

Health care restructuring in Canada in the 1990s is rife with tensions, contradictions, and rhetoric. The widely acclaimed and envied Canadian health care system teeters on the brink of dramatic change, possibly destruction, while power relations both within the system and among those who control the system shift and twist, and rhetorical battles play out on the pages of newspapers. Proclamations of having “the best” health care system in the world are heard with regularity as waiting lists grow for medical care, doctors withdraw services, and the numbers of services de-listed (not insured) by medicare grows. Aging and the

*Direct all correspondence to: Susan A. McDaniel, Alberta T6G 2H4, Canada.

Department

of Sociology, University of Alberta, Edmonton,

JOURNAL OF AGING STUDIES, Volume 11, Number 3, pages 211-227. Copyright 0 1997 by JAI Press Inc. All rights of reproduction in any form reserved. ISSN: OWO-4065.

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elderly are at the center of health care restructuring and the debate surrounding it in Canada, serving in the rhetoric as both the cause of the restructuring, i.e., population aging and the high demands of the elderly for health care, and as those most directly and immediately affected by the changes. Gerontological theory has been distant from, and for the most part unconnected with, current political economic and critical stances on economic/social restructuring and welfare state theorizing (Chappell 1995; Moody 1992; Tornstam 1992). By examining health care restructuring and the ways in which aging and the aged provide context as well as engaging in the process, theoretical expansions of both gerontology and welfare state theory are proposed, the latter to include the aged and aging as complex and contradictory forces of both change and resistance. As Clark (1993a, p. 501) suggests, “The public policy process-how it grapples with the challenges of an aging population-reveals much about the underlying integrity and cohesiveness of a society.” The Province of Alberta’s (a western Canadian province) ‘experiment’ in health care restructuring since 1993, revealed through public accounts and reactions reported in newspapers, is the case under study here. Alberta’s approaches to changes in health care, as well as Alberta’s deep cuts to other social programs have been heralded by some, including Canada’s “national newspaper,” The Globe and Mail (1993), as a model other provinces, and other countries, could follow. Although there is, by no means, consensus on Alberta’s approach, it is useful to look closely and glean insights and lessons, both empirical and theoretical, from the province that in the 1990s is most seriously challenging the continuation of Canadian public health care. The particular focus of this article, and hopefully its contribution to both the debate about health care in Canada and the larger international debate about how best to provide health care in the context of aging populations and declining public resources, is on the tensions and contradictions emergent in the 1990s over health care restructuring in Alberta.

CANADIAN

HEALTH CARE IN BRIEF

Access to medical care, when needed, without direct cost is a taken-for-granted reality for Canadians. Armstrong and Armstrong (1996, p. 1) recount the following revealing story: She was in her mid-twenties and pregnant with her first child She went on at some length about the price of Canadian products for babies. ‘It’s so much cheaper to have a baby in the States,’ she claimed. ‘But maybe,’ said her friend, ‘you should think about having your baby there. It would cost anywhere from $2,000 to $10,000, maybe more ’ ‘Nonsense,’ said the young motherif there are complications for you or the baby to-be, ‘nobody pays to have a baby.’

Consistently the most highly approved social program by Canadians, publicly administered health care insurance that is accessible, universal, comprehensive, portable, and administered on a non-profit basis, had been widely regarded as untouchable by politicians. In the 1990s however, Canadian public health care (known as medicare) is being challenged on several fronts, with significant implications for all Canadians, but particularly for older people. To set the stage for the empirical examination of health care restructuring in Alberta, a very brief description of the Canadian system is necessary.

