Making Medicare: New Perspectives on the History of Medicare in Canada 9781442662414

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MAKING MEDICARE New Perspectives on the History of Medicare in Canada

The Canadian health-care system is so indisputably tied to our national identity that its founder, Tommy Douglas, was voted the greatest Canadian of all time in a CBC television contest. However, very little has been written to date on how Medicare as we know it was developed and implemented. This collection fills a serious gap in the existing literature by providing a comprehensive policy history of Medicare in Canada. Making Medicare features explorations of the experiments that predated the federal government’s decision to implement the Saskatchewan health-care model, from Newfoundland’s cottage hospital system to Bennettcare in British Columbia. It also includes essays by key individuals (including health practitioners and two premiers) who played a role in the implementation of Medicare and the landmark Royal Commission on Health Services. Along with political scientists, policy specialists, medical historians, and health practitioners, this collection will appeal to anyone interested in the history and legacy of one of Canada’s most visible and centrally important institutions. GREGORY P. MARCHILDON

is Canada Research Chair in Public Policy and Economic History and a professor in the Johnson-Shoyama School of Public Policy at the University of Regina. He is also the author of Health Systems in Transition (UTP/WHO).

The Institute of Public Administration of Canada Series in Public Management and Governance Editor: Patrice Dutil This series is sponsored by the Institute of Public Administration of Canada as part of its commitment to encourage research on issues in Canadian public administration, public sector management, and public policy. It also seeks to foster wider knowledge and understanding among practitioners, academics, and the general public.

For a list of books published in the series, see page 323.

EDITED BY GREGORY P. MARCHILDON

Making Medicare New Perspectives on the History of Medicare in Canada

UNIVERSITY OF TORONTO PRESS Toronto Buffalo London

© University of Toronto Press 2012 Toronto Buffalo London www.utppublishing.com Printed in Canada ISBN 978-1-4426-1345-4

Printed on acid-free, 100% post-consumer recycled paper with vegetable-based inks.

Library and Archives Canada Cataloguing in Publication Making medicare : new perspectives on the history of medicare in Canada / edited by Gregory P. Marchildon. (Institute of Public Administration of Canada series in public management and governance) Papers previously published in the Canadian bulletin of medical history. Includes bibliographical references and index. ISBN 978-1-4426-1345-4 1. National health insurance – Canada – History. 2. Medical policy – Canada – Provinces – History. 3. Public health administration – Canada – Provinces – History. I. Marchildon, Gregory P., 1956– II. Series: Institute of Public Administration of Canada series in public management and governance RA412.5.C3M232 2012

368.4⬘200971

C2012-904806-2

University of Toronto Press acknowledges the financial assistance to its publishing program of the Canada Council for the Arts and the Ontario Arts Council.

University of Toronto Press acknowledges the financial support of the Government of Canada through the Canada Book Fund for its publishing activities.

Contents

Foreword vii Editor’s Preface and Acknowledgments ix 1 Canadian Medicare: Why History Matters 3 GREGORY P. MARCHILDON

Part One: National History of Medicine 2 The Foundations of National Public Hospital Insurance 21 ALECK OSTRY 3 Into Thin Air: Making National Health Policy, 1939-45 41 HEATHER MACDOUGALL 4 The Liberal Party and the Achievement of National Medicare 71 P. E. BRYDEN 5 Political Cartoonists Respond to Medicare 89 FELICITY POPE 6 After Medicare: Regionalization and Canadian Health Care Reform 110 TERRY BOYCHUK

Part Two: Individual Provincial Histories of Medicare 7 Four Precursors of Medicare in Saskatchewan 137 C. STUART HOUSTON and MERLE MASSIE 8 The Road Not Taken: The 1945 Health Services Planning Commission Proposals and Physician Remuneration in Saskatchewan 151 GORDON S. LAWSON 9 The Hoadley Commission (1932-34) and Health Insurance in Alberta 183 ROBERT LAMPARD 10 From Bennettcare to Medicare: The Morphing of Medical Care Insurance in British Columbia 207 GREGORY P. MARCHILDON and NICOLE C. O’BYRNE

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CONTENTS

11 Newfoundland’s Cottage Hospital System: 1920-1970 229 GORDON S. LAWSON and ANDREW F. NOSEWORTHY 12 The Partnerships between the State and For-Profit Hospitals in Quebec, 1961-1975: A Disappointing Experiment 249 ALINE CHARLES and FRANÇOIS GUÉRARD

Part Three: Oral History and the Birth of Medicare Witnesses to Medicare in Saskatchewan: Medicare Workshop at the University of Saskatchewan—Wednesday, 20 May 2007 13 The Struggle to Implement Medicare 277 ALLAN BLAKENEY 14 Working for Medicare 282 BETSY BURY 15 A Physician on the Front Line of Medicare 284 JOHN D. BURY 16 My Experience in the Medicare Battle and the Woods Commission 288 ROY ROMANOW 17 A Brief Retrospective on the Royal Commission on Health Services 291 JACK BOAN

Conclusion 18 A New Prescription: Adding Historical Analysis to Health Policy 295 HEATHER MACDOUGALL

Contributors 307 Index 311

Foreword

I write this on the 50th anniversary of the end of the Saskatchewan doctors’ strike, an unprecedented action in the annals of this country and, for all sorts of unfortunate reasons, not the last of its kind. The doctors in that province walked off their practices on Dominion Day, 1 July 1962, to protest the coming into effect of the Saskatchewan Medical Care Insurance Act. They raised arguments about patient rights, about funding, and about accountability. The prairie doctors made their point in the summer of 1962, but so did Saskatchewan, and so did Canadian society. Within a decade, prompted by massive funding from Ottawa, all the provinces had adopted some variant of the “Saskatchewan model.” The issues that were raised that summer, however, have been with us ever since. The event was profoundly symbolic of the tensions that have been the hallmark of Medicare for the past half-century. This anniversary makes this book all the more timely. First and foremost, this collection sheds light on the craggy battlefields of Medicare where many unexploded mines still remain buried deep in the mud of political memory. It carefully unearths some of the actions, reactions, and intentions that shaped the story from coast to coast and lays bare the tracks to many of the other events and policy positions that need to be understood and reflected upon. Together, these essays show that the adoption and adaptation of Medicare over the years has been the subject of as much improvisation based on political opportunities and short-term expediencies as it has been the product of visionary policy making and entrepreneurial public administrations. This book is important for a second reason: Medicare is undoubtedly the single greatest public policy story of the past 50 years and remains vitally important to Canadians. If a few opinion surveys are to be believed, Medicare is, for most Canadians, quasi synonymous with citizenship. It is the cornerstone of their idea (along with international peacekeeping) of nationhood. It is almost as if Canada would not exist

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if it were not for Medicare. If this policy action is the pride and joy (to say nothing of the comforting) of so many citizens, however, it has also been highly contentious. It has pitted the medical establishments against patients, against their membership, against provincial governments, and against the government of Canada. The impact of Medicare has rippled across many governance issues. It has contributed greatly to intergovernmental tension between the federal state that has imposed rules and the provinces that were charged constitutionally with the provision of health care; it has challenged our perceptions of what belongs in the public domain and what should remain in the private sphere of personal health care. It has defeated governments (the first victim was the government that wrought the Saskatchewan Medical Care Insurance Act), destabilized budgets (health care now consumes at least 40 per cent of most provincial budgets), and challenged public administrations at all levels in the task of balancing an ever-growing appetite for health-care services with public funds. The Canadian model is far from perfect—indeed it ranks very poorly against the health standards and outcomes of most OECD countries. Might this is be the consequence of its peculiar politics? This volume helps us in coming up with an answer. Finally, this book is important for the series in which it takes its place. This is the third book of the IPAC collection that focuses on health care. The first one is Candace Redden’s Health Care, Entitlement, and Citizenship, which examines the unique links between the ideas of Medicare and the ideas of Canada. The second is Al Johnson’s Dream No Little Dreams: A Biography of the Douglas Government of Saskatchewan, 1944–1961, which bears witness to the genesis and application of the controversial Saskatchewan law. Readers may want to revisit these companion works as they ponder the wisdoms of this one. Fifty years after the Saskatchewan doctors’ strike, the “Canadian model” is under duress and no clear, convincing answers are in sight on how to make this cherished system more responsive, more economical, and more sustainable. This book explores, with clear insights, how the various features of this country’s health-care delivery and finance have come to be and how the issue of Medicare has shaped the way Canadians see themselves as patients, taxpayers, and citizens. Fifty years ago today, an historic strike was resolved. Fifty years after the strike, Canadians face the same issues. I hope that fifty years from now, this will only seem to be a bizarrely difficult policy issue that has long been resolved. Patrice Dutil Ryerson University 23 July 2012

Editor’s Preface and Acknowledgments

For the last decade, I have been preoccupied with health-care policy in Canada. As a policy advisor, social scientist, and historian I have been continually fascinated by how often contemporary policy problems and solutions are perceived as brand new when in fact they have circulated in one form or another in the past. I have often thought that if only we understood our history better, then this would assist the way in which we analyse our problems as well as much improve our understanding of potential solutions. At a minimum, a better understanding of the evolution of public health care would allow us to separate the old from the new—those truly original policy ideas that have not been tried before. In other respects, however, we have many blind spots in this history. While we have developed a national mythology about Canadian Medicare, for example, the all-important details lay scattered about in a few archives or forgotten entirely. A further complication is that the evolution of much public health-care policy has occurred within individual provinces, and these histories do not always match. To shed some light on this half-forgotten and fragmented history, I called upon a number of historians and social scientists to prepare papers that would be exchanged and explored at a one-day workshop at the University of Saskatchewan in May 2007. I also asked some individuals who actually witnessed the birth of Medicare in Canada to speak to us about their experiences, and they too prepared written summaries of their roundtable presentation. Under the guidance of Cheryl Krasnick Warsh, these papers were peer-reviewed and then published in the Canadian Bulletin of Medical History, a specialized journal that had agreed to allow the articles to appear as chapters in a book published by the University of Toronto Press (UTP) in order to reach a larger audience. The collection was then reviewed by two scholars selected by UTP to evaluate its cohesiveness

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EDITOR’ S PREFACE AND ACKNOWLEDGMENTS

as a book. In response to the reviews, I prepared a more detailed and considerably revised introductory chapter. Heather MacDougall wrote a new conclusion. To reach out beyond specialists in the field, Felicity Pope extended her original work, while Terry Boychuk linked his postMedicare chapter on regionalization more directly to the history of Medicare. Finally, I arranged for the translation of the chapter on Quebec’s earlier experience with private-for-profit hospitals, prepared by Aline Charles and François Guérard. In addition, the other authors who appear in this volume were all responsive to earlier requests for revision based upon the workshop and subsequent peer review. I want to thank all of these authors for responding to my original request for papers addressing the historical blind spots and for their patience in seeing this project through to completion. I am indebted to historian Bill Waiser for providing his department’s boardroom for our workshop. I very much appreciate the assistance of Ingrid Larson of the Saskatoon Community Clinic in helping organize the oral history session as well as the enthusiastic participation of Allan Blakeney, Jack Boan, Betsy Bury, John Bury, and Roy Romanow. I am also grateful to the Canada Research Chair program, which gave me the time and resources to pursue this project. The title of this book—Making Medicare—was first used by the Canadian Museum of Civilization for an exhibit which can be found at www.civilization.ca/cmc/exhibitions/ hist/medicare/medic00e.shtml. Two of our authors, Heather MacDougall and Felicity Pope, were involved in putting this spectacular exhibition together. I want to thank Daniel Quinlan at the University of Toronto Press for steering this project and the Institute of Public Administration of Canada for its financial support. Finally, I must thank Heather MacDougall for her great support throughout this project. She assisted at every stage, providing sage advice when I most needed it. Gregory P. Marchildon

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1 Canadian Medicare: Why History Matters GR E GO RY P. MARCHILDON

WHY HISTORY MATTERS

Fed by profound ideological divisions as well as hard-nosed calculations of gains and losses in the event of policy changes, the debate on the future of the Canadian system of universal health care seems never-ending. In the early to mid-1990s, provincial governments either cut or slowed health-care expenditures, and some (most notably, Saskatchewan and Ontario) closed hospitals.1 As a consequence, satisfaction with public health care, once the highest in the industrialized world, fell precipitously.2 In response, governments reversed course by investing more in public health care. They also established commissions and advisory committees to recommend ways in which to fix or transform Medicare in Canada. The result—conflicting recommendations and the perception that spending on Medicare has begun to crowd out other public spending—has produced policy confusion.3 The debate on the future of Medicare was further polarized in recent years by the Supreme Court of Canada’s decision in the Chaoulli case in 2005. In addition, the Canadian model of Medicare began to be regularly demonized by Americans opposed to reforms first proposed by President Obama in 2009. Unfortunately, the debate on the present condition and the future direction of Canadian Medicare has generated more heat than light, in part because the arguments and positions are so often poorly informed by history. At a minimum, a more profound and accurate understanding of Medicare’s evolution assists in explaining the present by allowing us to understand with greater precision what has changed or not changed in terms of interests, institutions, actors, and attitudes since Medicare was first introduced. Knowing which arguments and which evidence, for and against Canadian Medicare, have been used (and by which individuals and interests) in the past also sheds light on present and future debates.

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Given the potential of well-grounded history to clarify the terms of the debate and isolate the new and original from the old and the stale, why have historians devoted so little attention to the history of Medicare? There are likely many reasons, but I would like to offer three explanations: (1) the limited interest in political history among professional historians, (2) the interdisciplinary complexity of policy history, and (3) the fragmented nature of Medicare’s history, itself a product of the decentralized character of the Canadian federation. First, public policy occurs within the framework of the state—the history of Medicare is, therefore, political history as well as policy history. Canadian political scientists in particular have been curious about the emergence of a universal health system in Canada and the absence of such a system in the United States, and have produced some very useful studies comparing the two countries.4 Unfortunately, historians have paid little attention to the history of Medicare, in part because of their declining interest in political history. There are a few exceptions. For example, David Naylor, a historian of medicine as well as a medical scientist, has examined the history of Medicare through the lens of organized medicine.5 Second, the history of Medicare has been neglected because of the sheer complexity of researching and writing policy history. Among other things, policy history requires: a working knowledge of state bureaucracies; a comparative understanding of health systems, including alternative funding and administrative arrangements; an understanding of policy and how it is translated into law, regulation, administrative machinery, and programs; and a knowledge of civil society actors and organizations that ultimately play both a coordinating and competitive role with the state in administering and delivering a social policy such as Medicare.6 This mix of skills, exemplified by Malcolm G. Taylor, whose long career as a public health-care administrator and consultant intimately familiar with government prepared him to write the first major history of Canadian Medicare.7 Finally, the history of Medicare has received limited study because of the nature of the Canadian federation. From the beginning, social policies such as Medicare have been initiated, implemented, and managed in a decentralized manner, reflecting the formal division of federalprovincial powers under the constitution as well as judicial interpretation of these powers over time. The result is that, with some important exceptions, provincial governments have assumed the primary responsibility and authority for public health care.8 At the same time, the Government of Canada, by using its “spending power ”—transferring a portion of the money its raises through federal taxation—has exerted considerable influence over Medicare. This fact, coupled with the nature of policy interdependence in an increasingly mobile society, encouraged

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provincial and federal governments to establish intergovernmental mechanisms and agencies in an effort to better coordinate their respective Medicare programs and policies.9 Again, political scientists, more so than historians, have been attracted to exploring Medicare within the context of a decentralized federalism.10 MEDICARE: A CONFUSING CONCEPT WITH A CONTESTED HISTORY

The word “Medicare” needs to be more precisely defined because it can be a confusing term used in inconsistent ways. In this book, Medicare means all universally provided public health-care services, even though the word “medicare” was first used as a shortened form for universal “medical care insurance,” first implemented in the 1960s to pay for physician services. Because this more contemporary definition of Medicare embraces more than “medical care services,” it is hereafter capitalized in order to avoid confusion with the historical term. Universal medical care insurance was built on the back of universal hospital insurance (or “hospitalization” as it was then known), which was introduced on a national basis in the late 1950s, a decade before medical care insurance was conceived. Because of this history, both hospitalization and medical care insurance were eventually conflated as Medicare in popular language. This fusion of the two became entrenched when insured hospital services as defined under the Hospital Insurance and Diagnostic Services Act (1957) and insured medical care services as defined under the Medical Care Act (1966) were combined as “medically necessary” and “medically required” hospital and physician services under the Canada Health Act in 1984. Henceforth, Medicare became shorthand for the insured services specifically protected under federal law—by the five principles of universality, comprehensiveness, public administration, portability, and accessibility—but administered by the provinces and territories. Medicare does not include all public-sector health-care services. In fact, Medicare is only a subset of “public health care,” and a relatively shrinking one at that. In the mid-1970s, hospital and physician services constituted close to 77% of all public health expenditures by the provinces and territories, but with the expansion of home care and long-term care services and the introduction of provincial drug plans, this fell to 63% by the turn of the century.11 This change was due to numerous advancements in medical knowledge and technology that reduced the need for hospital and physician care relative to other forms of health care. It can also be linked, at least for a brief period during the early to mid-1990s, to cuts in health-care spending by governments in response to a public debt crisis.12 As well, private spending on prescription drugs, dental care, vision care, and complementary and alternative medicines and therapies grew at

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rates that equalled or outstripped public spending, even after governments began to reinvest in public heath care in the late 1990s.13 Medicare is contested history, largely because it continues to be the focus of great political and ideological debate. Medicare’s fiercest critics are opposed to the policy because of the extent to which it redistributes resources from the wealthy and healthy to the poor and ill.14 In their view, Medicare stripped away individual responsibility and the incentive to use services more sparingly when it removed direct patient payment for services. The policy transformed what the critics defined as a privilege or benefit to be obtained through individual effort into a collective entitlement or right provided by the state.15 Such arguments not only marked Medicare when it was first introduced. They also predate the introduction of universal health care, and they continue to mark the debates that swirled around Medicare as it matured as a policy. Table 1 provides a chronology of the evolution of Medicare in Canada. By examining the steps in this evolution, from the initiatives in Alberta and Saskatchewan during the Depression-ridden 1930s to the political dynamics within the Liberal Party in the 1960s, the authors provide new perspectives on the history of Medicare. Of course, the evolution of Medicare was not linear. Nor was the result inevitable. At the root of the story of Canadian Medicare lies a profound, valueladen conflict involving two disparate visions of public health care and the role of the state. In the one vision, proponents desired a single-tier, universal system in which everyone would have access to the same services on the same terms and conditions. There would be only one insurer, and this single payer would be the province or a public authority designated by, and accountable to, the provincial government. Funding would be entirely tax-based (whether through general revenues or flat tax premiums). There would be no user fees of any kind, because these were perceived as blocking the access of Canadians with the least income. A minority of individuals in this camp went further, arguing in favour of state-owned hospitals and a state-salaried medical service. Though a version of such an approach had been established in Newfoundland by the late 1930s and in the United Kingdom by the late 1940s, the majority in the pro-Medicare camp rejected this approach in favour of a public payment but private practice approach.16 The proponents of other visions of public health care wanted existing inequities in access addressed by extending private health insurance. Provincial governments would provide subsidies for those who wished to purchase health insurance but could not do so because of income or illness. With multiple carriers would come multiple levels of service, although even the most subsidized service would have to meet a threshold of basic medical care. However, to attach a direct individual cost to the service—and to emphasize the direct relationship between providers

