Making AHS work

Three paragraphs from my 2011 essay Explaining the Health Care Disaster in Canada summarize the issues:

Systems evolve in response to external forces - and the evolution of Canadian health care since 1984 has been governed by the nationalization agenda behind Trudeau's Canada Health Act. Thus the process that got us where we are was triggered when policy makers substituted the government customer for the health care customer; accelerated when practicality forced regional boards to adopt program funding; and was realized when the invisible hand responded by shuffling the market's value criteria to recognize that the bureaucratic customer buys compliance and pays for documented health care expenditures, not positive patient outcomes.

Look at the operation of almost any health care program and you'll see the result: the paperwork is meticulous, the patient's welfare administratively incidental. That's why the average GP now spends just about as much time on paperwork as patients; why retests and patient transfers are now more financial than medical decisions; why tens of thousands of practitioners are working well above their long term sustainable stress levels as they try to use human flexibility and ingenuity to game the system in defense of their patients; why the public sees nothing substantive on outcomes quality; why costs keep rising; and why various kumbaya schools of immigration gaming are successfully staffing a health care time bomb in smaller communities and institutions across the country.

So how can we fix this? First recognize the obvious: the health care market in Canada now operates between bureaucrats with no patient representation - and because markets produce more of whatever the customer pays for, trading in documented program spending de-emphasizes health care while producing more and more program spending.

Eleven years later the right policy objective in trying to fix this remains the obvious one - More from 2011:

To change this, what we need to do is change the market: let the government write the check, but have the individual health care customer decide who gets it. Do that, and the market will produce more of what that customer wants: better outcomes, faster responses, and long term cost stability.

But, how? return full control of hospitals and other institutions as nearly as possible to their original owners; end all program funding; free practitioners to serve their patients instead of bureaucrats; publish comparative performance data for everyone in the system; and, restrict government's role to paying the bills.

It's simple; except it's not. None of this will be easy: service quality takes years to achieve; leftist idealogues, major media players, and today's financial winners will all oppose every change; and, breaking through the assumption that the ruling classes know more about what people need than the people do will be the hardest thing of all - but it can be done, and if we want to fix the system, it has to be done.

Now it's October 2022 and neither the upward trend on costs nor the downward trend in quality has changed direction. Our latest new premier, like all of her predecessors since Lougheed, seems committed to "fixing the system" but faces both political and personal opposition in that the bureaucracy, media, and NDP stand totally united in their opposition to any change and have almost forty years of success in leveraging the public's mistaken beliefs about Canadian health care (it's free and better than the American one) to draw on in their efforts to use health care as the anvil on which to hammer the UCP and Danielle Smith into oblivion.

So what to do? Well, first allow me to restate the obvious: add up all the bits and pieces and Alberta's Health Care System cost the taxpayers somewhat more than $30 billion this year - divide that by about four million Albertans and you find that the nominal family of four paid about $24,000 for free health care this year. More importantly, about 100,000 of those people don't have routine access even to a general practitioner, waits for specialist services can run up to eighteen months, and what the the average taxpayer with a medical problem gets for his $6,000 a year is an 8 to 20 hour wait in an emergency room before being seen by an exhausted intern barely capable of the most routine assessments.

A personal note: when I nearly ripped a foot off it took 9 hours in the waiting room at the Lethbridge hospital to get a next day appointment for an X-ray and surgery 10 days later - eventually producing three surgeries, two of which were botched at a level we consider minor and almost normal but an American lawyer would see as a million dollar payday.

As I wrote in 2011 the solution is obvious, but the getting it done part is (ahem, cough) "daunting". So with that in mind here are three ideas the UCP could follow through on:

1. nothing will stop things like the media's continuing attacks on Premier Smith - with Cam Tait's use of a rant about an (I assume imaginary) rude delivery driver under the head line "Some Scary Stuff Coming out of Smiths Mouth About AHS" to imply something about Ms. Smith's attitude to health care for the handicapped providing a particularly good example of clever writing in the service of vicious politics.

   Smith and the UCP party cannot stop the bureaucracy, NDP, and media from co-operating in their attacks on Ms. Smith, but their actions can be used against them by doing a Trump: simply understand that Albertans aren't stupid (they know what these people are and how they work) and bypass the media to connect directly with Albertans while using media attacks on her views and actions to draw more and more public attention to those direct channels.

   Thus I'm not personally a fan of locals.com but simply continuing to put her views on that platform without too much editing is a good start. Add in some podcasts and careful use of other social media along with lots of personal appearances and the more vitriolic the attacks get, the more voters the left will lose.

    

2. neither panic nor zealotry can be defused. The friends of medicare types will not learn - but most Albertans can be reasoned with and will accept realistic conclusions. So Smith can express deep concern about health care operations, admit to not knowing quite how to fix it all, create a public commission to find the right answers, and commit to a referendum on that commission's report in both its majority and minority opinion variants, eighteen months or so into her next term.

   Doing this will defuse much of the NDP's argument against the UCP for the next election, re-assure Albertans worried that government tends not to get change right, and align the UCP with majority opinion on health care for the next two provincial elections.

   Note, however, that getting the commission right is critical to this: I see the Mackinnon report as a hugely successful effort to get rid of Premier Kenney and weaken province wide support for the UCP - so let's not do that again. Instead, take it as a given that the power players Smith pretty much has to put the on the commission will dictate a platitudinous majority report recommending only cosmetic change while the minority report will, if the right people are in place, be the real thing - and then run the referendum as a choice between the status quo and the two sets of recommendations with caucus members free to vocally support any of the three options.

    

3. Indulge in some stage magic: make headlines "doing something" by firing the board along with the deputy minister and the entire executive at AHS. Then quietly move trusted people into lower level positions across both organizations (see this on where to find them) while extreme slow walking the search for replacement top level staff.

   Note that the AHS legal structure - created so the incumbents could accept higher salaries - probably requires that a board be in place. Assuming so, putting Brian Jean in as chair with other members drawn from caucus reflects the UCP's appreciation of his skills while reducing the threat some of his supporters pose to party unity and preparing the ground for longer term reform.