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The Canadian medicare system provides universal access to medical care by doctors and in hospitals through third party insurance where the insurer is each province. Cost-sharing, through the transfer of federal monies to the provinces, has given the federal level some clout on setting and maintaining national standards, and indeed makes the system viable (Brown 1980; Chappell 1993a, p. 489; National Council of Welfare 1991, pp. 5-6). Health care in Canada is not socialized; it is a private fee-for-service system, with the public as the insurer. Funded in Canada largely through federal and provincial taxes (National Council of Welfare 1991, p. l), insurance premiums ($34 a month for individuals and $68. per family in Alberta in 1996) are paid by employers and employees in various ratios and had been waived until recently for those not in the labor force, including seniors in several provinces (including Alberta). Concerns about regional and provincial inequities and erosion of health care led the federal government in 1984 to pass The Canada Health Act which specified the principles of Canadian health care: accessibility, comprehensiveness, universality, portability, and public administration. The Act also gives the federal government explicit powers to withhold cash transfers to the provinces in situations where violations of these basic principles occur. This is no idle threat. Transfer payments were withheld as of May 1994 from the Province of British Columbia which allowed physicians to bill patients extra to provincial health care payments and thereby contravened the principles of universal access to health care without cost as a factor. The same withholding by the federal government occurred in 1995 for Alberta because of its permitting of private (direct fee to patients) clinics. Although The Canada Health Act has been widely regarded as the leverage needed to prevent undermining the Canadian health care system, the clout of the federal government was reduced in 1990 when entitlements to provinces under the Established Programs Financing Act (EPF) were frozen (See Brown 1980 for background; National Council of Welfare 1991, pp. 14-15). This occurred without public debate on the implications for universal health care. Public policy without consultation has been termed “social policy by stealth’ (Gee and McDaniel 1992, McDaniel and Gee 1993). Drastic cuts in financing for health care have resulted, with 1994 federal transfer funds to the provinces reduced to approximately one-half of what they were in 1990. By 2000, the provinces will lose $97.6 billion in health care and higher education transfers from the federal government (National Council on Welfare 1991, p. 18). By 2005-2006, all federal cash transfer payments for health care will disappear, with transfers evaporating first in 1995-1996 for Quebec, then Ontario, with Alberta and British Columbia experiencing the slowest erosions of funding (all transfers to these provinces will evaporate by 2006). To compensate, at least partially, a scheme has been instituted whereby some transfers of tax points would occur from the federal to the provincial governments. The origins of the Canadian health care system are highly relevant to the current restructuring, but cannot be discussed at length here. Universal, government-sponsored health care insurance was legislated in Canada in 1966 (McDaniel 1988, Vayda and Deber 1992) eliminating financial barriers to health care, but public hospital insurance had existed in Canada since 1958. The beginnings of the system, however, can be traced to concerns about industrial unrest with workers possibly turning to socialism and communism, as well as overcoming the growing costs to employers of providing private health insurance for their employees (McDaniel 1988, p. 53, Vayda and Deber 1992). The future

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Prime Minister W.L. Mackenzie King understood how public health insurance support to capitalism rather than a socialist policy when he wrote, in 1918:

was a

Social insurance, which in reality is health insurance in one form or another, is a means employed in most industrial countries to bring about a wider measure of social justice, without, on one hand, disturbing the institution of private property and its advantages to the community, or on the other, imperiling the thrift and industry of individuals (King 1918, p. 222).

The Canadian Medical Association in 1934 had proposed a plan for provincially administered health insurance. Public health insurance, first introduced in Canada in British Columbia in 1935, with wide support in a public referendum and from business, was never enacted even though it set in motion the momentum and the means by which Canada-wide health insurance came to be some 30 years later. In 1960, the federal Liberals, led by Mitchell Sharp (who is a key advisor to Prime Minister Jean Chretien in the 1990s) consolidated the consensus on universal health insurance. The Conservatives, led by John Diefenbaker, created the Royal Commission on Health Care (1961-1965) which led to the Medical Care Act of 1966 (Taylor 1990). The introduction of public health insurance by Premier Tommy Douglas of Saskatchewan in 1960-1962 and the subsequent doctor’s strike, led to several concessions to the medical profession which remain central in today’s debate: the right to bill patients directly, the right to opt out of the public insurance scheme, and the maintenance of the feefor-service system. All but the latter were subsequently changed. Doctors, who had previously supported public health insurance, opposed its introduction in Saskatchewan because they saw themselves excluded from the process of change, and threatened in their efforts to offer medical services in the face of government cutbacks to assistance for the poor and increased competition from new professionals being brought in to staff the developing medical schools in that province.

HEALTH CARE RESTRUCTURING

IN THE 1990s

Multiple tensions exist in the 1990s challenges to Canadian health care, tensions which are apparent throughout Canada, but particularly exemplified in the Alberta case. Unblinking focus on the Canadian federal and provincial deficits and debts, and increased attention to the health care implications of an aging population, policy preoccupations have led to stringent cost-cutting by restructuring health care provision and, to a lesser extent, development of “community care” as a substitute for institutional care. Costs of health care in Canada have risen at the same time as less public money is available. The causes of the increases, however, are often lost in the rhetoric of public cost reduction and reduction in public services overall (Coutts 1996; Taft 1997). The challenges to health care in Canada in the 1990s extend beyond costs and shrinking public funds, to whether health care dollars are being spent wisely, whether the medical model should be dominant, to how restructuring should occur, and how choices might be made about allocation of health care dollars among the various groups in need, as well as