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Table 1. Chronology of Key Policy Events in the Evolution of Medicare Date Key Event 1916 Saskatchewan government amends law to allow municipalities to use revenue from property tax to build hospitals and pay for doctors 1934 Alberta Health Minister George Hoadley releases final report recommending contributory health insurance plan administered by municipalities 1936 First of 23 government-run cottage hospitals established in Newfoundland 1937 Provincial government does not introduce social health insurance plan for British Columbia, despite affirmative referendum result in election of that year 1939 Saskatchewan allows municipalities to raise personal taxes in addition to property tax to pay for hospital and medical services (“the Matt Anderson Act”) 1942 Federal government appoints the Advisory Committee on Health Insurance. In its report one year later (the Heagerty Report), the Committee recommends national health insurance 1945 Health Services Planning Commission in Saskatchewan recommends a government-run salaried medical service 1946 Federal health insurance proposals based on the Heagerty Report rejected by majority of provinces in Dominion-Provincial Reconstruction Conference 1947 Saskatchewan implements universal hospital insurance (Saskatchewan Hospital Services Plan) 1948 Federal Health Minister introduces Hospital Grants Program and British Columbia implements universal hospital insurance (British Columbia Hospital Insurance Services) 1950 Alberta introduces a provincially subsidized but municipally administered and financed hospital insurance that closely approximates the Hoadley Plan of 1934 1955 Canadian Medical Association passes resolution officially opposing universal health care 1957 Federal government under Liberal Prime Minister Louis St. Laurent enacts the Hospital Insurance and Diagnostic Services Act, which cost-shares hospital insurance with provinces 1958 Newly elected Progressive-Conservative Prime Minister John Diefenbaker removes obstacles to ensure rapid implementation of universal hospital insurance by provinces. Alberta, British Columbia, Manitoba, and Saskatchewan qualify in 1958, followed by New Brunswick, Nova Scotia, Ontario, and Prince Edward Island in 1959, and Quebec in 1961 1961 Diefenbaker government establishes the Royal Commission on Health Services chaired by Emmett Hall to examine the question of medical care insurance in response to concerns raised by organized medicine 1962 Saskatchewan implements universal medical care insurance after a provincewide doctors’ strike that lasts 23 days based on the terms of the resulting “Saskatoon Agreement” 1963 Alberta Social Credit Premier Ernest Manning introduces alternative to Saskatchewan’s universal medical care insurance, subsidizing existing private insurance plans, which is dubbed Manningcare by the media, while Ontario Progressive Conservative Premier John Robarts introduces a bill that also endorses a voluntary, multi-payer approach 1964 Hall Commission report recommends universal medical care insurance based on Saskatchewan model rather than Alberta-style Manningcare as promoted the CMA 1965 Premier W. A. C. Bennett of British Columbia introduces medical care insurance known as Bennettcare, a multi-payer plan involving non-profit insurance carriers

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Table 1. Chronology of Key Policy Events in the Evolution of Medicare (concluded) Date Key Event 1966 Liberal Prime Minister Lester B. Pearson and Cabinet sponsor passage of Medicare Care Act to cost-share universal medical care insurance with provincial governments 1968 Implementation of universal medical care insurance on national basis with British Columbia and Saskatchewan immediately qualifying, followed by Alberta, Manitoba, Newfoundland, Nova Scotia, and Ontario in 1969, Prince Edward Island and Quebec in 1970, and New Brunswick in 1971 1974 Government of Canada publishes Lalonde Report on factors beyond medical care such as lifestyle, environment, and biology that determine health outcomes 1984 Federal government, led by Health Minister Monique Bégin, introduces the Canada Health Act, which discourages extra billing and user fees for physician and hospital services

and recipients—some form of user fee would be placed on services, irrespective of the degree of state subsidization. When the debate over medical care insurance hit its peak during the early to mid-1960s, the first vision was pursued by the social democratic government of Saskatchewan, organized labour, church and volunteer organizations, the majority of the Canadian public (as indicated by the available public opinion data of the time),17 and one faction within the federal Liberal government led by Lester B. Pearson. It was established as a working model by the Co-operative Commonwealth Federation (CCF) government under Premier Tommy Douglas and his successor Woodrow Lloyd after a bitter 23-day doctors’ strike.18 An alternative was established in Alberta one year after public medical care insurance was implemented in Saskatchewan. Dubbed Manningcare by the media—a reference to Social Credit Premier Ernest C. Manning—Alberta-style medical care insurance had the support of most provincial governments, the Canadian Medical Association and its provincial affiliates, the insurance industry, and chambers of commerce throughout the country. Table 2 summarizes some of the key policy design differences. In the early 1960s, it was far from a foregone conclusion that Saskatchewan’s version of Medicare would become the model for the rest of the country. Medicare could just as easily have taken the form of Manningcare, which had been supported by the majority of provinces, the medical profession, and the business establishment. There was no inevitability, even considering that national hospital insurance adopted a decade earlier reflected the Saskatchewan design. In fact, the confrontation over universal medical care insurance in Saskatchewan symbolized by the Doctors’ Strike of 1962—so at odds with the acceptance of hospitalization in the province in 1947 and the country a decade

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Table 2. Policy Differences between Medicare and Manningcare Saskatchewan-Style Medicare

Alberta-Style Medicare (Manningcare)

Single-payer administration (managed by a single public authority accountable to the provincial government) Complete coverage of population (compulsory enrollment)

Multi-payer administration (managed by multiple private insurance carriers)

No user fees (rejected as tax on poor and funding restricted to premiums, later eliminated, and general tax revenues) Centralized provincial control of financing and administration

Partial coverage of population by choice of municipalities and individuals, with provincial government subsidizing enrollment of those who cannot afford to purchase insurance (voluntary enrolment) User fees (to restrain demand as well as raise funding additional to premiums and general tax revenues) Decentralized local government control for most of financing and administration

later—only strengthened the hand of those arguing in favour of a Manningcare model. Ultimately, however, the decisions and actions of the federal government loaded the dice in favour of Medicare on the Saskatchewan model. The first step was the early predisposition of the federal government to support a universal medical scheme as part of the reconstruction efforts towards the end of World War II. The second step was the implementation of provincial cost-sharing for universal hospital insurance by the Progressive-Conservative government under John Diefenbaker. The third, more difficult, and controversial step was the initiation and implementation of national medical care insurance by the Pearson government. This “national” history of Medicare is the subject of the first five chapters. NATIONAL HISTORY OF MEDICARE

Focusing on the changing role of hospitals over the past century, Aleck Ostry provides us with an overview of the evolution of national hospital insurance. The crisis of hospital financing in the Great Depression created a more open environment for state involvement almost immediately following World War II. The federal government dispensed hospital grants to the provinces, resulting in a hospital building boom and a rapid expansion in the number of beds. This was accompanied by the introduction of different types of public hospital insurance in the three most western provinces. Eventually, however, with the federal government’s intervention through legislation and shared-cost financing, the main design features of Saskatchewan hospitalization became the norm not only in Western Canada but in the rest of the country.

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Heather MacDougall recounts the first attempt by the federal government to introduce Medicare as part of its reconstruction agenda coming out of World War II. We see this history through the eyes of J. J. Heagerty, the long-serving director of public health services in the federal government. Working closely with the Canadian Medical Association, Heagerty proposed a shared-cost (federal-provincial) program that would have seen the federal government fund 60% of the costs of a broad set of curative and preventative health services administered by the provinces. The Heagerty Plan ultimately failed because federal funding was contingent on the provinces continuing to surrender their income, corporate, and succession taxes to the federal government, as had been done during World War II. Led by the heavyweights of Ontario and Quebec, most provinces refused this arrangement. Increasingly wary of the fiscal and social implications of such a major expansion of the welfare state, Prime Minister Mackenzie King was more relieved than disappointed about the failure of the federal health proposals. Penny Bryden analyses the high politics of implanting national Medicare under the aegis of the Liberal government of Prime Minister Lester B. Pearson.19 Although the Liberal Party of Canada had been promising some form of health insurance since the leadership convention of 1919, it was only during its time in opposition between 1957 and 1963 that the Liberals began to take the implementation of Medicare seriously. The Kingston Conference of 1960 allowed leading Liberal strategists to rethink social policy, and by the time of Pearson’s election victory of 1963, Medicare had become a key Liberal objective, due to the emergence of left-leaning reformers in his Cabinet (Judy LaMarsh, Walter Gordon, Allan MacEachen, and Maurice Lamontagne) and key advisors, in particular Tom Kent and A. W. Johnson. Kent was a strong advocate of universal social programs including Medicare, while Johnson was a former Saskatchewan bureaucrat directly involved in the implementation of Medicare in Saskatchewan who had moved to Ottawa to become a senior civil servant in the Pearson government. Supported by Kent, Johnson influenced the content and form of the intergovernmental negotiations leading to the introduction of national medical care insurance.20 Although implementation was delayed as a result of the leftright split in the Liberal Cabinet, the division focused on the issue of affordability rather than design, so when the Pearson government finally proceeded, it did so on the universal, single-payer model pioneered by Saskatchewan. Debates over Medicare, and the associated high political drama, provided an abundance of raw material for editorial cartoonists. Enriching our understanding of the political dynamics of Medicare from a more satirical perspective, Felicity Pope’s illustrated tour takes us back in time in a way that historical text cannot; a picture is truly worth a thousand

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words. The political cartoons selected by Pope cover an extensive period, from the federal government’s health program proposals at the end of World War II, to the shoring up of Medicare with the introduction of the Canada Health Act in the 1980s. Terry Boychuk’s chapter on regionalization is an epilogue to the history of the establishment of Medicare. As originally implemented, Medicare was a passive payment system that did not change the way in which existing hospitals and physicians actually worked. It was “health insurance” rather than a “health system.” Even as Medicare was being introduced, federal and provincial ministers of health were developing ways in which they could more effectively manage the system and its costs. The idea of regionalization, in which public authorities actively managed a range of health services on behalf of the population, was already circulating, but it would take a fiscal crisis to implement this structural change. As Boychuk points out, principles such as accountability, efficiency, and effectiveness became the focus of governments after universal access was achieved through Medicare. Though these reforms are too recent to render a judgment on their success or failure, the history of their implementation through the experiences of the “first movers” highlights the challenges faced by provincial governments in creating a truly co-ordinated health system. INDIVIDUAL PROVINCIAL HISTORIES OF MEDICARE

Canada is a decentralized federation in which provinces are the primary actors in social policy, including Medicare. Although the federal government entertained the idea of playing a more decisive role in establishing public health care at the end of World War II, it would be up to provincial governments to establish a beachhead for universal hospital and medical care insurance in Canada. Moreover, with time, each province in Canada has developed a unique political culture that expresses itself through differentiated approaches to public policy. As a consequence, to more fully grasp the history of Medicare, we need to understand the individual provincial histories of Medicare. These chapters fill some important holes in the provincial histories of Medicare, including British Columbia, Alberta, Quebec and Newfoundland, thereby considerably supplementing Malcolm Taylor’s focus on Saskatchewan and Ontario (in addition to national developments in Ottawa).21 Gaps remain, but these should be easier to fill, now that the archival record of the period is generally available—an advantage Taylor did not enjoy when he wrote his seminal account. The Great Depression left its deepest mark on the Prairie Provinces, because economic crisis coincided with prolonged drought in southern Saskatchewan and Alberta and a small corner of southwestern Mani-

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toba. This double tragedy meant that a large number of people living in the drought-stricken regions could not afford hospital and medical care, impoverishing physicians and threatening the closure of local hospitals. Consequently, provincial governments in Saskatchewan and Alberta were the first to respond to the pressure for reforms that would remove money as a barrier to access hospital and medical services, but they did so in almost diametrically opposed ways. Historically, the governments of British Columbia and Newfoundland were also early innovators, and they also adopted approaches that were unique to their provinces. While it remains true that most provinces required the stimulus of the national government—and its cost-shared dollars—before they were willing to implement either hospitalization or universal medical care insurance systems, they each adopted Medicare in their own time and their own way. Focusing on individual leadership at the local government level during the Great Depression, Stuart Houston and Merle Massie recount how a small group of rural municipalities in southwest Saskatchewan became the platform for the first provincial experiment in public hospital and medical insurance—the Swift Current Health Region.22 This chapter is an extension of Stuart Houston’s original work on the historical foundation of Medicare in Saskatchewan.23 This work raises an important question: what if Saskatchewan had built Medicare on the existing infrastructure of local governments rather than created a centralized provincial system? We may never know the answer to this question, but Houston and Massie make us aware of the depth of what we would today call “social capital” at the local government level in this rural province before World War II. The Saskatoon Agreement of 1962, the compromise reached between the CCF government of Saskatchewan and organized medicine after a bitter 23-day doctors’ strike, effectively entrenched fee-for-service remuneration of physicians in Canada. By some accounts, this was seen as a major capitulation by the CCF government that preserved the power of organized medicine and prevented the emergence of a more preventative approach to health care.24 Gordon Lawson’s chapter suggests that the CCF government’s acceptance of fee-for-service in 1962 was the continuation of a policy position established almost two decades earlier. Lawson examines the history behind the government’s rejection of the 1945 Health Services Planning Commission’s recommendation for a salaried medical service in rural Saskatchewan. An analysis of CCF party and government policy statements reveals that, unlike the CCF nationally and in Ontario, the Saskatchewan CCF had never been committed to a salaried medical service in the province. Moreover, Lawson demonstrates that Douglas himself was not committed to such a policy—a position shared by the province’s municipal doctors, many of whom re-

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ceived salaries but often obtained fee-for-service work outside their regular municipal contracts. Even if fee-for-service remuneration was not a major concession in the Saskatoon Agreement, the Saskatchewan government did make other compromises in response to the demands of organized medicine. By permitting physician-sponsored insurance carriers a limited role in paying physicians, for example, the provincial government could not prohibit the private provision of Medicare insurance.25 Robert Lampard introduces us to the Hoadley Commission and its subsequent policy influence in Alberta. George Hoadley was the minister of health from 1923 until 1935 in the United Farmers’ of Alberta (UFA) government. In 1932, he appointed an all-party Commission, with himself as chair, to design a health insurance plan. The Hoadley Commission’s recommendations reflected many of the elements of the Manningcare model in terms of local government control supported by provincial subsidies as well as contributory (and voluntary) as opposed to universal (and compulsory) coverage. The Hoadley plan was made law, pending the outcome of the provincial election. However, in August 1935, the UFA government was defeated and the new Social Credit government, facing near bankruptcy, set aside the legislation. Seven years later, a bill was passed based on the Hoadley plan, but since it was predicated on federal funding, it never became the provincial health-care plan. While the Hoadley plan would influence Premier Manning’s first versions of hospital insurance and medical care insurance, it would be abandoned in favour of Saskatchewan-style Medicare in order to meet the requirements for federal cost-sharing.26 A number of provincial premiers including John Robarts of Ontario, Duff Roblin of Manitoba, Ernest Manning of Alberta, and W. A. C. Bennett of British Columbia, opposed the Pearson’s government’s singlepayer plan for Medicare in favour of a multi-payer plan that would permit the participation of private insurance carriers. Nicole O’Byrne and I examine the evolution of Medicare in British Columbia. While Premier W. A. C. Bennett tried to portray his medical care insurance program as an alternative to both Saskatchewan-style Medicare and Manningcare, Bennettcare was actually much closer in principle and objective to Manningcare. However, to address some of the design flaws in the Alberta model, Bennett made sure that subsidies to purchase health insurance were generous enough to encourage a higher rate of subscription than in Alberta, and he limited the private carriers to notfor-profit enterprises, including co-operatives and the physician-based insurance plans. Though he achieved his goal of attaining 90% voluntary subscription to meet the federal condition of universality, Bennett was forced to change two key aspects of his plan in order to meet the requirements of the federal Medical Care Act. He had to discontinue, or at least

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stop encouraging, the practice of extra-billing by physicians. He also placed the not-for-profit insurance carriers under public administration so that the system of medical care insurance would be democratically accountable to the provincial Legislature. In the process, Bennettcare morphed from a variant of Manningcare into single-payer Medicare on the Saskatchewan model as the not-for-profit carriers exited the unprofitable business of medical care insurance in favour of non-Medicare supplementary and complementary health insurance. Gordon Lawson and Andrew Noseworthy examine Newfoundland’s cottage hospital system—small, state-run hospitals designed to serve the relatively isolated outport communities. Newfoundland was among the first provinces to join the federal hospitalization plan in July 1958, a direct result of a cottage hospital system initiated in 1936. Twenty years later, almost half of the province’s population—located in remote locations—received hospital and medical care through some 20 cottage hospitals. The hospitals, staffed by salaried medical personnel, were owned and managed by the provincial government. However, the subsequent introduction of national medical care insurance threatened the cottage hospital system—and salaried physician remuneration in particular— because of the incentives it provided for fee-for-service remuneration. In response, the government of Newfoundland increased salaries, pensions, and study leave for its cottage hospital doctors. As late as 2004, 40% of doctors still received salaries, making Newfoundland and Labrador distinct among the provinces. Lawson and Noseworthy’s study of Newfoundland’s cottage hospital system is of interest because it presents yet another potential model of Medicare that Canadians could have adopted but did not. In this model, hospitals could have been owned and operated directly by the government—very similar to the National Health Service when it was implemented in the United Kingdom—and physicians put on salary; in other words, a much more “public” system than the hybrid of, borrowing David Naylor’s memorable phrase, “public payment and private practice,” which ultimately became the Canadian system of Medicare. 27 In recent years, there has been a debate in Canada about the desirability of contracting out to private hospitals and day surgery clinics in order to spur greater efficiencies in Medicare. The assumption here is that hospitals have always been “public” in the sense of being religious, charitable, or municipal not-for profit organizations that were highly subsidized, and thus, it is argued, directed by provincial governments. This is even more apparent in the case of hospitals that were to lose their already limited autonomy and boards to publicly governed regional health authorities in the decade of the 1990s. As Aline Charles and François Guérard demonstrate, however, this narrative is flawed. At least in Quebec, there were a large number of small, private hospitals that

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had contractual arrangements with the government during the early years of Medicare—an arrangement that was permitted by the federal Hospital Insurance and Diagnostic Services Act of 1957. Not counting specialized maternity and chronic care hospitals, there were about 40 small (an average bed count of 27) private-for-profit hospitals. By the 1970s, however, the government of Quebec decided that the private-for-profit hospitals had no useful role in the public system, given their inability— due to size and modest ability to reinvest—to assure the safety of their patients. Stricter health and safety regulations, along with a growing union movement and a consequently higher wage environment, squeezed the lifeblood out of Quebec’s private hospitals. The next group of essays examines the history of Canadian Medicare from the perspectives of those who experienced these events when they were unfolding. Most of the participant experiences are directly related to the laboured birth of universal medical care insurance in Saskatchewan. As a minister in the Douglas and Lloyd governments, Allan Blakeney played a key role during the Doctors’ Strike of 1962. He describes the difficult nature of the struggle from the perspective of a government fighting for the new program, the introduction of which endangered its own survival.28 Betsy Bury experienced the introduction of Medicare as a CCF activist who was a leading proponent of community clinics, the main opposition to organized medicine and a fee-for-service model, in Saskatchewan.29 John Bury was one of the British physicians who moved to Saskatchewan in order to work in one of the community clinics established by doctors sympathetic to Medicare. In the “cold war ” following the Doctors’ Strike and the Saskatoon Agreement, Dr Bury and other proMedicare doctors were refused hospital privileges by a profoundly antiMedicare College of Physicians and Surgeons of Saskatchewan. The situation became so acute that the provincial government established a Royal Commission on Hospital Privileges to provide advice and recommendations on how to sort out the problem.30 Familiar to Canadians as the chair of the Commission on the Future of Health Care in Canada (2001-2) as well as premier of Saskatchewan (1991–2001), Roy Romanow recounts his experiences as a young college student during the Medicare battle in Saskatchewan. After the Doctors’ Strike, he played a direct role as assistant secretary in the Royal Commission on Hospital Privileges. Like many others who experienced this difficult birth of Medicare, Romanow was highly influenced by the experience for the rest of his life.31 Jack Boan was one of five scholarly researchers appointed to the Royal Commission on Health Services chaired by Emmett Hall, and he explains the inner workings of the Hall Commission. Contrary to the expectations

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of organized medicine, the Hall Commission recommended in favour of the Saskatchewan model—universal, single-payer, and publicly administered—rather than augmenting the existing system of employment-based private medical insurance.32 Heather MacDougall concludes with a clarion call for professional historians to devote greater effort on the history of policies such as Medicare, and for policymakers to take this history into account when reforming the system. By reviewing the history of policymaking in Medicare, she explores the extent to which historians and the knowledge of Medicare’s past have been relegated to a back seat by policymakers. At the same time, she shows how the historian’s craft can be used to assist policymakers in the 21st century. ACKNOWLEDGMENTS

