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Canadians sometimes wonder whether Alberta is actually tethered to the rest of the country, at least temperamentally. With its right-of-mainstream attitudes and its progressive, get-it-done mentality, Wild Rose Country is looking increasingly like the wild child of the Canadian family. From their vantage point, Albertans increasingly view the rest of Canada as a crotchety, aging relative: slow moving and stuck in the past.

The perceived stereotypical divide between the Yee-Haw province and Ye Olde Canada grew wider last week when Alberta Premier Ralph Klein plunked down a series of health-care proposals that collectively hit the country like a splash of cold water. Dubbed the Third Way, the bulk of the province's health-care "policy framework" is laudable stuff, though mostly not revolutionary. The first proposal, for instance, is to put patients' interests first. But mixed among the ideas, planners included an out-of-the-box proposal that would allow private clinics to offer certain services currently available only under Medicare and--gadzooks!--charge the patients directly for them. Another Canadian-taboo breaker is a proposal to allow Alberta doctors to work simultaneously in and outside the public-health sector; now doctors must choose one or the other. Antonia Maioni, director of the McGill Institute for the Study of Canada, calls the plan a significant departure from the status quo. "It's not turning the system upside down yet," she says, but "there is something going on, and that something is this legitimization of the private sector in health care."

Should Canadians, who consider their public system sacrosanct, panic? Here's a primer on the main issues on the table:

WHAT IS ALBERTA THINKING?
A principal justification for the Third Way is that the current system is unsustainable. "The health system must change to survive," Klein said last week. Alberta, the wealthiest province in the country, says if nothing is done by 2030, the public system will completely consume its provincial budget. National health care, of course, is already under stress from rapidly rising costs, as evidenced by long wait times for some treatments and overcrowded emergency wards. The problem, in many cases, is not a lack of doctors, says Alberta's Health and Wellness Ministry, but a lack of operating funds in hospitals to allow medical staffs to do more of certain procedures per week. In some cases, Health and Wellness officials say, practitioners are working the equivalent of only three or four days a week in their specialty.

WHAT IS ALBERTA'S SOLUTION?
Health and Wellness says it is adding facilities and staff to its system but can't continue to do so at the current rate indefinitely. That's why it wants the private sector to start taking up the slack, though only in three areas: knee and hip replacement and certain kinds of eye surgeries, such as cataract operations. The idea is that that would bring additional funding into the system and more fully employ medical staff. To work in the private sector, medical practitioners will have to submit a "business plan" to the health ministry, says Alberta Health and Wellness spokesman Howard May. "Then we appraise [each request] based on a number of things, the most fundamental of which is the fact that the public system will be protected." The ministry is currently ironing out criteria that would allow doctors to work in both systems. "But it will be done on a case-by-case basis," May says. One main criterion is that a doctor who wants to work in a private clinic would have to provide assurances that his private work there would not compromise his work in the public system, May says.

WHAT'S WRONG WITH THE PLAN?
Some say the Third Way is a dead end. One criticism is that it is inequitable because people willing and able to pay for certain treatments get faster access than those who can't afford them. Alberta is making no apologies. "That's a fair comment," says May. "That's exactly what we're looking at doing." A key objective, Alberta officials say, is to allow people living in discomfort to receive medical care faster than they might otherwise get it in the public system. "If we say that the guiding principle is to put the patients first and make sure that the public system is looked after," says Alberta health minister Iris Evans, "then why shouldn't those who want to pay for [quicker access] and are willing to make that investment have that opportunity?"

Allowing doctors to move between the public and private systems creates potential ethical problems, says the University of Alberta's Timothy Caulfield, a Canada research chair in health law and policy. Doctors in the private sphere might be tempted to recommend services that are costlier than is medically necessary, putting their financial gain before the patients' best interest.

Another danger is that a small opportunity for private care would eventually open wider and wider. Tom Noseworthy, director of the University of Calgary's Centre for Health and Policy Studies, says it's naive to think the public system would remain viable in such an environment. "There's a limited physician pool, and if [doctors] get distracted working in the private system, there's no management that can make them work in the public system," he says. There is the danger that the system would provide a bridge for physicians to move to a private system and that they would opt out of the public system once the private market grew large enough.

CAN AlBERTA LESSEN THE RISKS?
If Alberta allows doctors to work in both systems, Caulfield believes, strict regulations are needed to ensure that the public system remains viable. For instance, doctors should not be able to make more money in one system than in the other, to limit doctors' incentive to focus more on private-sector work. Liberal Senator Michael Kirby, who co-authored a 2002 review of Canada's health policy, says that to ensure the viability of the public system, the government will need to establish a "minimum-care guarantee," such as maximum wait times. Forcing governments to pay for all medically necessary services, in either the public system or eventually the private system, would create a powerful incentive for provinces to control costs.

WHAT'S NEXT?
The Alberta government last week started a one-month public-consultation period while it tries to establish exactly how the system is to work. It then plans to draft new legislation that could be ready this spring. During the process it will no doubt be watching for signs from Ottawa as to whether it believes Alberta's plan conforms to the Canada Health Act. If Alberta is found to contravene the act, Ottawa could withhold portions of the Health Transfer it hands over to the province. If it still opts to continue with its program, the future of the Canada Health Act could be in question.

Prime Minister Stephen Harper offered some hints about his views last week when he lauded the more modest Quebec health-care plan that was announced in February. Quebec would provide hip and knee replacements and cataract surgery within six months in the public system, or else it would pay for them to be done in private clinics. It's possible that Alberta eventually will end up closer to Quebec's position. But the increasingly feisty and wealthy province, led by a premier who is not seeking re-election, doesn't have much to lose by playing the game its own distinctive way right to the very end.

• STEVEN FRANK