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among various health care approaches. It has been aptly suggested that health care reform in Canada is “the issue from hell” (Evans 1993). Mounting pressures for abandonment of the principles of The Canada Health Act, and for greater provincial autonomy in health care provision, has seniors and those who will become seniors in the not-too-distant future concerned and fearful. These concerns loom largest for the poor, the sick and disabled, the chronically ill, and women (who spend more years in disability and poverty) (Chappell 1993b; Gee and McDaniel 1992; Keith and Landrey 1992; Marzouk 199 1; McDaniel 1993, 1994; McDaniel and Gee 1993; McDaniel and McKinnon 1993; Neysmith 1989; Victor 1989). A central tension that underlies all others, is the question of what the driving force(s) is(are) toward health care change in Canada in the 1990s. Among the contenders are cost escalations, inefficiency, the model of cure rather than care, inattention to health promotion, and population aging, in a far from complete list (Dickinson 1994; Dickinson and Bolaria 1994). Attention here is limited to the issues of costs and population aging. There is no question that health care costs have escalated dramatically, increasing by approximately 5% a year, far ahead of the rate of economic growth, over the decade of the 1980s and into the 1990s (Feschuk and Greenspon 1994, p. D5). Martin Barkin, former Deputy Minister of Health in Ontario, now a business executive, argues that costs are indeed the driving force to change, “If you can’t afford it, you can’t give it to anybody or at least everybody on an equal basis” (Feschuk and Greenspon 1994, p. D5). Yet it is also clear now that when Klein came to power in 1993 that Per capita [health care] costs had been contained for several years (adjusting for inflation). Systems were in place to ensure that spending would be tightly controlled and efficiencies would improve. These included caps on total payments to physicians, and a hospital funding system that compared productivity among hospitals and rewarded the most efficient ones (Taft 1997, pp. 93-94).

Interwoven with increasing costs is the question of whether the current system is costeffective and whether it is still providing accessible, equal care. Aging is presumed to be an additional challenge, with older people, it is argued, costing the most to care for and with the greatest health care expenditures incurred over the last ten days of life (Chappell 1993a, Evans 1988, 1989). A second tension is whether, or the degree to which, population aging is a driving force of the push for health care change in Canada. Barer et al. (1995), Chappell(1993a), Evans (1989), Felligi (1988), McDaniel (1987, 1993, 1994), and Northcott (1992, 1994) have argued, in varying ways, that population aging is not the driving force in health care cost increases. Fellegi (1988, p. 14), for example, concludes . should long term economic growth continue as it has in the past and unit costs evolve as assumed, then public expenditures in health, education and pensions would represent 50 years from now about the same claim on the economy as at present-in spite of the aging of the population. And Barer, Evans, and Hertzman (1995, p. 195) conclude, analysis of health care utilization data in Canada, that

on the basis of a meticulous

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. the effects of aging per se on health care costs have been quite limited . . these consistent research findings, like a lighthouse lost in the fog, have remained obscured by the persistent claims that the aging of the population will bankrupt our health care system.

Some authors suggest that population aging might even be an excuse for cost-cutting rather than a cause of cost increases and restructuring in health care. McDaniel (1987) argued that population aging may be the paradigm by which socio-economic problems are defined and policy decision taken. Recent survey research in Alberta has found that the public agree, to a large extent, that population aging is the driving force for increasing health care costs (Northcott 1994). This, of course, does not make it so, but can provide support for the political argument that population aging can be used as the excuse for cost-cutting. If the Canadian health care system is largely driven by the available supply of doctors, each with his/her own billing number, rather than demand by the public for services, then it is unlikely that population aging is a driving factor in cost escalation (McDaniel 1994). Conclusions of recent studies, put population aging in relation to health care costs in Canada into international perspective. Lied1 (1992, p. 106) concludes that the demographic impact on the health care sector in most industrialized countries is minimal compared to other factors. Heller et al. ( 1986), and Murphy and Wolfson ( 199 1) conclude that of all the major industrialized countries of the world, Canada faces the lowest public sector cost pressures, including cost pressures on health care, due to population aging.

DATA AND METHODS Data under analysis in this article are hard copy news articles and editorial pieces on health care change and restructuring published in the Edmonton Journal from the period since 16 June 1993 when the Progressive Conservative Government of Ralph Klein was elected, until the present time. The Edmonton Journal is the major newspaper in the capital city of Alberta, Edmonton, and thus is a source read by many Albertans. The analysis of newspaper stories is supplemented by analyses offered in three key books about Alberta under Ralph Klein’s leadership, The Klein Revolution by Mark Lisac (1995), The Trojan Horse: Alberta and the Future of Canada, edited by Trevor Harrison and Gordon Laxer (1995), and Shredding the Public Interest: Ralph Klein and 25 Years of One-Party Government (1997) by Kevin Taft, as well as by occasional news stories on Alberta’s health care change that appear in The Globe and Mail, Canada’s widely read national newspaper. News stories, analyzed first to discern the terrain and trends of health care restructuring, are then combed for key themes, sorted and recombed for tensions, contradictions, rhetorical differences and realities of health care experiences. The methodological approach taken here is socio-historical political economy, focussing on power and class differentials in the context of socio-political and economic change. It is consistent with an emerging critical gerontology (see Moody 1992, for example). In analyzing news stories, which are treated as qualitative data, quotes are utilized as exemplary of the themes, the common approach of qualitative analysis. News reports and analyses are interpreted here as information on what is occurring with respect to health care. In this analysis, the accounts cited are supported by substantive analyses appearing in the major books on the Klein “revolution,” and are verified accounts. If anything in the Alberta context, the print media tend to underreport problems resulting

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from the Klein cuts rather than sensationalize issues. Treating the media accounts as qualitative data, but data that are supported by analytical studies, enables this analysis to be reliable and credible.