I want to thank Heather MacDougall, Gordon Lawson, and Erika Dyck, as well as the two anonymous referees selected by the University of Toronto Press, for their insightful reviews of earlier versions of this introduction. NOTES 1 Carolyn H. Tuohy, “The Costs of Constraint and Prospects for Health Care Reform in Canada,” Health Affairs 21, 3 (2002): 32-46. On Saskatchewan, see Duane Adams, “The White and the Black Horse Race: Saskatchewan Health Reform in the 1990s,” in Howard Leeson, ed., Saskatchewan Politics: Into the Twenty-First Century (Regina: Canadian Plains Research Center, 2001), p. 267-93; and Amanda M. James, “Closing Rural Hospitals in Saskatchewan: On the Road to Wellness?” Social Science & Medicine 49, 8 (1999): 1021-34. On Ontario, see Duncan Sinclair, Mark Rochon, and Peggy Leatt, Riding the Third Rail: The Story of Ontario’s Health Services Restructuring Commission, 1996-2000 (Montreal: Institute for Research on Public Policy, 2005). 2 Robert J. Blendon, John Benson, Karen Donelan, Robert Leitman, Humphrey Taylor, Christian Koeck, and Daniel Gitterman, “Who Has the Best Health Care System? A Second Look,” Health Affairs 14, 4 (1995): 221-30. 3 On the two opposing perspectives, see Janice C. MacKinnon, “The Arithmetic of Health Care,” Canadian Medical Association Journal 171, 6 (2004): 603-604; and Stuart Landon, Melville L. McMillan, Vijay Muralidharan, and Mark Parsons, “Does Health-Care Spending Crowd Out Other Provincial Government Expenditures?,” Canadian Public Policy 32, 2 (2006): 121-42. 4 Gerard W. Boychuk, National Health Insurance in the United States and Canada: Race, Territory, and the Roots of Difference (Washington, D.C.: Georgetown University Press, 2008); Antonia Maioni, Parting at the Crossroads: The Emergence of Health Insurance in the United States and Canada (Princeton: Princeton University Press, 1998). 5 C. David Naylor, Private Practice, Public Payment: Canadian Medicine and the Politics of Health Insurance, 1911-1966 (Montreal and Kingston: McGill-Queen’s University Press, 1986). 6 See Aleck Ostry, Change and Continuity in Canada’s Health Care System (Ottawa: CHA Press, 2006), the most recent historical overview written by an epidemiologist and health-care policy expert. 7 Malcolm G. Taylor, Health Insurance and Canadian Public Policy: The Seven Decisions That

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Created the Canadian Health Insurance System, 2d ed. (Montreal and Kingston: McGillQueen’s University Press, 1987). See A. Paul Williams, “In Tribute to Malcolm Gordon Taylor, 1915-1994,” Health and Canadian Society 3, 1-2 (1995): 9-12. 8 See André Braën, “Health and the Distribution of Powers in Canada,” and Howard Leeson, “Constitutional Jurisdiction over Health and Health Care Services in Canada,” in Tom McIntosh, Pierre-Gerlier Forest, and Gregory P. Marchildon, eds., The Governance of Health Care in Canada (Toronto: University of Toronto Press, 2004), p. 25-82. 9 Gregory P. Marchildon, “Health Care,” in John C. Courtney and David E. Smith, eds., The Oxford Handbook of Canadian Politics (Oxford: Oxford University Press, 2010), p. 43450. 10 Gwendolyn Gray, Federalism and Health Policy: The Development of Health Systems in Canada and Australia (Toronto: University of Toronto Press, 1991). In her work, Carolyn H. Tuohy also addresses the nature of federalism and the interplay between central and sub-state governments: Accidental Logics: The Dynamics of Change in the Health Care Arena in the United States, Britain, and Canada (New York: Oxford University Press, 1999). 11 Commission on the Future of Health Care in Canada, Building on Values: The Future of Health Care in Canada (Saskatoon: Commission on the Future of Health Care in Canada, 2002), p. 36. 12 Tuohy, “The Costs of Constraint.” 13 Gregory P. Marchildon, Health Systems in Transition: Canada (Toronto: University of Toronto Press, 2006), p. 54-59. 14 Gregory P. Marchildon, “The Douglas Legacy and the Future of Medicare,” and Robert G. Evans, “Economic Myths and Political Realities: The Inequality Agenda and the Sustainability of Medicare,” in Bruce Campbell and Gregory P. Marchildon, eds., Medicare: Facts, Myths, Problems, Promise (Toronto: Lorimer, 2007), p. 36-41 and 113-55. Gregory P. Marchildon, Health Care in Canada and the United States: Consumer Good, Social Service or Right of Citizenship? (Phoenix: Arizona State University, Roatch Global Lecture on Social Policy and Practice, 2006). 15 For examples of this position, see David Gratzer, ed., Better Medicine: Reforming Canadian Health Care (Toronto: ECW Press, 2002). 16 The term “single payer system” has been regularly used by Americans since the 1990s to describe the Canadian system as a middle ground between publicly financed and delivered systems on the one hand and privately financed and delivered systems on the other. See Carolyn H. Tuohy, “Single Payers, Multiple Systems: The Scope and Limits of Subnational Variation under a Federal Health Policy Framework,” Journal of Health Politics, Policy and Law 34, 4 (2009): 453-96. 17 Naylor, Private Practice, Public Payment, p. 191. In 1960, a Gallup poll demonstrated six out of ten Canadians supported a comprehensive government-run medicare plan, even if this required an increase in taxes. 18 Robin F. Badgley and Samuel Wolfe, Doctors’ Strike: Medical Care and Conflict in Saskatchewan (Toronto: Macmillan, 1967); Edwin A. Tollefson, Bitter Medicine: The Saskatchewan Medical Care Feud (Saskatoon: Modern Press, 1964). 19 P. E. Bryden, Planners and Politicians: Liberal Politics and Social Policy, 1957-1968 (Montreal and Kingston: McGill-Queen’s University Press, 1997). 20 See Tom Kent, A Public Purpose: An Experience of Liberal Opposition and Canadian Government (Montreal and Kingston: McGill-Queen’s University Press, 1988), p. 366-67; and A. W. Johnson with Rosemary Proctor, Dream No Little Dreams: A Biography of the Douglas Government of Saskatchewan, 1944-1961 (Toronto: University of Toronto Press, 2004), p. 259-301. 21 In this sense, Taylor’s narrative of the history of Medicare follows his personal narrative in that he completed his PhD in political science at Berkeley on the Saskatchewan Hospital Services Plan (completed in 1949), was the Research Director of the Saskatchewan Health Services Planning Commission (1948-51), and a consultant for the government of Ontario in the 1950s and 1960s as well as the Hall Commission (1961-64). John A. Boan, entry for “Maldolm G. Taylor (1915–94)” in Encyclopedia of Saskatchewan (Regina:

18

22

23 24

25

26 27 28 29

30 31 32

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Canadian Plains Research Center, 2005), p. 926. Archives of Ontario, RG 3-23, Premier Leslie M. Frost Papers, B292341, Malcolm G. Taylor’s report on health insurance. See Joan Feather’s two articles: “From Concept to Reality: Formation of the Swift Current Health Region,” Prairie Forum, 16, 1 (1991): 59-80; and “Impact of the Swift Current Health Region: Experiment or Model?” Prairie Forum, 16, 2 (1991): 225-48. C. Stuart Houston, Steps on the Road to Medicare: Why Saskatchewan Led the Way (Montreal and Kingston: McGill-Queen’s University Press, 2002). Robin F. Badgley and Samuel Wolfe, Doctor’s Strike: Medical Care and Conflict in Saskatchewan (Toronto: Macmillan of Canada, 1967); Stan Rands, Privilege and Policy: A History of Community Clinics in Saskatchewan (Saskatoon: Community Health Co-operative Federation, 1995). See Gregory P. Marchildon, “Private Insurance for Medicare: Policy History and Trajectory in the Four Western Provinces,” in Colleen M. Flood, Kent Roach, and Lorne Sossin, eds., Access to Care, Access to Justice: The Legal Debate over Private Health Insurance in Canada (Toronto: University of Toronto Press, 2005), p. 429-53. Cam Traynor, “Manning against Medicare,” Alberta History, 43 (1995): 7-19. Naylor, Private Practice, Public Payment. For a lengthier account, see chapters 4 and 5 of Allan Blakeney, An Honourable Calling: Political Memoirs (Toronto: University of Toronto Press, 2008). The rise of the community clinics, and the relationship between clinic advocates and physicians on the one hand and the government and organized medicine on the other, remains an under-analysed aspect of the history of Medicare. For a summary of the limited literature as well as a scholarly history of the clinics, see Gordon S. Lawson and Luc Thériault, “Saskatchewan’s Community Health Service Associations: An Historical Perspective,” Prairie Forum 24, 2 (1999): 251-68. Saskatchewan Archives Board, Regina, A. E. Blakeney papers, R353, 138, Woods Royal Commission on Hospital Privileges. See Gregory P. Marchildon, “Roy Romanow,” in Gordon L. Barnart, ed., Saskatchewan Premiers of the Twentieth Century (Regina: Canadian Plains Research Center), p. 356-58. Canada, Royal Commission on Health Services (Ottawa: Government of Can-ada, Volume 1, 1964). On Emmett Hall as Chair of the Royal Commission, see Dennis Gruending, Emmett Hall: Establishment Radical (Markham, Ont.: Fitzhenry and Whiteside, 2005); Frederick Vaughn, Aggressive in Pursuit: The Life of Justice Emmett Hall (Toronto: University of Toronto Press, 2004).

PART ONE National History of Medicine

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2 The Foundations of National Public Hospital Insurance ALE C K OST RY

INTRODUCTION

According to Robert Putnam,1 “history matters.” Increasingly social scientists point to the need for a historically informed view of social policy. Historical institutionalists demonstrate that national health policies can be best explained through historical analysis which outlines the sequence and timing of major shifts, particularly at critical junctures, in health policy.2 These theorists also state that major changes in national health policy, such as the establishment of a public health insurance system, will occur infrequently.3 Furthermore, the rare windows of opportunity which allow these “earthquake” sized health policy events to occur will usually open under the pressure of a much broader set of social and historical conditions than those at work within the arena of health policy and these will structure the form that national health policies take.4 They also theorize that once such a health policy change has occurred, a new mix of institutional and political parameters arises shaping, in turn, a novel set of policy opportunities and constraints and a new inherent policy logic and development path which preclude certain future policy directions and enhance others.5 Historical institutionalists who have investigated health policy in Canada generally agree that one of the major critical junctures in the history of post-World War II health policy was the enactment in 1957 of the national hospital insurance plan which forbade the operation of private markets for hospital services and which became the model for comprehensive national medicare.6 In this paper, I argue that understanding why a national hospital insurance program was taken up by governments in the late 1950s (i.e., understanding why this was a critical and successful juncture in the history of health policy in Canada) requires a deeper analysis of the history of evolution of hospitals and hospital

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financing in the first half of the 20th century. In particular, it requires analysis of the foundations of the public hospital insurance system in Saskatchewan in 1947 and the reasons for its subsequent success and it requires exploration of the reasons why other provinces opted for a public hospital insurance plan in the late 1950s along the lines of the Saskatchewan model. To different extents in various regions and cities in Canada, hospitals had by the 1920s, moved from their 19th-century absolute reliance on government, religious institutions, and charities for money and began increasingly to source private funds. The hospital financing model (a mix of private and usually inadequate public financing of hospitals) that had evolved by the late 1920s in Canada failed miserably during the Depression. However, in the 1930s, the almost entirely public hospital system that had emerged in rural parts of Saskatchewan proved quite resilient. The expansion and consolidation of this rural model of hospital financing in the form of the Saskatchewan public hospital plan in 1947, its enthusiastic acceptance by the public and by the province’s medical profession, and its potential to solve, at least in the short term, the long standing problems of hospital financing for other provincial governments were key to provincial government acceptance of a fully public national hospital insurance plan in 1957. This paper first describes the development of two-tiered hospitals in many Canadian cities to the 1920s. The second section illustrates the chronic fiscal problems these two-tiered institutions faced and demonstrates the failure of this model of hospital financing under the economic stress of the Depression. The third and fourth sections of the paper shift to a discussion of Saskatchewan focusing on the roots of the rural hospital system and the implementation of a province-wide public hospital insurance plan. The fifth section outlines the continuing fiscal stresses facing hospitals in provinces without public or with partly public hospital insurance plans in the 1950s as they faced postwar pressures with inadequate financing mechanisms derived from the Victorian era. The final section outlines the main reasons why all the provinces signed onto a national public hospital insurance plan. The purpose of this paper is to provide the background to provincial and federal government acceptance of a national public hospital insurance plan in Canada. FROM ONE- TO TWO-TIERED HOSPITALS

In the mid-19th century public general hospitals were used only by the sick poor. Hospitals held little interest for most physicians who continued to treat patients in their offices, in patients’ homes, and in small private hospitals. However, between 1890 and 1910, hospitals evolved into two-tiered institutions with one tier, the public wards, for the indi-

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gent poor rigidly segregated from a second, new tier, catering to feepaying patients in semi-private and private beds. During this time, the new two-tiered hospitals became increasingly important to the professional and economic lives of physicians.7 There are several reasons for the early 20th-century move towards establishing two-tiered hospitals. First, with the opening of nursing schools and the professionalization of hospital administration beginning in the 1880s, hospitals became more organized, efficient, clean, and financially viable. Second, the acceptance by the medical profession of the germ theory by the 1890s and the subsequent greater use of asepsis, combined with advances in anaesthesia and better surgical instruments, meant that physicians were able to perform surgery with relative safety in hospitals. Third, these advances in medical and hospital technology occurred as medical education shifted to a firmer scientific foundation improving the quality of medical graduates. Fourth, the growing technical capabilities of medicine practiced in the new hospitals increased the prestige of both the medical profession and hospitals attracting philanthropic donations for hospital equipment and plant and increasing the appeal of hospital-based treatment to fee-paying patients.8 Finally, because of these improvements, surgeons increasingly operated in hospitals, so their patients were admitted for short stays which required a new type of hotel-style accommodation and service physically separated from the public wards. This was effected by constructing semiprivate and private rooms, wards, and even entire wings, which were built into new hospitals and added into old ones as the hospital system expanded in the late-19th century and, as nursing and ancillary services were re-oriented to handle the new “hotel” functions required on the private wards. The expansion of hospitals, although economically dependent on fee paying patients, was not driven solely by them. The Canadian population doubled in the last half of the 19th century with much of the growth due to immigration, particularly after 1885. As well, industrialization and the associated movement of people from countryside to city and town produced an increasingly important and growing urban working class.9 As this group grew in size, it required access to healthcare. In other nations, particularly in Britain, at this time, workers had banded together in Friendly Societies to obtain limited hospital insurance coverage.10 Canadian workers did not develop these organizations to the extent that many of their European counterparts did and often obtained treatment on the public wards when they could not afford to pay the hospital and physicians fee. The new working poor lived in the poorest and most unsanitary neighbourhoods in Canada’s rapidly industrializing cities and were part

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of the public health crisis to which reformers directed their attention and to which the expanding hospital infrastructure was increasingly seen as the solution. These people were, though perhaps not “respectable,” among the “deserving” poor, with higher social standing than charity patients, most of whom were viewed as delinquent, malingering, or otherwise “undeserving.” EMERGING PROBLEMS IN HOSPITAL FINANCING

While the securely wealthy and the upper-middle classes were well served by the upper tier of the new hospitals, patients of more moderate means faced uncertainty on several accounts.11 Such patients might, in this era of no insurance, be hospitalized for long periods of time. The fee would consume the patient’s marginal extra income (which would be fading rapidly because he/she was no longer working) and, as stay lengthened and ability to pay evaporated, the patient would be faced with the humiliation and health risk of transfer to a public ward. For economically marginal people who were already ill, prolonged hospitalization increased the probability of their eventual transfer to the lowest tier in the hospital. As well, healthy but economically marginal people were vulnerable to adverse economic cycles which could price them into the charity wards. Such uncertainty was psychologically difficult to handle as the working poor began to expect access to hospitals and physicians and to be treated better than the charity cases. Meanwhile, the problem of the growing numbers of marginal feepaying patients and their potential to swing from semi-private to charity status also had important implications for their physicians. General practitioners had worked hard to ensure, by 1915, that Canadian hospitals were open (i.e., that fee-paying patients be allowed their choice of doctor and not have these limited to the hospital-based specialists).12 However, even after general practitioners won hospital privileges, the charity wards remained a threat to their income. When their marginal patients faced economic difficulties and could not afford hospital fees, they could be treated at no charge in the public wards. Thus, during an economic downturn, the two-tiered system did not work effectively either for economically marginal patients or for many of the general practitioners who treated them. The financing of the system was also flawed for the hospitals. On the one hand, they were held to their charitable obligations through legislation passed by municipal and provincial governments that continued to undersubsidize the true cost of indigent care. On the other hand, hospitals were engaged in a competitive business acquiring the latest diagnostic equipment (e.g., expensive new x-ray technology became de rigeur in hospitals by 1915) and building private wings, in order to maintain and expand access to private fee-paying patients.

