Health reform? Ottawa must provide clarity

Posted on April 26, 2012 in Health Policy Context

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Published Thursday, Apr. 26, 2012.   Gerard Boychuk

Having won the Alberta election, Premier Alison Redford is now setting her sights on providing leadership in establishing the national agenda on health-care reform. In doing so, she won’t be able to ignore the issue of patient wait times. Wildrose may have lost the election, but it did propose some ideas in this regard that are likely to remain front and centre on the political agenda.

An important one that will have life in Alberta and beyond is a Patient Wait Time Guarantee, which would have allowed Albertans on lengthy waiting lists to seek care from independent health providers in or out of province with provincial public insurance coverage. Allowing such coverage is not merely Wildrose election rhetoric – basic elements of a plan to allow greater flexibility in provincial insurance coverage of services received out of province were contained in a leaked confidential Alberta Health and Wellness planning document in 2010.

Would such practices be consistent with the Canada Health Act or would they trigger financial penalties for the province? On this hot-button issue in health-care reform, Ottawa needs to clarify its position.

To comply with the Canada Health Act – to which Wildrose stated a clear commitment – independent health providers in Alberta wouldn’t have been permitted to extra-bill patients. But reimbursement for services provided elsewhere would have been at the rate provided for in the provincial schedule; if provided out of country, the patient would pay the difference between the Alberta rate and the fee actually charged – otherwise known as extra-billing.

Though detractors will claim that this violates the “spirit” of the act, the CHA allows this practice on out-of-country treatments. At the same time, it grants discretion to, but does not require, the federal minister to levy penalties for such practices should the minister determine they impede reasonable access to services.

The case is less clear for services provided by independent facilities in another province. The Wildrose proposal didn’t extend its restriction on extra-billing to independent providers in other provinces. While the CHA says there must be deductions from federal cash transfers for extra-billing “by medical practitioners or dentists in the province,” it’s unclear as to whether extra-billing by providers in another province automatically requires federal penalties.

This lack of clarity creates another grey zone, subject to the discretion of the federal minister. The minister also has discretion to levy penalties for such practices where the minister determines that reasonable access is impeded.

Wildrose said it didn’t “advocate” extra-billing; but its Patient Wait Time Guarantee certainly would have allowed it in these specific instances. But, then again, so does the CHA – unless, of course, the federal minister exercises the discretion granted in the act to say it doesn’t.

Should provinces wish to pursue reforms, they shouldn’t be hampered politically by a lack of clarity regarding consistency with CHA criteria. Rather, they should be able to make such decisions – and be forced to defend them on their merits – with relative certainty regarding consistency (or lack thereof) with CHA criteria. To help provide such certainty and clarity, the federal government should stop avoiding these public debates and, instead, clearly and publicly state its position on issues such as the proposed Quebec health deductibles or terms for out-of-province care as they arise.

Paradoxically, this might well place the CHA on a firmer political footing. The bias against reform generated by a lack of clarity has contributed to the sense that the CHA places a straitjacket on reform, which has resulted in calls for its suspension or repeal. Greater clarity and expanded political latitude for reform might well dull such calls.

Moreover, to the degree that providing such clarity is a key step toward meaningful public dialogue on health care in Canada, the federal government should do so. Clarity is one thing that’s clearly missing from current debates.

Gerard Boychuk is a professor of political science at the University of Waterloo and Balsillie School of International Affairs. His C.D. Howe Institute Commentary, Grey Zones: Emerging Issues at the Boundaries of the Canada Health Act, can be found at

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