THE ALBERTA ‘EXPERIMENT’ The Terrain Of Change and Emergent Themes The Province of Alberta in the 199Os, under the leadership of Premier Ralph Klein, is moving faster and further along the road of changing and challenging Canada’s health care system than any other province in Canada, thereby providing an opportunity to examine health care restructuring in an aging Canada as an ‘experiment.’ Alberta in the 1990s is governed by ostensibly the same party that has been in power since 1971, the Progressive Conservatives (Taft 1997). Albertans, as no other Canadians, evidence an abiding faith in the political party in power, a faith that has allowed the emergence of a virtual one-party system. Alberta is blessed with oil and gas resources and by 1985, had amassed an enormous revenue surplus, the Alberta Heritage Savings Trust Fund, for the Province’s proverbial “rainy day.” From 1985-1993, the Province made some widely publicized “disastrous” investments, including the largest single public loss ever recorded in Canada, Novatel, which totalled almost a three-quarters million dollar (Canadian $s) loss (Harrison and Laxer 1995). Lisac (1995, p. 28) puts clearly the way Albertans felt about Novatel: Novatel horrified the Conservatives. The company name turned into a one-word argument, an irresistible denunciation. Novatel was an encapsulated history of everything that had gone wrong in the government’s many business ventures. Whenever two people talked in Alberta and one of them said ‘Novatel,’ the word flooded the conversation. It burst with meaning. It was a final proof of incompetence.

In the face of such financial misadventures, it had been widely anticipated that voters would “turf out” the Conservatives in the next election. Instead, the party in power “reinvented” itself and continued in power in changed form. Although perhaps few recognized it at the time, the die was cast for the future course of health care policy in Alberta during a 1992 internecine battle among the Progressive Conservatives (Tories) for the leadership of the party (Lisac 1995). Ralph Klein, or Ralph as he prefers to be known, the populist former Mayor of Calgary, won the Party endorsement over the urbane Nancy Betkowski and eagerly campaigned to cut government spending. Many Albertans may have thought this would end the Novatel and other govemment misadventures. Ralph Klein’s majority victory was, in fact, a victory for a new federal political movement with its origin in Alberta, the Reform Party led by another Albertan, Preston Manning (see Harrison 1996). Widespread belief (well founded as it has turned out) held that Klein represented a new kind of conservative politics. Immediately on assuming power, the Klein government set in motion plans for eliminating the provincial deficit within three years in a province without a serious deficit problem. Taft (1997, p. 2) suggests that “By the time Don Getty resigned [in 19921, his government had already reduced spending in Alberta to levels at or below the average for Canadian

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provinces.” And Cooper and Neu (1995, p. 164) conclude that “. . . the rhetoric of deficit and debt currently serves as a convenient political rationale for restructuring Alberta’s social and economic landscape.” A program of deep cuts to public services ranging from 21% in higher education to 100% for several government sectors and departments, began with very deep cuts to social assistance and plans to privatize many public services. Health was targeted for a 25% cut over three years. Numerous lay-offs and ward closures had preceded the 1994 announcement. Structural changes to, and eventual elimination of, hospital boards and a 5% pay cut for all public sector workers including doctors, was dictated, although this was supposedly “negotiated” in the face of even more massive job losses were it not accepted. Regional superboards known as health authorities, were created with government appointed members, which had powers to control all aspects of health care in their regions, including hospitals as well as public health and medical laboratories some of which were private. Many regional superboards were created out of political jurisdictions, rather than in any established region per se. All funds for the regional authorities were provided by the Province, with the contradictory outcome that centralization of provincial control over health care spending was solidified even as the appearance of decentralized decision-making was presented. Regional authorities absorbed all public complaints about health care, but could do little about them, except to deflect potential political damage the cuts were having away from the provincial government. At the same time, a government appointed committee worked to develop a plan to deinsure (or de-list) “non-essential” services, including the establishment of private health insurance schemes to cover the de-listed services. To elicit public support for two-tiered health care, Klein suggested in an offhand remark to a radio talk show host, that cosmetic surgery would be an example of a non-essential health service. Such media comments have become the way in which Klein tests public reactions and gleans support for plans that typically involve much more than what is initially mentioned. Cosmetic surgery had never been covered by Alberta Health Care. The Province of Alberta, prior to the current cuts to health care and restructuring, was not among the biggest of health care spenders in Canada (Taft 1997, p. 93-105). In 1993, for example, Alberta spent 5.9% of the Gross Domestic Product on health care, compared to 6.9% for all of Canada (“Your Future Health” 1993). Health care is, however, the most expensive single program to the Province’s public coffers, consuming 29.5 cents of every tax dollar (“Your Future Health’ 1993). By 1996, Alberta was at the bottom of health care expenditures per capita among all provinces in Canada (Taft 1997, p. 94). Harrison and Laxer (1995, p. 2), make clear that, “Contrary to the prevailing myth, Alberta is the sole place in Canada that does not have a real fiscal problem.” It is important to emphasize that the massive changes occurring in health care and other public sectors in Alberta are profound structural adjustments. Draconian cuts have been argued, particularly assertively in Alberta but also elsewhere in Canada, to be a lessening of government involvement. Examined more closely, however, the draconian public cutbacks may also be seen as evidence of a strongly interventionist state policy, which is taking control over professional and union policies, granting private sector operators untold opportunities and shrinking the responsibilities of governments even as they increase government’s control. Contradictions and tensions abound. Alberta, which has never had an easy relationship with the federal government, has come to fiscal and political blows over health care restructuring. In the late 1980s for example,