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In spite of the cost savings due to captive nursing schools, as hospital expenses accelerated by the end of the first decade of the 20th century, the gap between the government subsidies for indigent care (which rose only very slowly during this time) and the costs of their care grew and were therefore increasingly cross-subsidized by fees from private patients.13 The situation was tenable when the economy was good because the proportion of fee-paying patients expanded while the proportion of charity cases contracted. This created a virtuous circle lowering pressure on fees because the need for cross-subsidizing charity cases was reduced, which stabilized the size of the potential pool of private patients. However, with recessions, economically marginal patients went to the public wards and as the charity case load grew, fees had to be increased, reducing the pool of private patients by pricing more marginal patients out of the private wards, turning what was a virtuous circle into a vicious one. From the end of the depression of the mid-1890s until the Great War, this circle was more virtuous than vicious. For example, in 1900, Ontario’s public hospitals had an income of approximately $600,000, of which patient fees contributed about one-third, increasing, by 1915 to $2.5 million, by which time approximately half of the provinces’ public hospital system’s income was obtained from fees paid by private patients.13 However, from the end of the Great War until 1925, wartime inflation persisted, unemployment remained high, the economy stayed in recession, and the number of indigent poor rose in many Canadian communities. (The roaring 1920s is a misnomer. The 1920s were economically difficult in Canada except for the years 1926 to 1929 when a small recovery occurred). The resultant increase in admissions of inadequately subsidized indigent patients reversed the trend of the previous 35 years as private patients were increasingly displaced. Predictably, hospitals raised the fees for the remaining private patients in order to make ends meet, pricing some of them out of the market for hospital care, further decreasing the proportion of private patients in hospitals. In the 1920s, after several years of modest surpluses, many hospitals began to incur sizeable deficits that the brief economic recovery between 1926 and 1929 did not relieve.14 As the pool of private patients shrank, the Canadian Medical and Canadian Hospital Associations argued that indigent patients took too large a share of hospital beds and that the principle of private fee-paying patients supporting treatment, particularly for the “undeserving poor” who “cannot or will not pay” was not justified.15 As well as suggesting strategies to “weed out” those among the charity cases who were perceived as malingerers, hospital and physicians’ associations pleaded with governments to reduce or free hospitals from their statutory

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responsibilities for indigent care and to play a stronger role in financing hospitals by increasing their subsidies and by distributing the tax burden for indigent care across more and higher levels of government. In 1928, the Ontario Hospital Association asked the provincial government to change existing legislation to distribute the full costs of treating these patients across provincial and municipal levels of government and agencies such as the Workmen’s Compensation Board.16 Instead, in 1931, the worse year of the Depression, the government repealed the Hospital and Charitable Institutions Act, replacing it with the Public Hospitals Act, which increased municipalities’ financial responsibility for the hospital care of indigents but without increasing the subsidy. As unemployment mounted, by 1935, the proportion of indigent patient days in Ontario hospitals reached 63%. The Depression worsened the financial crisis in the hospital system, lending urgency to ensuing debates over social and economic responsibility for health care in general and for hospital care in particular.17 By the end of the Depression, political, economic, and social conditions in Canada had shifted as physicians, hospital organizations, and the general public increasingly expected government to intervene by expanding the hospital infrastructure and supporting this with large subsidies from the public purse.18 Meanwhile in Saskatchewan, local governments had, as early as the 1920s, begun to take action. SASKATCHEWAN’S HOSPITAL INSURANCE SYSTEM IN THE INTER-WAR YEARS

In rural Saskatchewan by the 1920s, a unique system of hospital financing based on pooling of funds across several municipal and regional governments was entrenched. The provincial legislature facilitated the early development of “hospital co-ops” in 1916 when it provided municipalities with the authority to band together to form Union Hospital Districts. A Union Hospital District was essentially a co-operative consisting of several rural municipalities which banded together to expand the tax base for the construction and operation of rural hospitals. By 1920, there were 10 of these in the province and by 1944, there were 23.19 The legislature gave the UHDs authority to tax local property owners to finance the construction and operation of hospitals. Until 1934, property owners were the tax base. However, in 1934 the Rural Municipality Act was amended so rural municipalities could assess non-property owners a flat hospital tax. Through the Municipal Medical and Hospital Services Act of 1939, municipalities raised taxes from both property and individuals. Thus, by the end of World War II, many rural municipalities had developed fairly sophisticated local infrastructures and expertise

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for the purpose of tax collection and the management and operation of hospitals.20 Even with the passing of the Municipal Medical and Hospital Services Act, which gave rural municipalities an expanded tax base to fund their public health services, rural municipalities were still hard pressed to fund these appropriately. However, rural municipalities had a strong political voice in the province as they had their own co-op, the Saskatchewan Association of Rural Municipalities (SARM). SARM was a strong political voice which pushed consistently, throughout the depression years, for provincial and federal government funding for hospitals and medical care in order to relieve financial pressure on rural municipalities. Residents of rural Saskatchewan also developed a co-operative solution to pay doctors. This became known as the Municipal Doctor System (MDS). The first MDS was established in 1914 when the municipality of Sarnia, which was about to lose its physician, offered him a $1,500 annual salary to stay. Sarnia offered the contract without provincial legislative approval. In 1916, the legislature gave municipal councils authority to levy a tax to pay for doctor services and by 1931, 52 municipalities had contracts for service with physicians.21 Thus, by the 1940s, local government in many rural regions of the province had made hospital care and doctors’ services available at relatively low cost to most residents within their jurisdiction. While rural Saskatchewan was the site of innovations in the public financing of hospital care, private insurance plans had been established by 1939 in the cities. In 1939, a group of Regina laypersons established a medical insurance plan and began to hire doctors and pay them on a salary rather than fee-for-service basis. By 1945, there were four insurance plans in the province covering approximately 50,000 people for both hospital and physician’s services.22 Two of these companies, Medical Services Incorporated (MSI) and Group Medical Services (GMS) were controlled by the medical profession and became the largest plans in the province. They paid doctors on a fee-for-service basis and by the mid-1940s had enrolled approximately 6% of the population.23 Thus, by war ’s end, while rural places were largely served by systems of local and public hospital financing, private hospital insurance plans had gained a toehold but only in Regina and Saskatoon. THE SASKATCHEWAN PUBLIC HOSPITAL INSURANCE PLAN

The Co-operative Commonwealth Federation (CCF) became the first socialist government elected in North America when it won the Saskatchewan provincial election in 1944. One of the first things Tommy Douglas did upon taking office in 1944 was to establish the Health Serv-

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ices Planning Commission (HSPC) in order to plan initially for the introduction of state-funded hospital insurance and the subsequent development of comprehensive public health insurance. The HSPC moved quickly and radically so by 1947, many of the major CCF health reforms had been set in motion.24 Within two years the HPC had surveyed all of the province’s hospitals, devised a hospital insurance scheme, and set up the infrastructure to collect hospital taxes (using the municipal tax gathering system already in place over most rural regions in the province), sign up beneficiaries, and pay the hospitals. The province also set up a system of capital grants (four years in advance of the 1948 federal grants) to encourage the building and upgrading of hospitals. When the CCF took power in 1944, they expected to obtain federal cash to establish a system of insured medical and hospital care simultaneously and within a few years. At the 1945 federal/provincial constitutional conference, Saskatchewan was enthusiastically in favour of the health proposals as it deemed federal financing as key to moving forward within the province on a combined public insurance plan for both hospital and physicians services. However, because of federal foot dragging in general and the collapse of the 1945 federal/provincial constitutional conference in particular, this did not happen and instead the CCF could not afford to implement comprehensive public health insurance and began with a province-wide system of comprehensive public hospital insurance.25 The operation of a system of hospital insurance on its own and the establishment of hospital construction grants resulted in an infusion of capital into the hospital infrastructure. After establishing the Saskatchewan Hospital Insurance Plan (SHIP) in 1947, the injection of public money via the government hospital construction grants led to an immediate and rapid expansion of the hospital infrastructure and utilization across the province. The capitalization and expansion of the hospital infrastructure in terms of plant and personnel were unparalleled in Saskatchewan compared to any other province in the 1950s, as both hospital construction grants and SHIP funnelled public money into the hospital system.26 In 1947, the number of rated beds per 1000 people in the province was 5.1. This figure peaked at 6.7 in 1951, an increase of 31%. The total availability of beds shot up in this five-year period and the intensity with which patients who were in these beds were serviced also increased dramatically, from 1678 to 2209 days of patient care per 1000 beneficiaries (an increase likewise of 31%). This increase in utilization of hospital services may have been due to the unmet need within the population which had, relative to other parts of Canada, experienced such huge deprivation due to the depression and war.27

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This turn-around in infrastructure enhanced the ability of doctors to practice their craft. More hospitals, more beds, and more equipment meant greater publicly funded access to the tools of the doctor’s trade. This expansion in infrastructure and financing of hospital care helped bring doctors back into the province as many had left in the Depression due to severe economic hardships they faced. Although the population of Saskatchewan increased by only 11% between 1949 and the eve of the doctors’ strike in 1962, the number of doctors practising in the province increased by 43%, from 614 to 881.28 While the increase in the number of doctors practising in the rest of Canada was similar to the increases in Saskatchewan, the population in the rest of Canada grew at almost twice the pace that it did in Saskatchewan during this time.29 These data illustrate that, relative to other parts of Canada, the hospital infrastructure and the rate at which it was utilized expanded dramatically following the introduction of hospital construction grants and SHIP, and that these high utilization rates continued throughout the 1950s. This means that doctors were admitting patients into the province’s hospitals in numbers and at rates far greater than pre-SHIP averages and much higher than national averages. This injection of public funds enhanced the doctors’ ability to deliver services and their potential for increasing the range of services provided. It is no wonder that, by 1958, Saskatchewan doctors were the best paid in the country.30 During the 1950s, private hospital and physician’s insurance plans expanded dramatically across Canada. While the establishment of SHIP made it illegal to provide private hospital insurance for most hospital services in Saskatchewan, as in the rest of the country, private insurance plans for physician’s services expanded rapidly in the province. Although the growth of these private plans occurred mainly in the cities, they made some inroads in rural areas as the insurance companies made a deliberate attempt to slow both the spread of the MDS and UHD schemes. By 1955, the private plans for physician’s services had been negotiated with 60 out of approximately 180 rural municipalities, towns, and villages.31 Thus, the early expansion in UHDs and MDSs following the CCF ascension to power began to slow and reverse itself after 1948. Some rural municipalities abandoned their MDS in favour of private plans partly because “of the improvement of highways throughout the province and the corresponding desire of the people for the services of specialists who are located in the larger cities.”32 Clearly such improvements had increased the expectations of rural residents. The private plans gave the municipality a way of meeting these higher expectations as they could buy a range of specialist services not available under the less flexible MDS. Of course, because the plans usually had exclusions and conditions, a municipality purchasing such a plan usually reduced the scope of coverage in the community.

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The CCF made half-hearted efforts to stop municipalities from opting out of the MDS by refusing to give a municipality its health grant (used to pay for its doctor) if council contracted with a private plan. Because the health grants were small, many rural councils ignored the government and went ahead without their approval to negotiate with the private plans. By 1955, the MDS system was in decline. Private plans for physician’s services were expanding rapidly and the momentum for change shifted away from the government.33 By 1960, 288,818 people or 31.6% of Saskatchewan’s population was covered by private physician’s health insurance.34 The decade long expansion of a publicly funded hospital insurance system in conjunction with major increases in funding for hospitals, equipment, and personnel greatly enhanced physicians’ ability to practise in Saskatchewan as well as their status and income. The expansion of private plans for physicians’ service during the 1950s had a similar effect so that in 1962, when the CCF attempted to introduce public insurance for physician’s services, the situation was very different than it had been in 1947 on the introduction of SHIP. CONTINUING POSTWAR FISCAL PROBLEMS FOR HOSPITALS

At the end of World War II, new demands for modern healthcare were placed on an aging hospital stock which in provinces other than Saskatchewan, were still subsidized by a fiscal framework originating in the Victorian-era poor laws. By 1950, when the public hospital plan in Saskatchewan was well-established, some of the other provinces had a patchwork of private plans and in some cases (British Columbia and Alberta) fairly extensive public and partially public plans. While the hospital system in Saskatchewan was well funded, hospitals in these and other provinces continued to struggle financially in spite of the ending of the Depression. The new pressures arose for a number of reasons. The 1948 Hospital Grants programs established by the federal government underpinned a massive and historically unprecedented hospital construction boom. The Hospital Grants Program, in existence from 1948 to 1970, was the financial engine that built the current hospital infrastructure.35 The system was built in two stages. The first, from 1948 to 1959, was marked by hospital construction and the second, beginning in tandem with the first but continuing through the 1960s, was marked by rapid expansion in bed capacity. In 1945, there were 1102 hospitals in Canada with a rated bed capacity of approximately 111,000 beds. In the decade following passage of the Hospital Grants Program, an average of 30—mostly general and allied special hospitals—were built each year.36 The building boom peaked at

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1481 hospitals in 1959 at a rated bed capacity of 186,000 beds. Between 1945 and 1959, the number of hospitals increased by a third and the number of hospital beds by two-thirds.37 In the early 1950s, some existing general hospitals were re-classified as allied and allied special hospitals (i.e., chronic, communicable disease, convalescent, maternity, orthopaedic, and unclassified hospitals) and many of these new types of hospitals were purpose built. By 1959, public general hospitals accounted for 70.9% of all hospitals and 51.2% of beds, allied and special hospitals accounted for approximately 20% of all hospitals and 10% of beds and mental hospitals, while constituting only 5.6% of hospitals, had approximately one-third of hospitals beds. The remainder were tuberculosis hospitals and beds.38 The main change in the infrastructural mix during the 1950s was the increase in the number of public general hospitals, the rise of many, fairly small, allied and special hospitals, and the beginning of the end of the tuberculosis hospitals which had been a feature of the Canadian hospital system for 40 years.39 The tuberculosis hospital system peaked in terms of the number of beds in 1953 and over the next decade virtually disappeared as effective preventive and treatment measures were discovered and instituted.40 The mental hospital system continued to expand, reaching its peak bed capacity in 1961 when, as in the interwar years, mental hospital beds still accounted for one-third of all Canadian hospital beds in spite of the large increase in all hospital beds during the 1950s.41 In spite of the fact that growth in bed capacity outstripped population growth, during the first half of the 1950s, admission rates rose rapidly (at a rate of 3.6% per year) reaching 138 admissions per 1000 in 1955. Over the next 10 years, in spite of passage of national health insurance legislation in 1957, admissions rose more slowly (at 1% per year) only to increase again after the introduction of Medicare across most provinces in 1969. Although the system expanded rapidly in the 1950s, these new hospitals were still operated by a funding system left over from the 1920s. As well, rapidly evolving new technology in medical and hospital care placed additional operating and capital burdens on hospitals. And, as already outlined, hospital admission rates began to increase in the 1950s as postwar expectations by the medical profession and the public for highly technical hospital-based care increased. Complicating matters further was the rapidly increasing cost of hospital care. By 1948 in Ontario, for example, the cost per patient day was 14 times greater than it had been at the turn of the century.42 Although the proportion of indigent patients declined after the Depression and the war, accounting, in Ontario, for only 10% of all patients in the province’s public general hospitals by 1950, municipal and provincial grants still

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covered less than half the costs of their care. Costs were greater than for private patients as indigents were usually sicker and had less access to other sources of formal and informal care. Thus, as they expanded rapidly after 1948, hospitals still remained dependent on private funds (i.e., direct fee payments and insurance) to make up this shortfall. Overall expansion of the pool of private funds was helped by a booming economy and the growth in private health insurance plans. In 1950, for example, one in every four private patients admitted to a public general hospital in Ontario carried some form of hospital insurance. The major problem confronting the provinces’ public general hospitals in the face of higher demand for their services was still the unfair system of provincial and municipal grants which forced hospitals to overcharge private patients in order to subsidize the costs of maintaining public ward patients. Even in the late 1950s, the problem of the inadequate subsidy for indigent patients and for patients of moderate means remained unsolved.43 While private insurance plans had expanded enormously in the 1950s, they did not solve the problem of financing for indigent and poor patients who could not afford them, leaving the problem of paying for the care of these people largely to provincial governments. ACCEPTANCE BY THE PROVINCES

By the mid-1950s, while Saskatchewan was the only province with a universal and comprehensive public hospital insurance plan, four provinces had developed partially public hospital insurance plans. The existence of a completely public plan in Saskatchewan and partially public plans in four other provinces meant that by the mid-1950s, approximately one-third of Canadians were covered by some form of public hospital insurance.44 While growth of private hospital plans was not possible in Saskatchewan and while it was somewhat constrained in the four provinces with partially public plans, private hospital insurance continued to expand. Private insurance plans for physician’s services also expanded rapidly in the 1950s. Provinces, particularly those with public and partial public plans, were keener than a decade earlier (when they had been unable to agree at the conference on postwar reconstruction on public health insurance legislation) to obtain help from the federal government in the form of conditional grants to pay for the operation of their growing hospital sectors. The successful implementation and operation of the Saskatchewan hospital insurance plan provided a politically popular and practical public alternative to private hospital insurance and one that dealt effectively with indigent and poor patients. By the late 1950s, conditions were more favourable than they had

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been for some time for implementation of cost-shared federal/provincial programs. This was partly because the postwar economic boom continued with no end in sight and also because political conditions had shifted in Canada, leading to a more co-operative federalism than had been the case during the inter-war years and the 1940s. Five other factors were also key. First, shifts in political leadership at the provincial and federal level ushered in a new era of co-operative federalism providing the political framework for a national plan. Second, the provinces became increasingly interested in a national publicly funded program for hospital insurance. Third, public support for health insurance remained overwhelming and strong. Fourth, the political commitment and expertise of Health Minister Paul Martin (Senior) and his staff ensured that the program was effectively developed at the federal level. Fifth, the public popularity of the 1948 Hospital Grants Program bolstered the potential for political gains for any party bold enough to move to the next level, that is, implementation of a national health insurance plan. In 1949, the Liberal Prime Minister MacKenzie King was replaced by Louis St. Laurent and the Premier of Ontario, George Drew, was replaced by Leslie Frost. The new leaders got on well and the relationship between Toronto and Ottawa improved rapidly in the early 1950s. Canada’s largest province became more supportive of cost-shared programs, including public hospital insurance.45 As well, public support for public medical and hospital insurance was very strong. In a Gallup Poll conducted in 1949 (shortly after the federal election in that year) when asked, “would you approve or disapprove of a national health plan whereby you would pay a flat rate each month and be assured of complete medical and hospital care by the Dominion Government,” 80% of respondents approved.46 Thus, in the early 1950s, four of every five Canadians were in favour of some form of publicly funded hospital and medical care insurance. With the appointment of Paul Martin in 1946 as federal health minister, there was a building of resources in the research division of the ministry. Martin championed the introduction of the Hospital Grants Program in 1948 and continued to strengthen the research and analytical sections within his Ministry through the early 1950s. These resources were focused on further developing an information base and plans for a national public system of hospital insurance. Martin and his staff were particularly keen on developing a hospital insurance plan first as it would protect people from the cost of hospital bills while at the same time solving the problem of hospital deficits. However, while through the 1950s provincial governments and the public were supportive of a national public hospital insurance plan, support, which had been fairly solid among Canadian physicians since the

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mid-1930s, had evaporated. In 1934, the Canadian Medical Association had developed and advocated its own plan for “State Health Insurance” and actively supported the federal government’s postwar public health insurance plan.47 But in 1949, the Association withdrew its support for public health insurance for physician services declaring “that the role of government should be limited simply to paying to the voluntary plans the premiums, in whole or in part, on behalf of those unable to pay the full amount.”48 In 1956, with the private insurance sector building momentum, the association voted to withdraw its support, which it had previously pledged, for a national public hospital insurance plan. In spite of this opposition, the Hospital Insurance and Diagnostic Act was passed unanimously in Parliament in April 1957. Ottawa agreed to pay provinces 25% of national average per capita “eligible” hospital costs and 25% of the provinces’ average per capita “eligible” hospital costs multiplied by the number of insured persons.49 In return, the provinces agreed to establish insurance plans that were accessible throughout the province on uniform terms and conditions, would guarantee access for in-patient diagnostic services (with out-patient treatment to follow), cover at least 95% of the province’s residents, and that were portable across provinces. The 1957 Hospital Insurance Program absorbed and largely replaced the 1948 National Hospital Grants Program and by 1961 all provinces had agreed to join the plan.50 When the provinces joined the National Hospital Insurance Program, certain conditions were imposed on them by the federal government. They were required to introduce a comprehensive system of standards including licensing for their hospitals. They were also required to submit to a detailed annual federal audit of hospital expenditures in order to provide expenditure estimates so that these could be matched. In this way, the federal government ensured transparency and accountability of transferred matching federal funds. Over the next decade, the federal audit was increasingly viewed as an imposition and as constitutionally unwarranted interference in provincial autonomy. The condition that hospital insurance be made available universally and offered under uniform terms and conditions, as laid down in the 1957 Hospital Insurance and Diagnostic Services Act, prevented any province from adopting the Canadian Medical Association’s private plans with government subsidy for people with low income. Such a plan would have violated the principle that hospital insurance should be available to the entire population on “equal terms and conditions.” Thus, the federal condition of universality, offered under uniform terms and conditions, ensured public financing of hospital insurance in all the provinces as it excluded private insurance companies. The Canadian Sickness Survey conducted in early 1950s played an important role in the federal decision to adopt an entirely public hospi-

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tal insurance plan. This survey of 36,000 people, the first nationally representative investigation of the health and insurance status of Canadians, found “an inverse relationship between income and sickness and a direct relationship between income and volume of healthcare received.”51 In other words, the poor were both sicker and less likely to have health insurance than the rich.52 Those in the population who needed health insurance the most did not have it. As Taylor and many others have pointed out, it is “the combination of these two that creates the economic problem of medical care.”53 Most importantly, because it was representative of the whole population, the survey demonstrated that the number of poor sick people with no hospital insurance was so large, that the subsidy for private hospital plans would be more than previously realized and much greater than claimed by the Canadian Medical Association.54 This, and the efficiencies promised by the establishment of a single administration for public insurance in each province, persuaded the federal government to establish a single public system rather than a system of subsidies for many private plans. As well, the decreasing incidence of infectious diseases, with the epidemiological transition well underway by the 1920s, reduced the average lengths of stays in hospitals. The burden in the hospitals of long-stay patients with infectious illnesses began to drop. At the same time, through the 1930s and 1940s, women had been birthing in increasing numbers in the hospitals. By the end of the 1950s, over 95% of births occurred in hospitals and maternity patients represented about one in five admissions.55 With the rapid increases in life-expectancy through the 1930s and 1940s and the lack of alternatives for the elderly, by the 1950s hospitals were also rapidly filling with elder patients largely with chronic rather than acute healthcare needs. In the postwar decades, hospitals increasingly became the place where the elderly went to die. These new and growing demands for service on hospitals, in conjunction with the sheer pace of expansion in hospital infrastructure also ratcheted up pressures on provinces to solve the chronic financial problems of these institutions. By the late 1950s, as increasingly conciliatory winds blew between Ottawa and provincial capitals, Saskatchewan’s fully public hospital plan looked like a workable solution to Canada’s perennial twin problems of hospital financing and inequitable care for economically marginal Canadians. The two-tiered hospital system, in place in Canada for over 60 years, was about to disappear as new expectations, the success of the Saskatchewan model, the flowering of an age of co-operative federalism and most importantly, the availability of federal funds to help pay for increasing numbers of expensive hospitals, led to the establishment

