Roy Romanow is studying, Jean Chrétien is waiting, Michael Kirby is cogitating. Gary Mar, however, is acting.

Mr. Mar, Alberta's Health Minister, is not prepared to wait for the Romanow commission's report on medicare, or the Prime Minister's response to it, or for Senator Kirby's fifth volume of a prolonged study of health-care options for Canada. Instead, he's on the move as the driver of the Ralph Klein government's health-care changes.

Last January, the Premier's advisory council on health, led by former Conservative deputy prime minister Don Mazankowski, released its report on overhauling health care. It was, compared to the other provincial health studies, the most provocative. And within three weeks of its release, the Klein government endorsed all 44 recommendations.

It now falls to Mr. Mar to steer the government to implementation. Cynics who have seen other major studies gather dust assumed at least some of the Mazankowski recommendations would be too controversial, including the possibility of delisting some services from public coverage and more private money into health care. But, so far, Mr. Mar and his colleagues have ruled nothing out. The Mazankowski report has become the blueprint for Alberta action.

Mr. Mazankowski says he's pleased, even surprised, by how robustly Mr. Mar is following his report. A three-person panel has been established to monitor implementation, providing periodic report cards on how the government is doing. Three committees of Conservative MLAs are studying parts of the report, and their recommendations are due this fall. After their reports, more action is expected.

The premise of the Mazankowski report is itself controversial: "The current health-care system is not sustainable if it is solely funded from provincial and federal government budgets." Where does that conclusion lead? To uncharted health-care areas and possibly into a confrontation with the Canada Health Act, or at least the federal Liberal government's interpretation of it.

If taxes aren't sufficient to pay for health care, there's only one other source: the patient. This, of course, is the most politically volatile controversy of health-care change.

The Mazankowski report analyzed options without choosing one. Recommending one is the responsibility of a committee of Tory MLAs. Accepting or modifying that recommendation and selling it to the Alberta public is the responsibility of the provincial cabinet.

Without saying so directly, the Mazankowski report leaned toward an annual premium and a health account. The scheme's essence would be that an individual would pay an annual premium, as is now done in Alberta. That premium would be deposited in a personal health-care account.

Every time the individual used the health-care system, he or she would "pay" for a fixed portion of the service's cost. That "payment" would be deducted from the person's annual health-care account. If the individual did not use all of the account in one year, the remainder could be carried over to the next year. If the individual used more, he or she would pay up to 3 per cent of his or her taxable income.

Perhaps the Alberta government will balk at this premium and account idea. But the bottom line is that, somehow, patients in Alberta are likely to be paying for some portion of their health care.

In addition, Alberta is likely to encourage more private-sector providers to deliver health care, with services regulated and paid for from public funds. And doctors will be grouped in primary-care practices. Only a small portion of doctors are so grouped now, but Mr. Mar wants half of family doctors to be practising this way by 2004 with methods of payment other than the traditional fee for service.

Whatever decisions Alberta eventually takes, it will be pushing the envelope. In most other provinces, health-care reforms are within the existing parameters of the system -- everything from primary-care grouping of doctors to regional health authorities to patient health cards to better information-sharing among physicians.

These are the reforms preferred by "rational planners," who believe that changes within the system can extract sufficient savings to ease the pressure on provincial treasuries. Mr. Mar and his colleagues like all these reforms but believe they won't suffice to ease the relentless rise in health-care costs.

Something more, including more patient money for their own care, will be required. The government hasn't decided just how that should be done. But when it does, the change will set off fireworks in Alberta and beyond.