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when other provinces had legislated an end to extra-billing by physicians, Alberta physicians continued to extra-bill for millions of dollars annually (Northcott 1994b, p. 76). Alberta only began its campaign to end extra-billing when threatened by the federal govemment with loss of its share of federal funds for health care. However, another form of “extrabilling” now exists in Alberta with specialized private medical clinics that charge sizeable “facility fees” to patients while, at the same time, billing the public health care system. One of the best known of these is the Gimbel Eye Clinics owned and operated by a Calgary ophthalmologist who has the distinction of being widely known as Canada’s most highly paid physician. Over the short course of health care restructuring in Alberta since 1993, massive numbers of nurses and allied health care personnel as well as support staff have been laid off. It has been estimated that 1600 registered nurses were laid off in 1994 in Edmonton alone. It is estimated that 12,000 nurses and health care personnel might have lost their jobs in Alberta over 1993-1996 (“Your Future Health’ 1993). Most health sector layoffs have occurred in blatant violation of collective agreements, but one aspect of the agreements has been adhered to, the practice of senior nurses “bumping” nurses with less seniority. This has led to many nurses working in wards, including emergency, surgical, and geriatric wards, in which they have no experience and no training (“Your Future Health” 1993). In addition, hospitals are being merged, specialized and closed. One-half of the hospital beds in the two major cities in Alberta, Edmonton and Calgary, have been closed. Doctors have left and are leaving Alberta, among them several not easily replaceable specialists, one of whom announced that he would no longer practice “Third World medicine” in Alberta (Coutts, Globe and Mail, 7 September 1996, p. D5). Seniors are impacted in many ways by Alberta’s health care changes. Direct cuts to health care impact seniors more seriously than others, as has become clear in a series of news stories on individual cases of very lengthy waits for emergency care, being sent home from emergency only to die or require readmission soon after, to deaths due to neglect in hospital or infection resulting from unsafe medical situations in hospitals. With respect to deaths due to health care cuts, the case is difficult to prove definitively for a number of reasons, among them legal issues. However, Taft (1997, p. 119, note 1) cites the October 1996 Report of the Critical Assessment Committee, Region to Medical Staff, which provides “at least two examples of deaths that resulted from health care cuts.” Taft (1997, p. 119, note 1) also cites the 6 August 1996 resignation of the Chief of Anesthesia, Royal Alexandra Hospital in Edmonton, who described situations in which patients were dying needlessly due to cutbacks. All this has led to the recommendation that seniors take an “advocate” with them to hospital (Edmonton Journal 1996, p. Al). There are also indirect effects as seniors with relatively low incomes ($18,200 for a single person: $27,000 for a couple) now must pay their own health insurance premiums as well as for eyeglasses, aids to independent living, and newly privatized rental accommodation with much higher rents and less accessibility than seniors public housing for those with activity limitations. Outrage by seniors, particularly to the high cutoff income levels announced initially, led to protests and the formation of a seniors advisory committee led by a number of very articulate and well known seniors. The result was only a minor adjustment (of about $1,000, raising cutoffs to those listed above), in the levels at which seniors must pay for their own health insurance premiums and supports.