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of a national public hospital insurance plan all resting on the foundation of the largest expansion in hospital infrastructure in Canadian history. CONCLUSION

By the end of the first decade of the 20th century, many urban Canadian hospitals were two-tiered as their role began to shift from “treating the poor for the sake of charity to treating the rich for the sake of revenue.”56 The public wards were filled with the indigent (and after World War I, with incurable injured and sick veterans) whose care was inadequately subsidized by a combination of municipal and provincial governments and charitable and religious donations and who were cared for by student nurses and house physicians and specialists. These long stay patients were often minimally attended and were responsible for most of the hospitals’ patient days. The development of the nursing profession and its early subordination to the needs of the hospital in the 1890s, along with growing income from private patients laid the foundation for the expansion of the hospital system until the 1920s. In this decade increasing costs, the growing burden of indigent patients, in conjunction with frozen provincial and municipal subsidies for these patients, and decreasing admissions of private fee-paying patients led to hospital deficits. By the Depression, with an even greater burden of indigents and less private fees, hospitals began to revert to their mid-19th-century role as custodial institutions for the sick poor. While some hospitals went bankrupt, total hospital expenditures and the number of hospitals beds increased during the 1930s, likely due to greater utilization by the growing population of unemployed, destitute, and indigent. The post-World War II injection of money into the hospital system through the National Hospital Grants Program resulted in a rapid expansion in the number of hospitals and hospital beds. This created a crisis as provinces struggled to find operating costs for these new beds, a crisis which was only marginally helped by the growth of private insurance plans in the 1950s. While this scenario was the case for many hospitals in Canada, the situation was much different in Saskatchewan’s rural districts. North America’s first comprehensive health insurance system was built on the back of a rural tradition of co-operative economic and institutional development which evolved in the first half of the 20th century in the province of Saskatchewan. These institutions and traditions were unique in Canada and go some way towards explaining why public health insurance system first evolved in this province. While the strength of these rural traditions and institutions was rapidly eroded by the demographic shift from country to city in the 15 years following the end of World War II as well as by increasing postwar

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prosperity derived mainly from the non-agricultural economy, the election of a social democratic government (as well as the fact it managed to remain in power for a sustained period of 16 years) committed to public healthcare insurance, provided the political will and continuity to ensure survival of these older rural traditions in the new public health insurance scheme. In Saskatchewan, with a comprehensive and universal public hospital insurance plan in place in 1947 (and to a lesser extent in those other provinces with partial public plans), municipal government relief from the pressure of providing for indigents was assured as these costs were now spread more evenly across the provincial tax base. However, in those provinces with no public hospital insurance plan, the Victorian era municipal and provincial government funding mechanism still inadequately underwrote costs for indigent care. The Depression brought the difficult financial situation of hospitals into full view. Many hospitals and associated nurse training schools were bankrupted. The financial difficulties facing physicians were so severe that most provincial and the national medical association came out fully in support of public health insurance for both hospital and physician’s services. The war brought full employment and the postwar years brought a population and economic boom both of which lasted until the early 1970s. The 25-year-postwar boom transformed the healthcare system into a modern and co-ordinated one. This was an era of welfare state construction and public hospital and physician’s insurance was its centre piece. The 1948 Hospital Grants Program initiated a hospital construction boom leading to overbuilding of hospitals across Canada. The expansion in the hospital system was unprecedented and replaced much of the building stock constructed in the first major expansion of the Canadian hospital infrastructure in the last quarter of the 19th century. While the 1948 Hospital Grants Program paid the construction costs to increase the size of existing hospitals and build new ones and this and other programs in the 1950s paid to train the increasingly technical healthcare workforce, hospital operating costs were still largely the responsibility of municipalities and provinces. The old financial problems, of how to pay for the sick and indigent in the hospitals, remained unsolved notwithstanding the dramatic expansion of private hospital insurance in the 1950s. Provinces supported the 1957 passage of national hospital insurance legislation because it provided money to operate the increasingly expensive hospital system for which, given the hospital building boom underway, the provinces were increasingly responsible. The hospital system expanded rapidly through the 1950s and 1960s in two phases. The first through the 1950s was driven by the construction of new hospitals while the second was driven more by the increase of

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the numbers of beds in the newly built hospital system. The pace of admissions accelerated the most in the early 1950s (probably tapping unmet need) and in the late 1960s, after passage of Medicare probably as the major financial barriers to access to the healthcare system were removed. The critical juncture in 1957 when provinces moved to sign on to a national hospital insurance plan were founded on another critical junctures; the adoption and successful modeling of a public hospital insurance plan in Saskatchewan. As shown in this paper, the roots of this system of financing had a long history prior to the 1947 implementation of SHIP based on the co-operative traditions in the province. The successful operation of this plan, its ability to both cope with the new postwar demands on hospitals, its high level of both medical and public support and approval, and its rescue of hospitals from chronic financial instability all helped make this model attractive to other provinces in the context of a small window of co-operative federalism and a rapidly expanding economy. NOTES 1 Robert D. Putnam, Making Democracy Work (Princeton: Princeton University Press, 1993), p. 8. 2 J. Haker, “The Historical Logic of National Health Insurance: Structure and Sequence in the Development of British, Canadian, and U.S. Medical Policy,” Studies in American Political Development, 12 (1998): 57-130. 3 Carolyn Tuohy, Accidental Logics: The Dynamics of Change in the Health Care Arena in the United States, Britain, and Canada (New York: Oxford University Press, 1999), p. 113. 4 Haker, “Historical Logic of National Health Insurance,” p. 57-130. 5 Paul Pierson, “When Effect Becomes Cause: Policy Feedback and Political Change,” World Politics, 45, 4 (July 1993): 595-628; Ruth Collier and David Collier, Shaping the Political Arena: Critical Junctures, the Labour Movement and Regime Dynamics in Latin America (Princeton: Princeton University Press, 1991), p. 10-12, 27. 6 Haker, “Historical Logic of National Health Insurance,” p. 57-130; and Tuohy, Accidental Logics, p. 55. 7 David Gagan and Rosemary Gagan, For Patients of Moderate Means: A Social History of the Voluntary Public General Hospital in Canada, 1890-1950 (Montreal: McGill-Queen’s University Press, 2002), p. 40. 8 Aleck Ostry, Change and Continuity in Canada’s Health Care System (Ottawa: CHA Press, 2006), p. 170-71. 9 George Woodcock, Canada and the Canadians (Toronto: Oxford University Press, 1970), p. 194-95. 10 Anne Crichton, David Hsu, and Stella Tsang, Canada’s Health Care System: Its Funding and Organization, rev. ed. (Ottawa: CHA Press, 1994), p. 183. 11 Gagan and Gagan, For Patients of Moderate Means, p. 15. 12 Gagan and Gagan, For Patients of Moderate Means, p. 8. 13 David Gagan, “For Patients of Moderate Means: The Transformation of Ontario’s Public General Hospitals, 1880-1950,” Canadian Historical Review, 70, 2 (June 1989): 151-80. 14 Gagan, “For Patients of Moderate Means,” p. 151-80.

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15 E. E. Dutton, “A Hospital Problem Survey,” Canadian Hospital 3 (1926): 12. 16 Anonymous, “Paying the Hospital Bill,” Canadian Hospital, 4 (1927): 9. 17 Malcolm G. Taylor, “The Hospital Challenge for the Future,” Canadian Hospital, 54 (1957): 33. 18 D. Coburn, G. M. Torrance, and J. M. Kaufert, “Medical Dominance in Canada in Historical Perspective: The Rise and Fall of Medicine,” International Journal of Health Services, 13, 3 (1983): 407-32. 19 Malcolm G. Taylor, “The Saskatchewan Hospital Services Plan: A Study in Compulsory Health Insurance,” PhD dissertation (Berkley: University of California, 1949), p. 83. 20 Ostry, Change and Continuity, p. 24. 21 Malcolm G. Taylor, Health Insurance and Canadian Public Policy, 2d ed. (Montreal: McGill University Press, 1987), p. 70-1. 22 Robin F. Badgley and Samuel Wolfe, Doctors’ Strike: Medical Care and Conflict in Saskatchewan (Toronto, 1967) p. 24. 23 A. Ostry, “The Roots of North America’s First Comprehensive Public Health Insurance System,” Hygeia Internationalis, 2, 1 (2001): 25-44. 24 Duane Mombourquette, “An Inalienable Right: The CCF and Rapid Health Care Reform, 1944-1948,” Saskatchewan History, 43, 3 (Fall 1991): 101-16. 25 Ostry, Change and Continuity, p. 36-37. 26 Thomas H. MacLeod and Ian MacLeod, Tommy Douglas: The Road to Jerusalem (Edmonton: Hurtig, 1987), p. 148-49. 27 E. Tollefson, Bitter Medicine: The Saskatchewan Medicare Feud (Saskatoon, 1963), p. 40. 28 Saskatchewan College of Physicians and Surgeons Brief to the Saskatchewan Government’s Advisory Planning Committee on Medical Care, 1962, p. 39. 29 Ostry, Change and Continuity, p. 38, 121. 30 J. Granatstein, Canada 1957-1967: The Years of Uncertainty and Innovation (Toronto: McClelland and Stewart, 1986), p. 171. 31 Saskatchewan, Public Health Annual Report (Saskatoon: 1955), p. 26. 32 Saskatchewan, Public Health Annual Report (Saskatoon: 1956), p. 25. 33 Ostry, “Roots,” 25-44. 34 Saskatchewan, Public Health Annual Report (Saskatoon: 1956), p. 93. 35 Ostry, Change and Continuity, p. 180. 36 Until 1975, hospitals were classified as general (including paediatric); allied special; mental; or tuberculosis. When hospitals offered more than one type of service, the predominant type is usually applied to the entire hospital. The allied special category includes chronic, communicable disease, convalescent, maternity, orthopedic, and unclassified hospitals. Almost all mental and tuberculosis beds were in public hospitals. Most general beds were also in public hospitals but a significant number were in federal hospitals. Approximately 20% of private beds were in allied special category. See F. H. Lacey, ed., Historical Statistics of Canada, 2d ed., Cat. No. 11-516-XIE (Ottawa: Statistics Canada, 1983). 37 Ostry, Change and Continuity, p. 181. 38 Ostry, Change and Continuity, p. 181-82. 39 As the system expanded in the 1950s the need for quality control and proper methods of accreditation grew. During the 1920s, the American College of Surgeons established an accreditation program for general hospitals which it extended to Canada. But by 1951, accreditation had become too big a task, financially and administratively, for the American College. In the year a commission composed of the Canadian Medical Association, the Royal College of Physicians and Surgeons of Canada, l’Association de Médicines de Langue Francais du Canada, and the Canadian Hospital Association, adopted the standards evolved by the American College of Surgeons over 35 years. By 1954, Canadian survey teams were reviewing Canada’s hospitals. In spite of this, by 1958, only about 37% of eligible Canadian hospitals were accredited compared with 60% in the United States. In 1959, the Canadian Hospital Association assumed

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full responsibility for the survey and accreditation of hospitals in Canada. See D. Woods, “Canadian Council on Hospital Accreditation, Part 1: History and Philosophy of the Council,” Canadian Medical Association Journal, 110, 7 (6 April 1974): 851-52. Statistics Canada and Social Science Federation of Canada, “B141-188. Rated Bed Capacity in Reporting Hospitals, Canada 1932-1975,” in F. H. Lacey, ed., Historical Statistics (Ottawa: Statistics Canada, 1983). In 1942, Canada had 55 mental hospitals growing to 77 by 1957. See D. Conn, “Canadian Mental Health Services,” in Eleanor Sawyer and Marion Stephenson, eds., Continuing the Care: The Issues and Challenges for Long-Term Care (Ottawa: CHA Press, 1995): 209-26. Gagan and Gagan, For Patients of Moderate Mean, p. 73. Ontario Ministry of Public Health, Report of the Ontario Health Survey Committee, Vol. 2 (Toronto: Ministry of Health, 1950). W. Godfrey, The Struggle to Serve: A History of the Moncton Hospital (Toronto: McGill-Queens Press, 2004), p. 152-53. Tuohy, Accidental Logics, p. 49. Tuohy, Accidental Logics, p. 51. Taylor, Health Insurance and Canadian Public Policy, p. 166. R. S. Bothwell and J. R. English, “Pragmatic Physicians: Canadian Medicine and Health Care Insurance 1910-1945,” in S. E. D. Shortt, ed., Medicine in Canadian Society (Montreal: McGill-Queen’s University Press, 1981): 479-94. Malcolm Taylor, M. Stevenson, and P. Williams, Medical Perspectives on Canadian Medicare: Attitudes of Canadian Physicians to Policies and Problems of the Medical Care Insurance Program (Toronto: Institute of Behavioural Research, 1984), p. 5. H. Lazar, F. St. Hilaire, and J. Tremblay, “Federal Health Care Funding: Toward a New Fiscal Pact,” in H. Lazar and F. St. Hilaire, eds., Money, Politics and Healthcare: Reconstructing the Federal-Provincial Partnership (Montreal: Institute for Research on Public Policy, 2004): 189-241. H. Lazar, F. St. Hilaire, and J. Tremblay, “Vertical Fiscal Imbalance: Myth or Reality,” in Lazar and St. Hilaire, eds., Money, Politics and Healthcare, p. 137-82. Taylor, Health Insurance and Canadian Public Policy, p. 177. Robin F. Badgley and Samuel Wolf, “Equity and Healthcare,” in C. David Naylor, ed., Canadian Healthcare and the State: A Century of Evolution (Montreal: McGill-Queen’s University Press, 1992): 193-237. Taylor, Health Insurance and Canadian Public Policy, p. 177. Badgley and Wolf, Équity and Healthcare,” p. 193-237. Ostry, Change and Continuity, p. 246. Paul Starr, The Social Transformation of American Medicine (New York: Basic Books, 1982), p. 159.

3 Into Thin Air: Making National Health Policy, 1939-45 HEATHER MACDOUGALL

On 27 June 1941, at the end of a letter thanking Dr. Gregoire Amyot for sending him information about British Columbia’s health insurance legislation, Dr. John Joseph Heagerty, the long-serving Director of Public Health Services in the federal Department of Pensions and National Health commented: “I do hope the whole thing doesn’t end in thin air.”1 The “thing” was the federal government’s first attempt to create a national health insurance program. Heagerty was prescient in his observation because the proposal that he and his minister, Ian Mackenzie, a Liberal from British Columbia, were formulating would undergo significant modification because of the many challenges of policy making during wartime. World War II was an extraordinary moment in Canadian history because it allowed federal bureaucrats and politicians to break away from traditional neoclassical economic thinking and to attempt to reconceptualize the Canadian federal structure and the roles of each level of government. Beginning with the report of the Royal Commission on DominionProvincial Relations in 1940 and ending with the Dominion-Provincial Conference on Reconstruction in August 1945, health insurance advocates experienced first hand the vagaries of policy formulation as the Advisory Committee on Reconstruction battled with the Economic Advisory Committee2 for control of the federal government’s postwar health agenda. Through this process, Heagerty and his supporters discovered that policy making is contingent on circumstances, personalities, and shifting political tides with the result that the overarching vision presented in 1943 became merely one component of the reconstruction proposals of 1945, due to internal and external opposition and demands for change. By examining the policy making process through Dr. Heagerty’s experience of watching his lifelong ambition disperse into “thin air,” the many threads which explain why carefully constructed and theorized policy proposals fail to get adopted will be woven together. Do these lessons from the past have relevance for us today?

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THE BACKGROUND

Born on 26 December 1879, John Joseph Heagerty was raised in Montreal, received his MD from McGill University in 1905, and then went abroad for a year ’s further study financed by travelling around the world as a ship’s doctor. During his year away, he studied tropical diseases and public health insurance in Germany. After several years of private practice, he was appointed as a federal bacteriologist at Quebec in 1911 to assist with a feared cholera outbreak. He then pursued a diploma in public health at McGill in 1912 and joined the federal government as head of the quarantine hospital at Grosse Isle where he served until sent to Saint John, New Brunswick in 1919 to assist with medical inspection of returning soldiers, their families, and immigrants.3 After a brief period at the Connaught Research Laboratories in Toronto,4 Heagerty returned to Ottawa to become the head of the Venereal Disease Control Division in the newly created federal Department of Health.5 He served as the director from 1920-286 and engaged in crosscountry speaking tours on the subject with Dr. Gordon Bates of the Canadian National Council for the Control of Venereal Disease and the British suffragist, Emmeline Pankhurst, until prohibited from travelling by the Treasury Board, which refused to pay his salary increase unless he remained in Ottawa.7 This was not only an attempt to muzzle a leading expert while apparently promoting the idea of a neutral civil service,8 but also demonstrated the King government’s growing commitment to budget reduction in shared-cost health care programs with the provinces.9 Heagerty, however, was a first generation public health activist and believed strongly in the duty of professionals to engage the public, health care providers, and provincial deputies in discussions about social policy issues. He would champion the cause of a national health insurance program with the same vigour that he had proselytized against sexually transmitted diseases and in June 1943, his dedicated service was recognized by his appointment as a Companion of the Imperial Service Order.10 In addition to his administrative duties, Heagerty was an amateur historian and he published a two-volume history of Canadian medicine in 1928. Four Centuries of Medical History in Canada was based on extensive primary research in the National Archives of Canada, the Quebec Archives, the Montreal Archives, and the Department of Indian Affairs in Washington courtesy of support from his superiors, Dr. John Amyot, the Deputy Minister, and Dr. D. A. Clark, the Assistant Deputy Minister. Although Heagerty dedicated the study to the “medical profession of Canada,” he may well have had a larger audience in view because during the 1930s, he used some of the material from his research for articles on the history of health and disease in Canada that were published in

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the Health League of Canada’s bimonthly magazine, Health, and broadcast nationally on CBC radio.11 In 1940, he produced a shorter version called The Romance of Medicine in Canada whose sales were dedicated to generating funds for the Canadian Red Cross. These literary endeavours revealed his view of the role of the doctor in society. In the foreword to Four Centuries, Heagerty commented that, “The early explorers came to Canada to found a spiritual as well as a material empire.”12 This statement was paralleled in 1940 in his injunction to physician readers to appreciate the historical role of the various denominations in establishing curative and educational institutions, to recognize that disease had been central “in controlling the destiny of Canada” and that “the trend of public health is toward health insurance.”13 For Heagerty, history was destiny and he expected Canada to fulfill its calling by introducing a comprehensive program of health insurance during the war. But would this be possible given the generational and concomitant attitudinal shift that was occurring in various federal departments? And what role did preventive medicine have in the postwar demand for hospital and medical services? CREATING THE ADMINISTRATIVE FRAMEWORK

For a variety of reasons, the Department of Health had been merged with the Department of Soldiers’ Civil Re-establishment in 1927 to create the Department of Pensions and National Health. Resolving conflict over veterans’ pensions, introducing federal cost-shared old age pensions, and cutting overall government spending by uniting administrative functions to cut down the number of federal departments justified unification according to the King administration.14 But also underlying this action was concern about overlapping jurisdiction over health and agriculture. In 1927, each federal department was asked to prepare a memorandum explaining its duties as part of a review of the division of powers during the 60th anniversary of Confederation. Heagerty worked with Amyot to indicate that little duplication of services existed but a decision from the Deputy Minister of Justice, William Stuart Edwards, that the federal health department must limit its role to the powers specified in the BNA Act contradicted the department’s emerging interest in health insurance.15 As part of the reorganization, Heagerty was made Chief Executive Assistant to the Deputy Minister. Through this position, Heagerty became closely involved in the burgeoning quest for health insurance. In 1928 and 1929, the House of Commons Committee on Industrial and International Relations passed motions calling on the Health Department to begin studies on the topic of sickness and disability insurance. As well, the Canadian medical profession was recognizing the need to examine the topic as middle-class patients were find-

