How Canadians Built a Fair Health Care System from the Bottom Up

Date: 13 Dec 2010 | posted in: equity, From the Desk of David Morris, The Public Good | 0 Facebooktwitterredditmail

David Morris originally wrote this piece for All That We Share: How to Save the Economy, the Environment, the Internet, Democracy, Our Communities and Everything Else that Belongs to All of Us

The seeds of the current Canadian health system were sown in rural Saskatchewan in the early 20th century when small cities with no doctors began to subsidize a physician to come and set up practice. Several communities then joined together to open publicly-funded hospitals.

In the 1930s, a new Canadian political party, whose name reflected its philosophy, the Cooperative Commonwealth Federation (CCF), came to power in Saskatchewan. In 1946 the province enacted legislation that guaranteed free hospital care. Premier Tommy Douglas had hoped to offer universal health care, but the province lacked the financial resources.

In 1958, building on a decade of success in Saskatchewan, the Canadian federal government used the power of the purse to coax other provinces to introduce public hospital insurance. Ottawa promised to pay 50 percent of the cost of provincial programs that satisfied the following rules, which were shaped by the idea of health as a commonwealth, or commons.

  1. Public Administration: The plan must be run by a public authority, and be non-profit.
  2. Comprehensiveness: All necessary medical services must be covered.
  3. Universality: Every resident of a given province or territory must be entitled to the same level and extent of coverage.
  4. Portability: When insured persons travel or move within or outside Canada, their coverage must be maintained.
  5. Accessibility: All insured persons must have access to hospital and physician services

By 1961, all provinces had adopted a hospitalization insurance program.

Taking the Next Step Toward Universal Coverage

Since Saskatchewan had been paying 100 percent of the cost of its program, the 50 percent federal match allowed it to extend public health coverage to physicians’ visits. A promise to do so by Tommy Douglas, who still led the CCF, became the principal issue in the 1960 provincial elections. The CCF won and on July 1, 1962, the new system went into effect. That day 90 percent of the province’s doctors went on strike.

It was a defining moment in Canada’s health care history. Aided by the American Medical Association, Saskatchewan’s doctors used some of the same rhetoric that have proven so effective in U.S. health care debates: socialized medicine is communistic and would patient’s choice of doctors.

But by 1962 Saskatchewans had been served by a commons-based health care system for more than 15 years. When the doctors called a mass public demonstration against socialized medicine, expecting 40,000 to attend, only 10 percent that number showed up. The strike ended two weeks later.

In 1964, came further evidence of how deeply rooted the idea of a health commons had become in Saskatchewan. The CCF party lost the elections. The incoming Liberal party had opposed public insurance for physicians, but it did not try to overturn the 1962 law.

In 1966, Ottawa offered to fund provincial health plans for doctors under the same conditions as it had funded provincial health plans for hospitals. By 1972, every Canadian was covered by the new Medicare insurance.

Thirty years later, a Commission on the Future of Health Care summed up the process, “The principles of the Canada Health Act began as simple conditions attached to federal funding for medicare. Over time, they became much more than that…The principles have stood the test of time and continue to reflect the values of Canadians.”

Lessons in Defending the Health Commons

The Canadian experience also shows that the price of defending a commons, as with liberty in general, is eternal vigilance. Once created, a commons will face continuing challenges from two major forces. One is the ingenious ability of individuals and corporations to find loopholes that allow them to maximize their income at the expense of the commons. The other is the tendency of governments during difficult economic times (or when driven by market ideology) to starve the commons, which undermines public support by reducing its effectiveness.

Canada’s health commons has had to defend itself against both forces. The original Canada Medicare legislation permitted doctors and hospitals to charge patients extra for better service. The law required universal access. But it did not specifically prohibit doctors and hospitals from charging additional fees or allowing patients pay to jump ahead on the waiting lists. In 1984 Canada responded to this threat by passing a new Health Act that effectively eliminated user charges or surcharges on publicly insured services.

More recently, Canada’s health commons has had to deal with shrinking federal support. By the early 2000s, federal share of the provincial health care budget was down from 50 percent to 20-30 percent. Ever-longer waiting lines resulted in ever-broader public grumbling and ever-more-aggressive lobbying by for-profit companies to be allowed to deliver the same health services.

In 2005, the issue came to a head when the Supreme Court of Canada voted 4-3 that Quebec’s prohibition against private health insurance for medically necessary services laws violated the Quebec Charter of Human Rights and Freedoms. Chief Justice Beverly McLachlin wrote, “Access to a waiting list is not access to health care.”

Quebec responded in two ways. In 2007 it allowed private insurance for the three surgeries that had the longest waiting times: knee and hip replacements, and cataract surgery. At the same time it improved the delivery structure of its health system to reduce waiting times. In March 2009, Quebec’s Health Minister announced that nearly all patients seeking knee and hip replacements in the public system were beginning treatment within three months, down from nine months or more.

At the same time, CBC News reported, “More than two years after Quebec legalized private medical coverage for select surgeries, the insurance industry says it has not sold a single policy.”

In a national poll sponsored by the Canadian Broadcasting Company in 2004, Canadians voted Tommy Douglas as “the Greatest Canadian”.

Photo used under Creative Commons License, courtesy of truthout.

Follow David Morris:
David Morris

David Morris is co-founder of the Institute for Local Self-Reliance and currently ILSR's distinguished fellow. His five non-fiction books range from an analysis of Chilean development to the future of electric power to the transformation of cities and neighborhoods.  For 14 years he was a regular columnist for the Saint Paul Pioneer Press. His essays on public policy have appeared in the New York TimesWall Street Journal, Washington PostSalonAlternetCommon Dreams, and the Huffington Post.