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The rhetoric of health care restructuring involves health promotion, with proposals being put forward for penalizing those who fail to live healthy life styles. These include possibly requiring those whose health problems are deemed “self-induced,” to pay, fully or partially, for their own medical care. Klein, (Edmonton Journal, 6 September 1996, p. Al), has said that as much as 70% of all illness is caused by unhealthy lifestyles. For smoking cessation, weight reduction or exercise programs, there is minimal redistribution of health care dollars in Alberta and no future plans to invest much in health promotion programs per se. Seniors, whose lives have been influenced by historical forces which encouraged smoking, consumption of junk food, and limited exercise, may now be expected, instantly, to “shape up” or pay the price of their own health care in their later years. A boom in home care was predicted by Lyle Oberg, one of the central Ministers charged with masterminding health care change in Alberta (“Your Future Health” 1993). Yet very limited health care fund redistribution is provided for home care. Instead, home care has been revealed (Bond 1992; Neysmith 1989 among others) to be mainly family care with a meagre back-up of professional services. In Alberta, the hope seems to be that laid off health care workers will service the unmet needs of seniors in the private sector at the same time as the disposable incomes of seniors shrinks dramatically, their available health care options shrink, and their needs possibly increase, particularly in light of the increasing stresses seniors face in Alberta. With the massive move away from hospital-based care accompanying the move toward outpatient surgeries and medical interventions, there are serious short-term implications for seniors. As more services are provided outside of hospitals, and more substitution occurs for hospital care, drug costs covered by public health insurance in hospital become private costs outside hospital. With cuts to seniors’ benefits, many seniors simply do not have the means to pay for newly private health care costs. The added burden becomes very large for seniors who rely, more than others, on multiple prescriptions as well as on aids to daily living. The paradox, of course, is that these supports and prescriptions are well known to be the very factors, along with community and family support, that can prevent longterm institutionalization and costly burdens to the taxpayers for health care (Chappell 1993b, Neysmith 1989). This is not reform to health care, but intensification of medical interventions, whereby greater responsibilities are placed on individual seniors and their families, with few additional home care options. Four central themes emerge from the analysis of hardcopy news stories on health care change in The Edmonton Journal over the period from June 1993, when Ralph Klein took office, until September 1996. These themes mark dramatic shifts with the advent of the Klein “revolution.” Changes occurred in the rhetoric used to discuss health care by the Klein government compared with the previous government. Patients became consumers. Stakeholders became the common parlance in discussing health care, as if there is no longer a public stake in health care. Public planning and the concept of public good has been usurped by “business plans” for government departments, including the Department of Health. Concerns about health care rhetoric emerged as early as 1993, when a public opinion survey conducted by four health care unions in Alberta found that: l

61% of Albertans are scared by what they see as a trend towards U.S.-style health care;

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65.9% disapprove of provincial plans to cut $900 million, roughly 25%, over 4 years; and 7 1.6 worry cutbacks will backfire and increase longer term costs, by spreading infectious diseases, for example (Edmonton Journal, 20 November 1993, p. A7).

These findings led Patricia Ennis, President of the Health Sciences Association of Alberta to suggest, “If people knew what Ralph Klein and his group were going to do, I don’t think they would have been voted in” (EJ, 20 November 1993, p. A7). In articles, the titles of which (“Out with Old-Speak and into Klein-Talk,” (_U, 28 January 1995, p. H3), and “Catch Phrases and Twisted Language,” (EJ, 28 January 1995, p. Hl), reveal massive rhetorical changes, the centrality of rhetoric to health care restructuring emerges. In “Out with Old-Speak . . .“, this is said: The new language of Alberta, touted to be the emerging language of the nation, translates the needs of many into the greed of the few. Along the way, it has changed the meaning of ‘entitlement’ to mean something close to ‘parasitical.’ In “Catch

Phrases

. . .“, the rhetoric

of Klein’s

Alberta

is dissected:

It was getting difficult to sort out principles from cliches-living within our means; balancing the budget to avoid hitting the wall; deregulation; realizing that we have a spending problem rather than a revenue problem; reforming public life by streamlining government and trimming administration; competitive taxation; getting government out of the business of business; cutting layers of fat. These were the catch phrases and ideals. If you looked at actual events a far different pattern would emergedentralized control; privatization; flat taxes.

On 6 April 1995 (EJ, p. Al), after strenuous denials that restructuring health care in Alberta would mean a two-tier system, Ralph Klein admitted, “It perhaps could be construed as a two-tier system.” The problematization of health care issues in Alberta by the Klein government is a theme closely allied to rhetorical changes. Variously, the problems with health care have been defined as abuse of the system by demanding patients, escalating costs by greedy doctors, too many demands by nurses’ and other health care workers’ unions, as well as concerns with inefficiencies and with “cutting layers of fat.” The challenge of problematization is summed up early in the Klein years: What we are experiencing in Alberta is pseudo-debate, limited by thought and fear, about an ill-defined paradigm existing in the minds of those who can see and can afford The Way (EJ, 12 March 1994, p. Al 1)

On 8 April 1995 (EJ, p. A6), issues of problematization revealed as very clouded:

of health care restructuring

There is a puzzling side to the talk from Premier Klein and from the head of the Alberta Medical Association of deinsuring some procedures and selling some hospitals for private use. No one in government has said that this is part of the plan. Yet the slide toward privatization is being pictured as inevitable; of course we have to have private hospitals, the argument goes, what else can we do with the ones being closed?