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ing the cost of diagnostic services, hospitalization, and medical services increasingly burdensome.16 The Department of Pensions and National Health provided logistical support for the Canadian Medical Associationsponsored Medical Services conferences in 1927 and 1929 and funded the publication of their deliberations. As he had with the anti-VD campaign, Heagerty started to give public addresses extolling health insurance as a solution to the problem of affordable access in the early 1930s in spite of the constitutional constraints.17 Such behaviour demonstrated his personal convictions and close reading of changing public and professional views but did not conform to the quiet, behind-the-scenes activity increasingly expected of senior civil servants. ONE STEP BACK: THE BENNETT YEARS, 1930-35

In July 1930, with the arrival of the Bennett Conservatives in office, the chances of federal action in health insurance diminished as departmental budgets were cut further and staff increases were prohibited.18 Furthermore, the new minister of health, Dr. Murray MacLaren of Saint John, was not interested in the matter and failed to respond to demands for it from medical members.19 The Prime Minister did not view the issue as important until he began to contemplate what became known as his “New Deal.” Indeed in November 1933, he had informed the Royal College of Physicians and Surgeons that Canada was a young country and that its citizens would not support such old world programs as health insurance and state medicine and furthermore, that he had no control over what the provinces wished to do in this area.20 In 1867, the British North America Act had made provision and funding of health services and education principally provincial responsibilities, but by the mid-1930s, many provinces were facing severe difficulties in maintaining them. British Columbia and Alberta had created commissions to examine health problems and both prepared legislation to create provincial health insurance plans. Unfortunately, the United Farmers of Alberta government which passed the first bill supporting contributory health insurance was defeated in August 1935 and its successor, the Social Credit led by William Aberhart, did not implement the legislation.21 British Columbia’s Liberal government under Duff Patullo discovered that public support was not sufficient when faced by opposition from intransigent doctors, the business community, and insurance companies. But was the failure due to the lacunae of the proposed plan or the lack of federal funding to help underwrite its costs? A debtor province like its prairie counterpart, BC had long argued that federal resources should be provided to support the expansion of social welfare programs.22 In response, Bennett and his closest advisors decided to develop a

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Canadian New Deal which would bring federal funding to bear on social issues such as health, employment standards, wages, and hours of work. The Employment and Social Insurance Act was introduced and passed in the spring of 1935, but Pensions and National Health had not been consulted in its preparation.23 Would Heagerty and the Deputy Minister, Dr. Robert E. Wodehouse, have been pleased with a bill which simply required their department to conduct studies into the feasibility of health insurance? Such a prospect is unlikely since the Canadian Medical Association Committee on Economics report of 1934 supported the concept of a national health insurance program, the department was receiving letters from concerned citizens and professionals across the country, and the topic was attracting attention in the daily press and national magazines.24 In the 26 May 1934 issue of Saturday Night, columnist B. K. Sandwell’s article, “The Growing Faith in State Medicine,” was subtitled, “Canadian Opinion Has Changed Remarkably From Hostility to Approval in Past Several Years.” Correctly identifying the Great Depression’s cash nexus as a problem facing both doctors and their patients, Sandwell outlined the Alberta plan in detail, noted that the BC plan was not fully developed and reminded his readers of the success of the British health insurance program that had been functioning since 1913.25 And he noted that Canada and the United States had “been so dilatory in adopting a social reform” that was successful in Britain and on the continent because of their federal structures. But for Sandwell and many others, it was time to rethink the division of powers and revenues because “without financial contribution, unifying influence, and probably also some persuasive leadership from the Dominion, there is little hope of anything being done in this direction in Canada for a good many years.”26 Sandwell’s views appeared to have been negated by Bennett’s legislation but during the Commons discussion of the bill, the Liberal opposition raised the issue of its constitutionality. While Bennett was planning to use recent judicial interpretations which had broadened the scope of federal activity to justify this incursion into provincial jurisdiction,27 the Liberals indicated that they would test the matter in court if their party was returned to office in the upcoming election. In 1935, several new parties contested the general election. On the left, the Co-operative Commonwealth Federation led by James Shaver Woodsworth advocated government control of the economy, efficient planning and socialized health services. In contrast, the Alberta Social Credit called for a social dividend that would put cash in the pockets of desperate farmers and their families and Harry Stevens’ Reconstruction Party argued for legislation which would protect small business from gouging by large corporations.28

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HOPE RENEWED? THE LIBERALS RETURN

The Liberal victory under Mackenzie King resulted in Bennett’s New Deal legislation being sent to the Canadian Supreme Court where it was declared ultra vires in 1936 and then appealed to the Judicial Committee of the Privy Council.29 Through 1936, Heagerty prepared a series of memoranda for his new minister, Charles (Chubby) Power, a decorated war veteran representing a Quebec constituency. The Chief Executive Assistant was also invited to speak on health insurance in Canada and the United States and used these presentations to alert his political head to the rising public interest in the topic. But Heagerty was well aware of the nuances of constitutional boundaries and was careful to indicate that federal action in this field would require provincial co-operation.30 In January 1939, he put together a compilation of the Department’s information on “state medicine, group medicine, group hospitalization, and health insurance in Europe, Great Britain, the British Empire, Canada, and the United States” in preparation for the regular House of Commons debate on the topic. Heagerty used this opportunity to raise questions about the possible development of such policies and programs. After carefully explaining the activities of each province and various professional groups, he pointed out to the Minister that: In recent years in Western Canada many organizations have gone on record in support of some form of state medicine on a province-wide basis…. The humanitarianism behind such plans constitutes a powerful appeal to the imagination and this is one of the factors which sway large conventions and groups to make an insistent demand for social reform of this character. Just because a project is highly desirable does not necessarily mean that it is economically feasible and this point is sometimes overlooked in the eagerness of the wish to put it into immediate operation. Before such beneficial programs are adopted and put into effect, the cost must be counted if there are to be no subsequent regrets. There must not only be a realization of what the cost will be, but also the source of the necessary funds; in other words, who is going to pay, and how. In this connection, it is not amiss to point out that the cost of a province-wide scheme, no matter in what form it may be levied, can only come out of the pockets of the people of that province, at any rate until such time as it may be adopted as a national scheme.31

Such carefully argued support for health insurance was tempered by Heagerty’s awareness that costs escalated when such systems were first introduced. And he well knew the health consequences of 10 years of Depression because throughout that long, dire period, he had been participating in the meetings of the Dominion Council of Health. This consultative body, which consisted of the provincial deputy health ministers, representatives of labour, farmer, and women’s organizations and a scientific advisor discussed current health problems and public health measures intended to alleviate them. But was this type of consensus

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building exercise sufficient to create national standards? And, given the discrepancy, for example, between Saskatchewan’s economic position compared to Ontario’s, how could provincial governments provide equal public services? In part to answer such questions, Mackenzie King established the Royal Commission on Dominion-Provincial Relations in 1937. Initially under the direction of Ontario’s Chief Justice Newton Rowell, and then chaired by Dr. Joseph Sirois after ill-health forced Rowell’s departure, the commission travelled across the country to hear testimony and receive briefs from citizens, voluntary organizations, and provincial and municipal governments.32 But the commission also sponsored research studies by noted Canadian academics including social scientist A. E. Grauer of the University of Toronto.33 Grauer prepared reports for the Commission on housing (1937), labour legislation (1937), public assistance and social insurance (1939), and public health (1939). In his report on Canadians’ health and the public health services that they received, Grauer was careful to credit both the federal and provincial governments with good intentions while noting that their efforts were stymied by lack of funding and the problem of divided jurisdiction. He stated that conditional grants had achieved some advances but noted regretfully that The great argument for a complete programme of public health, however, is not the saving it might make for the public treasury along specific lines, but the increase in health, welfare, and efficiency, it would bring to citizens generally. It is sixty-five years since Disraeli’s famous declaration that “The first consideration of any Government must be the health of the people,” but it is doubtful if that statement can be accepted as true of Canadian governments.34

For Heagerty, this was a personal and professional call to action and the publication of the Rowell-Sirois Report in May 1940 not only added to the momentum that had been building during the 1930s, but also motivated him to work diligently to create a better postwar world. ARMAGEDDON AND HEALTH POLICY

Canada declared war against Germany on 10 September 1939 and on 19 September, Mackenzie King reorganized his Cabinet by shifting Ian Mackenzie from National Defense to Pensions and National Health and making Chubby Power the Postmaster-General. A BC-based MP, Mackenzie was deeply loyal to King but not an effective administrator so he was demoted.35 In spite of this, Mackenzie was writing to King by the end of December about the need for unemployment and health insurance as war measures which would encourage Canadians to participate in the war effort. As reconstruction projects, Mackenzie supported constructing the St. Lawrence Seaway, creating a national housing program,

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providing assistance to municipalities, encouraging land settlement and reforestation, and building national highways. All of these activities were intended to ensure that Canadians did not experience the type of economic collapse which had followed the end of World War I. He asked the Prime Minister for permission to discuss these matters with the Cabinet, since planning for the future was critical, but at this early point in the hostilities few of his colleagues were willing to listen to his arguments that the federal Liberals should take advantage of the presence of Liberal governments in eight of nine provinces to effect change. Undeterred by this lack of political enthusiasm, Mackenzie instructed Heagerty to begin to prepare a national health insurance program. On 10 May 1940, Heagerty forwarded a memorandum to Minister Mackenzie outlining the recent history of federal interest in health insurance. Starting with Mackenzie King’s questions regarding the federal role as envisaged by Bennett’s Employment and Social Insurance legislation, Heagerty moved on to echo BC Provincial Secretary George Weir’s view that Ottawa’s main task was to serve as paymaster while individual provinces developed the programs which suited their populations. Heagerty did not encourage his minister to contemplate amending the British North America Act and generally seemed to favour federal funding and standard setting in tandem with provincial definition and administration. Was native caution reasserting itself? Was Heagerty remaining true to the principles outlined by the Canadian Medical Association Committee on Economics in 1934? Or had he received inside information about the Rowell-Sirois Report’s recommendations? As Douglas Owram and Jack Granatstein have so ably demonstrated, a new generation of mandarins arrived in Ottawa during the late 1930s and through the war. Drawn to the Department of Finance and the Bank of Canada, these young economists were highly educated and dedicated to improving the quality of Canadian life by centralizing economic planning at the federal level.36 One of the leaders of this group, John Deutsch, became Heagerty’s son-in-law on 1 June 1940. As the assistant secretary to the Rowell-Sirois Commission, Deutsch would have been privy to its deliberations and conclusions and may well have discussed some of its recommendations with his future father-in-law. It is equally plausible to suggest, however, that Heagerty’s many years of experience had made him alert to shifting political expectations and also honed his sense of the politically feasible. But now that he finally had a minister who supported health insurance, Heagerty was able to focus his energy and attention on achieving his long-denied goal. The process began with collecting the most recent available information about the existence of voluntary hospital and medical services insurance plans in the various provinces. Here Heagerty could draw on his close ties to Canada’s leading public health professionals. Throughout

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his career, the Director of Public Health Services (1938-45) had argued forcefully for combining curative and preventive services—a view which these colleagues shared. But like them, he also shared organized medicine’s belief that “state medicine” was unacceptable and that medical experts should play a dominant role in the development, delivery, and administration of health insurance programs.37 On 7 January 1941, Heagerty outlined these points as he summarized the views of the small departmental sub-committee on health insurance for Deputy Minister Wodehouse. First and foremost, “The principle of health insurance is approved.” Second, “Health insurance should be closely linked up with public health and form an integral part of it.” The third, fourth, and fifth points argued for administration of the plans by provincial health departments with medical representatives participating and allowing existing voluntary plans to merge with the provincial program. Heagerty and his colleagues, Drs. Ross Millar and F. S. Burke, also urged the inclusion of periodic health examinations, funding for low income Canadians, their families and indigents, and reciprocal arrangements for interprovincial payment of transients’ health care costs. These recommendations reflected the concerns which had been expressed at meetings of the Dominion Council of Health and by members of Parliament during the annual discussions of health insurance in the 1930s. But the crux of the matter lay in the constitutional arrangements. Here the subcommittee carefully hedged its recommendations: 9. The Federal Government might participate in any health insurance scheme inaugurated by a province. 10. If the Dominion Government participates, it should have a supervising interest in order that the provisions of the scheme and its administration should be equalized. The financial support given the provinces by the Dominion should vary with the need of the province. 11. Any health insurance scheme should not be selective but should include rural as well as urban areas. 12. The patient should have free choice of doctors and the doctor should be paid on a fee basis where possible. This should not interfere with existing municipal doctor schemes. In sparsely settled areas where there are no existing medical facilities, salaried doctors should be established.38

Coming one week before the Dominion-Provincial Conference on the Rowell-Sirois Report recommendations, this memorandum clearly outlined the position that Heagerty would continue to argue for the rest of his career. But with the failure of the conference to resolve the respective roles of the two levels of government, Heagerty and his supporters were compelled to focus on building support among various conflicting constituencies. Starting inside the government, Heagerty forwarded a copy of the Canadian Medical Association’s 1934 Committee on Medical Economics

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report to A. D. Watson, the government’s Chief Actuary for his comments. Watson was impressed by the extent of the report and had some sage remarks to make. He queried the stress on solely institutional care, using epidemics and lack of hospital accommodation as an example, and raised the issue of cash benefits. More importantly, he questioned the doctors’ emphasis on income limits. While noting that the new unemployment insurance program limited contributions to those making under $3000 per annum because higher income earners were unlikely to lose their jobs, Watson pointed out that this would not be appropriate for health insurance and suggested a universal approach. To enable wealthier Canadians to receive the standard of care to which they were accustomed, the Chief Actuary recommended allowing them to purchase access to private rooms and other amenities. As well, he urged the Heagerty committee to consider a flat rate contribution similar to those used in Great Britain for sickness and unemployment insurance, provided that it would raise the necessary funds and not be too much of a burden on lower income Canadians. He was skeptical about having the state pay premiums for the indigent and thought that paying for them at the time of service would be more appropriate. To deal with the ongoing problem of medical services in rural or remote areas, he suggested that governments fund the positions and advertise them competitively. To respond to fears that unmet demand would overwhelm existing doctors and hospitals when the plan was first introduced, Watson recommended having small fees or charges which would be phased out as the program matured. After several additional comments, he concluded by suggesting that, “It is just possible that in general a flat rate of income plus smaller fees for service than would otherwise be necessary might be more satisfactory to medical men and at the same time lead to sounder practices. Probably the flat amount would have to vary with different areas.”39 Well prepared with this information, Heagerty focused on creating a discussion document for the June 1941 meeting of the Dominion Council of Health. The attendees list was expanded to include Drs. Duncan Graham and T. H. Leggatt of the Canadian Medical Association, Dr. Grant Fleming of the National Committee of Mental Hygiene, Dr. Harvey Agnew of the Canadian Hospital Association, Dr. Alan Brown of the Advisory Committee on Child Welfare, Dr. Gordon Bates of the Health League of Canada, Dr. G. J. Wherrett of the Canadian Tuberculosis Association, Dr. Wilder Penfield, President of the Royal College of Physicians and Surgeons, representatives from the McGill, Université de Montréal and Laval medical faculties, and Dr. P. E. Moore of the Indian Affairs Branch. As usual, all of the provincial deputy ministers, Mrs. H. D. Smith of Vancouver and Dr. R. D. Defries of the Connaught Laboratories attended. Notably absent from this list are representatives

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of either agriculture or labour. Was it an oversight, due to wartime travel restrictions, or did it reflect the dominance of professional culture? Or had his labour colleagues already provided their views? For the first segment of the meeting, Heagerty presented a review of existing public health services and their limitations. Drawing heavily on the Grauer Report and information provided by the voluntary groups at the table, he made a strong plea for additional funding for local health work and professional training. His recommendation that a per capita public health grant of $1 be made for all citizens, split in thirds between the federal, provincial, and local governments received strong endorsement. Next the meeting turned to health insurance. After opening his remarks with the statement that, “The fact that most countries have adopted health insurance would appear to be sufficient evidence to warrant the assumption that health insurance is not a luxury but a necessity,” Heagerty presented a six-page history of the evolution of the concept in Canada which concluded with six quotations from labour groups across the country in support of it. He also cited the recommendation of the Royal Commission on Dominion-Provincial Relations: The Commission is of the opinion that, owing to differences from Province to Province, medical and hospital services should remain a Provincial responsibility, and that public health insurance, if established, should also be a Provincial responsibility. It does suggest, however, that the Dominion might be in a better position to collect fees for health insurance, especially if there should be a Dominion scheme of compulsory unemployment insurance or contributory old-age pensions.40

That Heagerty disagreed with this limited interpretation of federal action was evident in the 13 points which he used to outline the argument in favour of centralizing control of health insurance at the federal level. The most salient arguments were that federal control would ensure “universality of legislation,” “identical benefits,” more secure collection and distribution of funds for the program, more effective administration than under “local politics,” more effective relations with the medical profession, and “the difficulty of inducing nine provinces to adopt health insurance would be avoided.” Clearly as point 13 stated: “Social security applicable to the entire country should be centralized.” With these bold words, Heagerty was challenging all interested groups to become involved in creating an effective national health insurance program which defied constitutional limitations. But the remainder of the document somewhat undercut the challenge by proposing a contributory program for wage earners and their dependents which used an income of $2400 as the cut off for inclusion. This mirrored the failed BC Health Insurance legislation but also conformed to the expectations of the Canadian Medical Association. The

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federal government was not to provide funds but if a deficit arose was expected to guarantee payment, alter contribution levels annually while providing for the collection and distribution of the insurance funds, and pay for the overall administration of the plan. Initial estimates pegged the cost at $16 per person, but Heagerty warned his audience that costs were generally higher than anticipated and that careful costing must occur prior to the implementation of a plan.41 After this meeting, Heagerty opened negotiations with the Canadian Medical Association and to an extent with his own deputy minister. On 24 June 1941, he sent an air mail letter with a draft copy of the Dominion Health Insurance Act that he had crafted at the request of Minister Mackenzie to Wodehouse while the latter was at a medical meeting in Winnipeg. Heagerty noted that Mackenzie agreed in general with the principle of assisting the provinces to provide health insurance but did not think that federal funds should be used to pay for the care of indigents. But the Minister did request that a model provincial health insurance act be prepared, that the program should be costed, and that Heagerty should prepare a covering memorandum to justify “the whole thing” as Mackenzie had not yet received approval from the Prime Minister and Cabinet.42 There is no reply to this letter in Heagerty’s correspondence file which may well indicate that Wodehouse preferred to leave this activity entirely to his subordinate. Or did it demonstrate his passive resistance to the extension of government action in a provincial field? Prior to joining Pensions and National Health, Wodehouse had been a local MOH, provincial district health officer in Ontario, Lieutenant-Colonel in the Canadian Army Medical Corps and the Executive Secretary of the Canadian Tuberculosis Association. In the latter position, he had developed a close relationship with Canadian insurance companies which funded public health nursing and anti-tuberculosis campaigns in the Maritimes. Unlike Heagerty and Mackenzie, he was not a fervent supporter of public health insurance.43 Nevertheless on 14 July 1941, Heagerty and Wodehouse met with Drs. Gordon Fahrni and T. H. Legatt to discuss the role of the Canadian Medical Association in the creation of a national plan. In spite of Wodehouse’s concerns, by September Minister Mackenzie had agreed to the creation of a formal committee, largely one imagines, to prevent a repetition of the conflict which had doomed the British Columbia experiment to failure. As David Naylor so clearly recounts, under the leadership of Dr. T. C. Routley, the CMA encouraged Heagerty to modify his initial approach to meet the principles on which the Association was prepared to accept a national plan. Indeed at a meeting held in the library of Pensions and National Health in October, the CMA Executive Committee indicated to Mackenzie, Wodehouse, and Heagerty that not only did they approve the federal proposal but that it was possible that

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fee for service medicine might be modified if the plan were a success.44 In retrospect, this would be the high water mark of professional approval. INTERNAL CHECKS AND BALANCES

Armed with this support, Mackenzie sent a letter to J. L. Ilsley, the Minister of Finance, asking for his endorsement. Ilsley, whose department was focused on winning the war and developing national economic planning for the postwar reconstruction, took nearly a month to prepare his negative reply. In it, he indicated that he understood the rising public demand but that such a proposal required “the most extensive and careful consideration by the Government and by Parliament” because of the controversy it would generate. But the heart of the matter was money and the division of powers. Ilsley argued that Canadians were already feeling overtaxed for the war effort, that health insurance was not a cyclical cost like unemployment insurance, and that he thought an amendment to the BNA Act was necessary to “give us powers that would be commensurate with the responsibilities we were assuming.” His personal preference was to support contributory old age pensions because he thought the need was greater. But he saved his most devastating comment for the final paragraph when he stated: 7. Finally, I believe in an integrated program of social security, and thought that it was the general understanding that as the unemployment insurance scheme was brought into smooth working operation it was to be a function of the Commission to consider and report upon the various other measures of social security that might gradually be developed to supplement our unemployment scheme.45

For the Finance Minister, his colleague’s proposal was an unwelcome intrusion in the policy-making process because Isley’s brilliant young economists were working on postwar reconstruction plans that focused on economic growth policies rather than specific social welfare programs.46 Within Pensions and National Health, however, Heagerty and Mackenzie were not prepared to retreat. Heagerty dictated a firm rebuttal to all of Ilsley’s criticisms and took the opportunity to redefine the goal of the federal plan. “The object of health insurance is not so much the provision of medical services for the relief of suffering as it is the reduction of morbidity and mortality of diseases which are reducible through public health measures and the provision of adequate medical services.” Arguing that many years of research in other countries’ plans, as well as consultation with and support from the medical, nursing and dental professions, as well as strong public demand made the implementation of a plan imperative, Heagerty heaped scorn on the proposal

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that the laymen on the Unemployment Insurance Commission should be permitted to study health insurance and propose a plan. Both he and Wodehouse believed that such a plan would fail either through lack of support from doctors or because it would include a cash benefit requiring a medical certificate and thus lead to the types of problems found in England. But most importantly, health insurance had to trump old age pensions to compensate for past neglect and to aid in developing a healthy people for the postwar world.47 This did not sway Ilsley or his department, and as a result, Mackenzie took the matter to Cabinet where on 5 February 1942, he obtained an order-in-council to create an interdepartmental Advisory Committee on Health Insurance under Heagerty’s direction. The Advisory Committee was one of 17 committees on reconstruction that Mackenzie was directing but the real power lay with the committee he did not control: the Department of Finance’s Economic Advisory Committee. Beyond Ottawa, interest was also growing. The Hepburn government responded to pressure from the Ontario Federation of Agriculture by promising to study co-operative health schemes because northern farmers wanted to adopt Saskatchewan and Manitoba’s rural doctor plans. George Hoadley, Alberta’s former Minister of Health, aided the Ontario farmers in their quest.48 The Canadian Federation of Agriculture also prepared an extensively distributed pamphlet called, “Health on the March” which argued: As a matter of fact, health so far as the individual Canadian citizen is concerned, is already the greatest common denominator we possess; for it is a fundamental human need at all levels of society. The thinking of the people is far ahead of that of their governments, or of any political party; because they recognize this problem as a basic national need, entirely removed from any artificial barriers. They are looking to the National Government for leadership NOW, so they can face the period of reconstruction after the War with a greater degree of confidence. This is the challenge which must be met.49

The farmers called for federal direction and funding of health insurance under an independent lay-dominated commission to ensure that patient’s views were considered. To deal with costs, they called for federal funding through the consolidated revenue fund rather than contributions or a per capita charge. And they condemned the current system of sliding fees with the pithy observation that Also, it must be realized that up to the present, a minority in the medical profession has been situated so they could demand high fees; but the great majority have had patients with variable incomes, low incomes or no income at all. “Rugged individualism” has resulted in a multitude of far from rugged individuals-amongst both doctors and patients. In justice to the great majority of doctors, who have given their services unstintingly under tremendous odds, we wish to point out that under a National Plan, the Canadian people wish a just reward for all doctors, as well as a just service for all the people.50

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Their views would be echoed by the Canadian Labour Congress and other workers’ organizations as health insurance became a prominent public issue. Indeed Canada’s endorsation of the Atlantic Charter early in 1942 led many citizens to conclude that a better world would emerge after the hostilities ended. DRAFTING THE HEALTH INSURANCE LEGISLATION

Throughout 1942, then, Heagerty worked with his colleagues from the Dominion Bureau of Statistics, the Chief Actuary and Leonard Marsh who had been seconded from the Advisory Committee on Reconstruction on preparing new draft legislation and the Report of the Advisory Committee on Health Insurance. As the work proceeded, public interest increased. In March, for example, the Canadian Association of Adult Education published material created by the Ottawa group of the Fellowship for a Christian Social Order, which reviewed the development of health issues in Canada and provided information about international and national insurance plans. As well, the CBC broadcast a series of addresses called, “Our Wartime Health” from 17 March to 28 April, starting with a presentation by Dr. James J. McCann, Liberal Member of Parliament for Renfrew South and president of the Canadian Public Health Association (CPHA), entitled “Health Services in the Community.”51 Not surprisingly, the CPHA passed a motion favouring health insurance at its annual meeting in Toronto in June. To gain further support, Heagerty prepared a questionnaire that he asked George Davidson, Charlotte Whitton’s successor as the director of the Canadian Council of Welfare, to distribute to social workers and social work agencies throughout Canada. Although Davidson did so, the response rate was limited and he failed to complete the task.52 Nevertheless, this example of nonmedical outreach demonstrated that Heagerty was aware of the need to expand his support network. But the pitfalls of such an approach were apparent in Heagerty’s dealings with Dr. Gordon Bates of the Health League. Bates had met with Mackenzie in late June and then returned to Toronto to prepare press releases supporting health insurance. He sent the first one to Heagerty and received a very frank response in return. The Director of Public Health Services was deeply perturbed by the description of the British health insurance plan because he had concluded that informing the public about existing programs, “many of which … are to-day obsolete” would distract public attention from the real goals of health insurance which he characterized as follows: The mere treatment of illness is of secondary importance to the building up of a healthy race. Good housing, good nutrition, adequate income, higher standard of living—all these factors are what concern us now and, if we do not take cognizance of the need and seize the opportunity that presents itself, we are not

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worthy of citizenship in this great country. I fear that the medical profession may miss the opportunity that presents itself by not giving leadership to the movement.53

This cri du coeur indicated the depth of Heagerty’s commitment to the development of a comprehensive health insurance program which included measures that provided preventive as well as curative services. In September 1942, Minister Mackenzie and the Health Ministers of each province met to discuss federal plans for venereal disease control, physical fitness, and health insurance. Generally, the provincial ministers were “noncommittal” and Mackenzie asked them to consult with their governments and to send any comments or criticisms regarding federal funding for health insurance to his department.54 The consultation process continued to include the CMA, but the Ontario College of Physicians and Surgeons (CPSO) also requested a meeting and in September, Wodehouse reluctantly agreed to this. In fact, the CMA was beginning to criticize the changes that were occurring as other groups’ views were used to modify the 1941 plan. Organized medicine was particularly concerned about universal coverage and argued that it was the first step on the road to “state medicine.” To ensure a united front, the CMA and CPSO leaders met in Toronto in December and as a result, when the CMA was presented with the draft legislation which was to accompany the Advisory Committee’s report, unanimity reigned.55 FRIENDS OR ENEMIES? INTERNAL AND EXTERNAL CRITICS, 1943

By 28 December 1942, the fourth draft of “An Act Respecting Health Insurance, Public Health, the Conservation of Health, the Prevention of Disease, and other matters related thereto” was ready for public examination. Mackenzie presented it to Cabinet in January 1943 but his colleagues referred it to the Economic Advisory Committee for an assessment of its economic feasibility and costs. The Prime Minister was influenced by Sir William Beveridge’s report, Social Insurance and Allied Services56 and by the rising popular support for the Co-operative Commonwealth Federation with the result that he informed the Cabinet that the government needed to deal with social security legislation.57 But the EAC did not approve of the Heagerty plan or its cost projections and firmly stated that such a plan could not be undertaken without further modification. Concerned that many years of dedicated work would be lost, Mackenzie wrote to the PM indicating his continuing support for his department’s proposal and recommending that further discussion take place in Cabinet. His request was granted and on 22 January, Mackenzie, Heagerty and A. D. Watson, the government’s Chief Actuary, appeared before the Cabinet only to have their proposal

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severely criticized by the Deputy Minister of Finance, W. C. Clark.58 Finance was focused on developing an alternate approach to social security measures through the application of Keynesian theory and full employment. To achieve this goal, they intended to restructure the Canadian tax system to maintain the centralized control that was working so effectively during the war.59 As a result, they were unwilling to allow a line department to develop and implement an expensive shared-cost program. The Heagerty report and legislation, therefore, would be sent to Parliament for examination by a special committee on social security.60 In the late January 1943 Throne Speech, the Liberal government announced that it would be introducing the concept of health insurance for public discussion and on 16 March, the first meeting of the Special Committee on Social Insurance opened with Ian Mackenzie tabling the draft bill on health insurance, the Report of the Advisory Committee on Health Insurance (the Heagerty Report) and Leonard Marsh’s Report on Social Security for Canada.61 Mackenzie explained the origins of the legislation in the appointment of the Advisory Committee on Health Insurance in 1942, outlined the extent of its provisions for medical, dental, nursing, pharmaceutical, and hospital services and argued that his own interest stemmed from his experience as a young man fighting for the acceptance of Lloyd George’s health insurance program in Scotland. He made it clear to his audience that health insurance which provided support for preventive and curative measures was the most significant gap in Canada’s current social security program and that the role of the special committee was to examine the legislation and to listen to the views of Canadians on the matter.62 The Special Committee had 41 members: 31 Liberals, 6 Conservatives, 2 CCFers, and 2 Social Crediters and was chaired by Dr. Cyrus Macmillan, a Liberal who was a former Dean of Arts and Science at McGill.63 Throughout the committee’s deliberations, Heagerty and A. D. Watson were seconded from their departmental duties to attend the meetings in order to respond to queries from various witnesses and committee members regarding the details of the proposed legislation and the information found in Heagerty’s 558-page report. As the 117 witnesses representing 32 organizations presented their briefs, support for and opposition to the draft legislation became evident. Both the Trades and Labour Congress and the Canadian Federation of Agriculture expressed grave reservations about the dominance of health care commissions by the medical profession and made strong calls for consumer participation. Labour groups objected to the income ceilings and the contributory approach while the farmers’ associations wanted general tax revenue used to fund the plan to ensure equality of service and access. And both groups objected to the use of patients for medical edu-

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cation. But both also argued forcefully that consumer-directed health insurance was an essential postwar measure.64 Osteopaths, chiropractors, chiropodists, and optometrists all objected to being left out of the proposed plan and several of these groups alluded to their inclusion in various provincial workmen’s compensation board benefits. For the medical members of the Special Committee, such alternate practices threatened to infringe on their control of the medical, hospital, and nursing services which were to be provided, so advocates for these activities were subject to severe scrutiny.65 The Canadian Hospital Association offered tepid support66 while the Catholic Hospital Council reminded the committee of the dedicated work provided by nursing sisterhoods and indicated that they could only agree to a plan which accepted their religious values and ensured them seats on the national and provincial commissions.67 The Canadian Life Insurance Officers Association registered its support for the concept but expressed concern about the linkage between curative and preventive services.68 As the Special Committee meetings continued, concern about the complex contributory arrangements in the draft legislations became more evident. On one side, the CMA, Heagerty, Mackenzie, and other economic traditionalists argued, as did Sir William Beveridge, that the public had to pay a portion of the cost through premiums or user charges in order to control demand and to maintain the “insurance” aspect of these programs. This group also continued to support an income ceiling which would leave the well-to-do outside any national plan. In contrast, George Davidson and the CCW, the Canadian Association of Social Workers, farmers and labour called for government funding through general taxation for a universal program.69 By July 1943 when the Special Committee finished its report, these conflicting views had not been fully resolved. As a result, the Special Committee recommended that the House approve the general principles of the draft legislation but that senior officials from Pensions and National Health visit the provinces to explain the proposal, the federal government hold a federal-provincial conference on the matter,70 and that further study of the bill take place in both the House of Commons and through the Interdepartmental Advisory Committee.71 Although Heagerty had told the House Committee that he too was worried about being able to afford the contributions to the plan that he would be paying for himself, his wife, and his son because he was going to be superannuated in a few months, as a dedicated senior civil servant, he continued to work to revise the contentious aspects of the draft legislation.72 In the summer, contact with the CMA was resumed and in October, Heagerty appeared at the Ontario Hospital Association meeting in Toronto. But as Heagerty and Mackenzie realized, external political forces were reshaping the national health insurance plan. The rapid

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growth of public support for the CCF enabled the party to become the official opposition against George Drew and the newly elected Conservative government in Ontario. Since the CCF advocated universal, comprehensive, publicly funded “socialized medicine” based in community health centres, the complex federal plan appeared undemocratic, classbased, and too supportive of medical interests.73 And on the right, the publication of Charlotte Whitton’s critique of both the Marsh and Heagerty Reports in The Dawn of Ampler Life indicated that the new Progressive Conservative party led by John Bracken was developing its perspective on postwar reconstruction planning. What should the Liberal party and Pensions and National Health do and how would that affect the draft health insurance legislation? POLICY AND PRAGMATISM

Through the fall, news stories kept Canadians informed that “continuous study” of health insurance was occurring and that “the draft bill which contemplates Federal grants to Provincial governments to assist them in financing a more-or-less uniform system of health insurance” was under discussion again. 74 In November, Mackenzie dealt with internal criticisms of the financial aspects of the draft plan by setting up an Interdepartmental Health Insurance Finance Committee. The members included leading young experts such as R. B. Bryce, Department of Finance, H. C. Hogarth, Assistant Chief Inspector of Income Tax, J. E. Howes, Bank of Canada research staff, E. Stangroom, Chief Insurance Officer, Unemployment Insurance Commission, and J. T. Marshall, DBS. By 28 December this group had completed an interim report in which they reviewed the financial aspects of the bill and presented an alternate funding option, which combined an acrossthe-board $12 contribution with federal per capita funding based on provincial costs. As the committee noted: “We do not believe it would be desirable to delude the public into thinking that health insurance is not costly. It involves very heavy burdens and the public should realize that it is getting valuable services worth paying for.” 75 Equally important, the draft legislation also involved breaking the well-known principle that the government providing services should be using tax money it had collected, rather than funds from another level of government. To resolve this dilemma which had occurred as a result of the wartime tax sharing agreement, the committee stepped outside its jurisdiction and suggested the appointment of federal representatives to provincial health insurance boards or commissions. Such an extension of federal involvement in an area of exclusive provincial action countered previous concerns about divided powers and also demonstrated the committee’s firm belief in central direction.76 This memo-

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randum prompted Mackenzie and Heagerty to revise the draft legislation yet again. But health insurance was no longer the Prime Minister’s main social security interest. After the Cabinet decided to create three new departments—Reconstruction, Veteran’s Affairs, and National Health and Welfare—on 11 January 1944, King raised the issue of family allowances two days later, noting that this was exclusively within federal jurisdiction.77 By 24 January, the Heagerty proposal was no longer acceptable to the PM because it was not clearly part of the national social security scheme, because he had been convinced by the Finance Department that it was unaffordable and because he did not approve of Heagerty’s active promotion of it.78 At the same time, preparations for the Dominion-provincial conference which the Special Committee on Social Security had requested began, partly, in response to George Drew’s demand for a meeting and, partly, in response to pressure from young Liberals such as Brooke Claxton, who were very concerned about the increasing public support for the CCF.79 The 1944 Throne Speech on 27 January therefore included the announcement that a nationwide health insurance plan would evolve through consultation with the provinces and that other components such as full employment, family allowances, and benefits for veterans were to be part of the Liberals’ reconstruction package.80 MAINTAINING A PUBLIC PROFILE: HEALTH INSURANCE IN 1944

Liberal strategy required, however, that the revised draft legislation be presented to the Commons Special Committee on Social Security again. In contrast to the high expectations that had greeted the 1943 bills, the committee was dismayed to discover that its recommendations for dominion-provincial consultation had not been followed and that it was being asked to assess draft legislation which was not a government bill.81 As the hearings which started on 24 February progressed, opponents from both right and left weighed in with their demands. The London, Ontario Chamber of Commerce condemned the proposal in a widely distributed critique in April, and in June, the Financial Post condemned the measure as a “vast, unwieldy and very costly piece of legislation.” Medical economists from British Columbia and Quebec challenged Heagerty’s financial analyses and Charlotte Whitton condemned the proposal for overpaying doctors while underpaying nurses. The unanimity displayed by organized medicine began to splinter and even Dr. A. E. Archer, a long time champion, was careful not to overstate the benefits in an address on health insurance to the CMA annual meeting in Toronto. And as in 1943, chiropractors, osteopaths, optometrists, and podiatrists again demanded inclusion.82 Roman Catholic groups also began to voice their opposition. On 12

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February, James Boyle of the Cape Breton division of the Nova Scotia Hospital Association wrote to Ian Mackenzie to outline his group’s criticisms and request that their concerns be presented to the Special Committee. First, and most important, the Cape Bretoners objected to government activity because “Statism is a threat to liberty. It is against the best in Canadian political traditions.” Second, they did not want to see the valuable principle of volunteerism replaced by “federal job-holders with the attendant evils of political manipulation, deadening bureaucracy and regimentation.” Third, they argued that expanding public health services was a legitimate government activity and next that the proposed legislation would maintain the current low standard of living when “Steady employment at equitable wages, rather than federal handouts, is the solution to our hospital and other problems.” The remainder of the letter stressed the role of prepaid voluntary plans, rejected European health plan models, expressed the fear that the measure would lead to state medicine, and stated that administrative costs would waste public funds.83 Similar concerns were raised by Quebec doctors and local media. Dr. Oscar Mercier, a professor at Université de Montreal’s Faculty of Medicine and head of the Urology Department at the Hôtel Dieu, commented that with its large families, Quebec needed government assistance but he thought the draft federal legislation would lead to state medicine and turn doctors into bureaucrats. In La Patrie, Roger Duhamel commented favourably on Dr. Mercier’s address and further noted that this legislation continued federal wartime centralization and that Quebec, in particular, had to safeguard its autonomy. And Le Courier de St. Hyacinthe editorialized about the federal health insurance plan by questioning whether Canada had to follow European trends, since they had not resolved the health care challenges faced by many countries in which they had been implemented, noting that the medical profession opposed it, and pointing out that it infringed on provincial responsibilities.84 From within the Cabinet, Louis St. Laurent wrote to Father Emile Bouvier of the Canadian Catholic Hospital Association that “je suis convaincu qu’on est encore loin d’un projet definitive acceptable aux autorités provincials, aux corps professionels intéressés et à la population elle-même…[et] sa realisation me paraît toujours assez lointaine.”85 Both the Canadian labour movement and the farmers repeated their criticisms of medical dominance of the health insurance commissions and expressed concern about the lack of funding for preventive services. The Canadian Association of Social Workers reiterated these concerns in its brief to the Special Committee and added a new argument: health insurance should be part of a comprehensive social security program and funding for training health professionals should be expanded to include support for social work programs, because health and welfare