are

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In a 24 January 1994 (EJ, p. Cl) article, questions are raised about how problems in health care are measured: “Do you test the efficiency of the hospital system by applying bed-utilization standards?’ The locus ofresponsibility/locus of control is another theme that emerges from the analysis. The move seems to be toward individual responsibility for health and away from public responsibility or consideration that social structural factors play a role in health. Shifting responsibilities involve both victim-blaming and scapegoating. For example, when a small child so sick he was barely able to sit up, died in a taxi after being sent home from hospital in the wintertime (a distance of some 150 kilometres) without nursing care, an inquiry was done none other than by the Department of Health. An Editorial in the Edmonton Journal (27 January 1995, p. A14) has this to say: Many Albertans will be suspicious of the inquiry’s findings because they know a provincial government willing to cut $750 million out of health care over three years has a vested interest in underplaying its own mistakes. Premier Ralph Klein dismisses ‘victim of the week’ stories. He accuses hospital administrators, nurses and doctors of exaggerating the negative impact of budget cuts to alarm the public and to protect turf.

Shifting locus of control has meant that structural forces at play in health status and needs can be overlooked as regional authorities take responsibility for health dollar allocation, but with no consideration for how regions might differ. So, a region with an older or poorer population would have no more funding to deal with the needs of that population. Similarly, regional health authorities are held responsible by the public for negative outcomes of health care restructuring but they are government appointees and have no control over the total purse they are provided by the province. A fourth theme emerging from this analysis is generational issues. On one hand, the rhetoric holds that health care restructuring is necessary to preserve the system for future generations. Ralph Klein’s Government argued in a Speech from the Throne (EJ, 14 February 1995, p. AS): Albertans know that the difficulties we experience today are minimal compared with what could happen to our children and grandchildren if we do not accept the challenge of change. We still have the opportunity to chart our own course, rather than have external forces do it for us.

On the other hand, there is the rhetoric that suggests that health care restructuring today is preserving what the elders brought in, “This is about our tomorrows. This is about leaving to the next generation the kind of Alberta left to us,” notes Klein (EJ, 18 June 1994, p. Al). A sharp counter to this is provided in a letter to the Editor (EJ, 19 March 1994, p. A9) by a self-described “old timer” who reveals not only the discontinuity he feels between the values of seniors who created Alberta and what is occurring with the Klein “revolution,” but his immense dissatisfaction with the Klein approach: I can truthfully say that I would be ashamed to be associated in any manner whatsoever with our present government. I was born in Alberta and have lived here all my life. My mother came to Fort Edmonton in 1898. My father came to Leduc in 1910. I am happy they are not here to see what is going on. I know there are many people who have abused

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our medical and educational systems but most of us are not among them. The majority of old timers, and I am one of them, worked hard and saved for their old age.

Not surprisingly, substantially more seniors feel the impact of health care cuts: 5 1.2% of those aged 60+ in 1995 have had a negative experience or someone in their families have had such experience with health care in the past 18 months, compared with 27.9% of those aged 18-29, or 34.8%of those aged 30-39 (EJ, 8 July 1995, A7). And 68% of Albertans feel that the “Klein Revolution” has had a negative impact on seniors overall in a 1995 survey (EJ, 19 March 1995, p. C3). This overall dissatisfaction of seniors matters to health and well-being in that severe cuts have been made to non-medical health options such as outside of hospital drug coverage, reductions in supports to aids to daily living, etc. Klein’s response on 21 March 1995 (EJ, p. Bl): We have been accused of relegating seniors to climbing through dumpsters. This simply isn’t happening.

Or throwing seniors out of their homes. This simply isn’t happening.

DISCUSSION

AND CONCLUSION

Lessons, both empirical and theoretical, are gleaned from the Alberta ‘experiment’ in health care restructuring in an aging society. At the empirical policy level, several lessons emerge. First, in a public health care system, cost containment, whether motivated by cost concerns or ideologies of lessening the role of government in public services such as health care, most immediately disadvantages seniors at the same time as their voices in the process of restructuring become less clearly heard, or even silenced. Second, rhetorical or punitive emphasis on health promotion, even with limited reallocation of funds from health care to health promotion, severely disadvantages seniors whose life course and subsequent health are shaped by previous times. Without reallocation of resources from medical care to health care broadly defined, which is the situation in Alberta, all are disadvantaged, but seniors particularly since it is most likely in the later stages of life that health problems most often occur. Third, redistribution of health care dollars from medical care can potentially help seniors and at the same time reduce costs. Chappell (1993a, p. 500) notes that integration of home care, social services and some community care is occurring in many provinces, but may be compromised rather than encouraged by the current zest for radical cost cutting, as suggested in the Alberta case. Fourth, older people as subjects and as actors, are central to the playing out of health care restructuring as evidenced in the Alberta “experiment.” More at risk for health problems, seniors will experience frustrations, delays and inefficiencies before others will. They are the ones most likely to benefit from the services of private clinics such as the Gimbel Eye Clinic, because of problems with cataracts or other vision impairments. And they are the ones who can least afford, in terms of time, to wait in long queues for public health care. As one man of 81 says, ‘Six months wait for me is a larger portion of the time I have left than for someone younger.” (“Your Future Health” 1993). Thus, paradoxically, much of the pressure for health care accessibility, even if private, may come from seniors who will, perhaps without being aware of the consequences, disproportionately seek care in the private sector and possibly lobby for private health care options. The paradox, of course, is that these are the very people who strongly supported public universal health care in

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Canada at its inception in the 1950s and 1960s and in the earlier political struggles over it. Seniors emerge clearly as forces of both resistance and change. Fifth, and this is may be the most important lesson of the Alberta ‘experiment,’ policies emerge, as Clark (1993a, 1993b) argues, not in isolation, but in the context of social, intellectual and political frameworks. Socio-political debate, discourse and public consensus about the universal health care system in Canada have brought into the open core social values which have guided post-World War II social in Canada and, in fact, have become the hallmark of being Canadian. It is the Canadian health care system that is the centrepiece of the self-image of Canada as a caring society, and an essential component of the claim to cultural distinctness from the United States. In sum, the distribution of social goods such as health care is a public moral issue in Canada, as well as a political/fiscal issue. Public process and public consensus over health care matters to the definition of Canadians as a society and as a people. As Clark (1993a, p. 501) eloquently puts it, “. the ‘moral economy’ of aging is as significant as the political economy in framing major social problems . . ” The process of health care change in Alberta is stampeding over the issues of process, values, Canadian identity, and the moral economy of aging, as citizens and groups are pitted against each other in fierce competition for declining resources. In short, is Alberta’s approach a model for the rest of Canada to follow? If the lessons of history that led to the development of the Canadian health care system in 1966 and the passage of the Canada Health Act in 1984 are heeded, the answer would seem to be a clear no. For all those, including physicians, who fought for a national health insurance program to pool risks and narrow regional, class and age differences in access to health care, the answer would be that the Alberta experiment takes us backward, not forward. For the overwhelming majority of Canadians who still strongly support the principles of the Canada Health Act, the answer is also no, since the Alberta approach, in the long and short term, counters those principles. To those, however, who believe that privatized health care of the kind that exists in the United States (which is widely acknowledged as the most expensive, least universal, most problematic to seniors, and least liked health care system in the world) is in Canada’s future, the Alberta ‘experiment’ is, indeed, a model to follow. The lessons for health care analysts and policy-makers in Canada and elsewhere from the Alberta ‘experiment’ in health care restructuring are significant. With the end of transfers within a decade from the Canadian federal government to Alberta, goes federal clout through the Canada Health Act. In the meantime, the frustrations of Albertans, particularly older Albertans most in need of health care and with some resources, could cause seniors to turn away from the lessons of their youth when health crises meant bankruptcy, to begin lobbying for more private health care in order to avoid waiting lists and increasingly inadequate services in the public health care sector. Seniors, paradoxically, may be the force that pushes health care in Canada back into the past at the millennium. Theoretically, the conclusions from this analysis of the Alberta ‘experiment’ are useful in expanding traditional gerontological and social welfare theories. Although health care restructuring in Alberta or elsewhere in Canada and outside, is not directly motivated by population aging either in rhetoric or reality, complex and contradictory interrelationships among population aging, the aged and health care restructuring are apparent. Hints exist that the nature of these interrelationships may become even more complex and unpredictable, as seniors are at once victims, lobbyists, special interests, scapegoats, and visible and invisible participants in health care processes, including health care restructuring. Seniors

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are at once subjects and actors in health care restructuring in that they are among the earliest victims of health care cuts and reductions to access, but they are not without voices and political power which can both undermine neo-liberal political agendas such as that of the Klein Tories, and can hasten the advent of private and two-tier health care, thereby enhancing the Klein agenda. This dualism suggests a need for adjustment of traditional approaches in gerontology and expansion of theories of disengagement and dependency. The paradigms of traditional gerontology are being actively pushed, as Moody (1992, p. 294) suggests to “burst the borders,” and move in new directions by the engagement of seniors in dismantling the welfare state simultaneously as they lobby for its perpetuation and extension, and by the political and rhetorical discourse of population aging in the context of rapid public policy shifts. The author wishes to thank Susan Hutton for research assistance, Kerri Calvert for help with references, Neena Chappell and Herb Northcott for helpful suggestions. Responsibility for views expressed and any errors/omissions are the author’s own.

ACKNOWLEDGMENTS:

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