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were so intimately connected.86 These views were gaining ground inside the federal government as the King Liberals watched public support for national health insurance climb to 80% in 194487 and observed the success of the CCF in Saskatchewan in June, even though the previous Liberal government had rushed a health insurance bill through prior to the provincial election. On 10 May, Mackenzie had convened a federal-provincial health ministers meeting at which he outlined the revised federal plan.88 Although he received approval in principle from the assembled ministers, most were leery of the federal plan because without clarification of future taxation arrangements, the less affluent provinces would not be able to provide both preventive and curative services.89 After this attempt to regain momentum for the proposal failed, Mackenzie’s attention turned to the creation of two new government departments through dividing Pensions and National Health into its component parts. The legislation to create the Department of National Health and Welfare was introduced in the House by Mackenzie King on 26 June 1944, had its second reading on 27 June and then went to third reading and committee discussion on 14 July. In the meantime, the Special Committee completed its hearings and reported the revised legislation to the House of Commons on 28 July. Once more, it recommended the proposal and called for a dominion-provincial conference on the matter. But the committee would not have known that Cabinet had decided to forgo further action on health insurance because family allowances were going to be the first order of business for the new department.90 On 18 July Cabinet agreed that health insurance would be incorporated in the proposals which were being prepared for the federal-provincial reconstruction conference and as Malcolm Taylor observed “its prospects [were] conditional on a massive reorganization of the financial underpinnings of the federal system.”91 THE FINAL PLAN

Through the late summer and fall of 1944 as Canadian troops pushed further into Europe, several key events contributed to the final evolution of the 1940s health insurance proposal. On 14 August, Mackenzie King announced that the Dominion-Provincial Reconstruction Conference would not be held until after the next federal election. This enabled the re-establishment of the interdepartmental committee on health insurance finance and led to the development of a new funding approach after the draft legislation was abandoned. Equally important, the new Department of National Health and Welfare (DNHW) became operational when Brooke Claxton was named Minister on 13 October 1944.92 The new Deputy Minister on the health side of DNHW was Dr. Brock

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Chisholm, a highly regarded Canadian Army Medical Corps psychiatrist, while the social welfare post went to George Davidson of the Canadian Welfare Council. J .J. Heagerty continued to serve as director of public health services and on 29 November sent a memorandum to his new deputy minister in which he responded to criticisms of his earlier proposals by observing that I would also suggest that, unless it is the intention to proceed with a complete programme of health insurance such as is in effect in many other countries, the whole project be abandoned. If it is worth doing, it is worth doing well.93

But what was the federal government prepared to do? Creating the family allowance program occupied much of the new department’s attention while the conflict over conscription affected the public and the Cabinet. In January 1945 the Throne Speech again announced the government’s interest in health insurance but only as one component of a social security program. Nevertheless, Claxton immediately began to press his deputy ministers for priority items to include on the agenda of the upcoming reconstruction conference. By late May, the Minister was announcing a six-point health program to the Dominion Council of Health and the Canadian public. The first two points were a national health insurance plan and preventive health measures and Claxton indicated that the department did not intend “to compete with any province or municipality, or with any private health agency.”94 This co-operative approach was necessary as the King government was engaged in a general election campaign in which all of the contestants were offering similar social welfare programs. On 11 June, Canadian voters expressed their reaction to the various party platforms by returning 125 Liberal, 67 Progressive Conservative, 28 CCF, 13 Social Credit, and 12 independent members of Parliament. Armed with victory in Europe and this slim majority, King’s Liberals now began the final preparations for the reconstruction conference that would design the postwar financial relationship between the federal and provincial governments. For Heagerty this was the final opportunity to get support for the concept of combining preventive and curative services that he had championed since the 1930s. In a mid-June memo to Brock Chisholm reporting on a meeting of the subcommittee on health insurance finance, Heagerty urged that the minimum benefits under provincial health insurance plans should include hospitalization, general practitioner, and nursing services. He also recommended that each province establish a provincial health commission to prepare a plan which would be developed in conjunction with advice from federal experts.95 Chisholm evidently agreed with this because the provincial deputy ministers were requested to send information to Ottawa about their current or future

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plans for health insurance programs and by mid-July, Alberta, New Brunswick, Nova Scotia, and Saskatchewan had submitted their responses.96 Thus, when the federal government presented its proposals for a national health insurance plan, as well as health grants for a variety of preventive services and hospital construction as part of the Green Book proposals in August 1945, they reflected the consensus which had emerged as a result of all the discussion and examination of the topic between 1940 and 1945. Treading carefully around the vexed questions of provincial and professional autonomy and recommending staged implementation of various services, the national health insurance plan no longer contained the administrative and financial features which had made farmer and labour groups object to the draft legislation. But like many of the other proposals in the Green Book, federal funding was dependent on all the provinces agreeing to continue to surrender their income and corporate taxes as well as their succession duties. And it was this requirement that led Ontario, Quebec and Nova Scotia to oppose the comprehensive approach.97 LESSONS LEARNED?

As J. J. Heagerty prepared to retire at the end of 1945, had his vision of a comprehensive system of preventive and curative services available to all Canadians died? Had his years of study and advocacy gone for nought? Did the failure of the 1945 health insurance proposal signal the end of the early 20th-century form of public health activism which his career had personified? For historians and political scientists such as Robert Bothwell, John English, C. David Naylor, Jack Granatstein, Douglas Owram, Malcolm Taylor, Antonia Maioni, Alvin Finkel, and David Bercuson, the reasons for the failure of the Green Book health proposals lay in the excessive ambition of the planners, shifting political support from the Prime Minister, changing attitudes in the medical profession and business community, and the need for a pilot project like Saskatchewan’s experiment in provincial hospital insurance. As this paper has demonstrated, there are other key variables which should be added to the existing story. The changing role of the bureaucracy as a result of the generational shift at Finance and the Bank of Canada had a significant impact because it brought competing visions of Canada’s future social security programs into conflict. Heagerty had planned a cradle to grave health care system which emphasized prevention and the determinants of health as much as curative services but his younger colleagues believed that full employment and family allowances to ensure immediate purchasing power in the postwar world would be more beneficial to the economy and hence the public.98 And because they had been so successful at directing the war effort, they

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were less attuned to the nuances of provincial and regional needs than Heagerty who had spent his entire career participating in the semiannual meetings of the Dominion Council of Health where he learned first hand about the needs of his provincial counterparts. Hamstrung by the Rowell-Sirois condemnation of conditional, shared-cost programs, Heagerty’s draft bills were a careful attempt to stay within constitutional boundaries and it was not until he had public support from labour and farmers that he was able to challenge these restraints. But he was a man of his times and his profession and that seems to have blinded him to the rising democratic spirit which challenged medical dominance of the provincial and national health insurance commissions. In the end, then, his grand vision failed to gain the internal political and bureaucratic support that it needed to rise to the top of the political agenda in 1945 and indeed vanished into thin air. NOTES 1 Library and Archives of Canada (LAC), Department of National Health and Welfare, Record Group 29, Vol. 1061, File 500-3-3, Part 1, Letter dated 27 June 1941 from J. J. Heagerty to G. F. Amyot. 2 David W. Slater, War Finance and Reconstruction: The Role of Canada’s Department of Finance, 1939-1946 (Ottawa: David W. Slater, 1995). In this study, Slater examines the role of the Finance Department of which he was a member during World War II. After Canada declared war, the King Cabinet created the Economic Advisory Committee “as an interdepartmental group of senior officials” whose role was “to advise the prime minister, cabinet, and individual ministers on economic questions referred to it” (p. 97). After being very active from 1939 to late 1941, the committee was dormant until late 1942 when demobilization and reconstruction became central issues. At this point, “it became the principal co-ordinating body in reconstruction planning in 1943 and 1944. It began by critiquing the interim report of Cyril James’s reconstruction committee and was asked to assess the constitutional and financial aspects of the Marsh and Heagerty Reports (p. 187-202). 3 “A Fine Public Servant,” Toronto Star Weekly, 5 June 1943; Anonymous, “Dr. John Joseph Heagerty,” Canadian Medical Association Journal, 54 (1946): 318. See also J. J. Heagerty, “Sanitary Conditions Aboard Transports,” Public Health Journal, 10 (1919): 145-47 and J. J. Heagerty, “Influenza and Vaccination,” Canadian Medical Association Journal, 9 (1919): 226-28. 4 “News,” Public Health Journal, 11 (1920): 98. 5 The federal Health Department was created in 1919 in response to pressure from lay and military medical experts, women’s groups, the Trades and Labour Council and former Liberals such as Newton Rowell, the President of the Privy Council in the Union Government. Bill 37 to create the Department of Health was introduced in March 1919 and discussed vigorously in the House of Commons on 4 and 10 April because it aroused concern about federal-provincial powers and because its supporters wanted federal funding and oversight of venereal diseases, tuberculosis, and maternal and infant mortality as measures to rebuild Canada’s population. See Canada, House of Commons, Debates, 26 March 1919, p. 843; 4 April 1919, p. 1164-1206; 10 April 1919, p. 1366-80; and 11 April 1919, p. 1383. Bill 37 received royal assent 6 June 1919 and the new Department commenced on 1 July 1919 with Rowell as the first minister. 6 J. Heagerty, “Progress of Venereal Disease Control in Canada,” Public Health Journal, 12 (1921): 459-63.

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7 Jay Cassel, The Secret Plague: Venereal Disease in Canada, 1838-1939 (Toronto: University of Toronto Press, 1987), p.176-98, 214-45. 8 See R. M. Dawson, The Civil Service in Canada (London: Humphrey Milford for Oxford University Press, 1929) for an analysis of the role of civil servants in Canada’s “reformed civil service.” On p. 242, he discusses the tangible and intangible rewards of public service as follows: “The civil servant also enjoys the feeling that he is doing really big things, and is making decisions which profoundly affect the destinies of the whole nation—a sense of combined power and patriotism which is somewhat enhanced by the short and uncertain tenure of the ministers.” 9 Cassel, The Secret Plague, p. 194-98. 10 “285 Civilians Honored in the King’s Birthday List,” Globe and Mail, 2 June 1943, p. 18. The actual investiture occurred in Ottawa on 24 November. See “Officials, Scientists Receive Honor Awards,” Globe and Mail, 25 November 1943, p. 9 which notes “Dr. J. J. Heagerty, the Federal Government’s expert on health insurance and drafter of the bill now under consideration, with 32 years….” 11 J. J. Heagerty, “Epidemics That Guided the Hand of Destiny,” Health, 5 (Summer 1937): 33, 46-48; Heagerty, “The Romance of Medicine in Canada: Scurvy Ended First Attempt to Establish a Canadian Colony,” Health, 7 (Summer 1939): 31, 41, 52-53. The latter is one of the CBC talks reprinted in full. 12 J. J. Heagerty, Four Centuries of Medical History in Canada (Toronto: Macmillan, 1928), Vol. 1, p. xvii. 13 J. J. Heagerty, The Romance of Medicine in Canada (Toronto: Ryerson Press, 1940), p. vii-viii, 112-3. 14 Desmond Morton and Glenn Wright, Winning the Second Battle: Canadian Veterans and the Return to Civilian Life, 1915-1930 (Toronto: University of Toronto Press, 1987), p. 202-13. 15 LAC, Department of Health and Welfare, RG 29 Vol. 23, File 21-1-1, Memorandum re: Agenda Item No.2—Agenda, Interprovincial Conference Social Insurance, circa January 1933. 16 C. David Naylor, Private Practice, Public Payment: Canadian Medicine and the Politics of Health Insurance, 1911-1966 (Toronto: University of Toronto Press, 1986), p. 44-57. See also David and Rosemary Gagan, For Patients of Moderate Means: A Social History of the Voluntary Public General Hospital in Canada, 1890-1950 (Montreal and Kingston: McGillQueen’s University Press, 2002) and J. T. H. Connor, Doing Good: The Life of Toronto’s General Hospital (Toronto: University of Toronto Press, 2000). 17 LAC, Department of National Health and Welfare, RG 29, Vol. 1062, File 502-1-1 Part 1 Health Insurance Studies, Health Insurance General 1928-1947, news clipping, “Health Insurance Urged for Canada,” Alexandria Times, 12 September 1930. 18 Larry Glassford, Reaction and Reform: The Politics of the Conservative Party under R. B. Bennett 1927-1938 (Toronto: University of Toronto Press, 1992), p. 99-136. 19 LAC, Department of National Health and Welfare, RG 29, Vol. 23, File 21-1-1, Agenda— Interprovincial Conference—January 1933 and attached Memorandum by the Department of Pensions and National Health Item No.2—Agenda, Interprovincial Conference, Social Insurance. 20 LAC, Department of National Health and Welfare, RG 29, Vol. 1062, File 502-1-1, Part 2, news clipping, “State Medicine Is Not Bennett Plan,” Toronto Daily Star, 28 November 1933 and “State Medicine for Dominion Unlikely,” in Mr. Bennett’s View, Toronto Globe, 29 November 1933. 21 Robert Lampard, “Cardston Medical Contracts and Canadian Medicare,” Alberta History, 54 (2006): 5-10. See also Naylor, p. 52-54. 22 Margaret W. Andrews, “The Course of Medical Opinion on State Health Insurance in British Columbia, 1919-1939,” Histoire sociale/Social History, XVI (mai-May 1983): 129-41; Allan Irving, “The Doctors versus the Expert: Harry Morris Cassidy and the British Columbia Health Insurance Dispute of the 1930s,” BC Studies, 78 (Summer 1988): 53-79; and Naylor, Private Practice, Public Payment, p. 54-63, 70-89.

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23 Glassford, Reaction and Reform, p. 159-66. 24 LAC, Department of National Health and Welfare, RG 29, Vol. 502-1-1, Parts 2, 3 and 5 contain the correspondence, news clippings and copies of the CMA Committee on Economics report which Heagerty and his staff used to prepare memoranda for the Minister and his Deputy. 25 The National Insurance Act, 1911 was passed by the Liberal government under the direction of David Lloyd George, the Chancellor of the Exchequer. Based on Bismarck’s German health insurance plan, the health insurance component was a contributory plan which required contributions from employees, employers and the state. In return, workers received medical care, including drugs, from panels of practitioners, 10 shillings a week in sick pay, dropping to 5 shillings a week for lengthy illnesses, and a limited maternity benefit for their wives. The major flaw with the legislation was that it failed to cover women and children and hospital care. See Trevor Lloyd, Empire to Welfare State: English History 1906-1967 (London: Oxford University Press, 1970), p. 34; and Marvin Rintala, Creating the National Health Service: Aneurin Bevan and the Medical Lords (London: Frank Cass, 2003), p. 19-28. 26 LAC, RG 29 Vol. 1062, File 502-1-1 Typescript of B. K. Sandwell, “The Growing Faith in State Medicine,” Saturday Night, The Canadian Illustrated Weekly, Toronto, Canada, 26 May 1934. 27 F. R. Scott, “The Privy Council and Mr. Bennett’s ‘New Deal’ Legislation,” Canadian Journal of Economics and Political Science, 3 (1937): 234-41. 28 Glassford, Reaction and Reform, p. 175-204. 29 W. H. McConnell, “The Judicial Review of Prime Minister Bennett’s `New Deal,’” Osgoode Hall Law Journal, 39 (1968): 39-86; R. C. B. Risk, “The Scholars and the Constitution: POGG and the Privy Council and Canadian Law Teachers in the 1930s: `When the World Was Turned Upside Down,’” in A History of Canadian Legal Thought: Collected Essays, edited and introduced by G. Blaine Baker and Jim Phillips (Toronto: The Osgoode Society for Canadian Legal History and University of Toronto Press, 2006), p. 233-70, 341-99. 30 LAC, Department of National Health and Welfare, RG 29 Vol. 1063 File 502-1-1, Part 5, undated speech by Heagerty circa 1936, Health Insurance in Canada by J. J. Heagerty and memorandum to Minister (C. G. Power) dated 22 October 1936. 31 LAC, Department of National Health and Welfare, RG 29, Vol. 1063, File 502-1-1, Part 6, document complied January 1939, p. 11. 32 Margaret E. Prang, N. W. Rowell: Ontario Nationalist (Toronto: University of Toronto Press, 1975), p. 489-97. 33 Albert Edward Grauer typified the younger generation of academics who conducted research for the Rowell-Sirois Commission. Born in BC in 1906, he graduated with his BA from UBC in 1925, completed his PhD at the University of California in 1929 and received a BA (juris) from Oxford in 1930 where he was also a Rhodes Scholar. He was called to the BC Bar in 1930 and joined the University of Toronto Economics Department as a lecturer in 1931, rising through the ranks to become a full professor and chair of the Department of Social Science in 1937. In 1933, he married Shirley Woodward, daughter of E. A. Woodward and they returned to Vancouver in 1939 when he became the General Secretary of the BC Electric Railway Company. He had an influential business career through the 1940s and 1950s and became Chancellor of UBC in 1957. See The Canadian Who’s Who 1948 (Toronto: Trans-Canada Press, 1948), p. 384. 34 A. E. Grauer, Public Health: A Study Prepared for the Royal Commission on Dominion-Provincial Relations (Ottawa: King’s Printer, 1939), p. 72. 35 Robert S. Bothwell, “The Health of the Common People,” in John English and J. O. Stubbs, eds., Mackenzie King: Widening the Debate (Toronto: Macmillan, 1978), p. 193. 36 Douglas Owram, The Government Generation: Canadian Intellectuals and the State, 1900-1945 (Toronto: University of Toronto Press, 1986); J. L. Granatstein, The Ottawa Men: The Civil Service Mandarins, 1935-1957 (Toronto: University of Toronto Press, 1998); and J. L. Granatstein, Canada’s War: The Politics of the Mackenzie King Government, 1939-1945 (Toronto: Oxford University Press, 1975).

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37 LAC, Department of National Health and Welfare, RG 29 Vol. 1063, File 502-1-1, Part 7. Correspondence with provincial deputy ministers and copies of CMA pamphlets on Health Insurance, November 1940. 38 LAC, RG 29, Vol. 1063, File 502-1-1, Part 7. Memorandum to Dr. R. E. Wodehouse, Deputy Minister from Drs. Heagerty, Millar and Burke dated 1 January 1941. 39 LAC, RG 29, Vol. 1063, File 502-1-1, Part 11. Letter dated 28 April 1941 from A. D. Watson to J. J. Heagerty. 40 LAC, Department of National Health and Welfare, RG 29, Vol. 1061, File 500-3-3, Part 1, Postwar Public Health and Medical Services dated 28 August 1941. 41 LAC, RG 29. Vol. 1061, File 500-3-3, Part 1. 42 LAC, RG 29, Vol. 1061, File 500-3-3, Part 1, Letter dated 24 June 1941 from J. J. Heagerty to R. E. Wodehouse. 43 The Canadian Who’s Who, 1938-39 (Toronto: Trans-Canada Press, 1939), p. 709-10; and Bothwell, “The Health of the Common People,” p. 194. 44 Naylor, Private Practice, Public Payment, p. 102-3. 45 LAC, Department of National Health and Welfare, RG 29, Vol. 1061, File 500-3-3, Part 1, Copy of letter dated 28 November 1941 from J. L. Isley to I. Mackenzie. 46 David W. Slater with two chapters by R. B. Bryce, War Finance and Reconstruction: The Role of the Department of Finance, 1939-1946 (Ottawa: D. W. Slater, 1995), p. 169-76. 47 LAC, Department of National Health and Welfare, RG 29, Vol.1061, File 500-3-3, Part 1, Draft of letter dated 9 December 1941 from I. Mackenzie to J. L. Ilsley. Dictated by Dr. Heagerty with a handwritten notation by REW (Dr. Wodehouse). 48 LAC, Department of National Health and Welfare, RG 29, Vol.1063, File 502-1-1, Part 7, “Ontario Plans Co-operative Health Study,” Toronto Globe and Mail, 20 January 1942. 49 LAC, Canadian Child Welfare Council, Manuscript Group 28, I 103, Box 345, Health Insurance—Canada 1943. The material in this pamphlet was presented by H. H. Hannam, the CFA president to Heagerty on 13 October 1942 and published in January 1943, p. 5. 50 LAC, Canadian Council on Child Welfare, MG 28, I 103, Box 345, p. 28. 51 LAC, Department of National Health and Welfare, RG 29, Vol. 1063, File 502-1-1, Part 11, Food for Thought, Vol. II, Toronto, March 1942, No. 7. The text would suggest that Heagerty provided much of the information regarding health insurance in this document. 52 LAC. Canadian Council on Child Welfare, MG 28, I10, Vol. 52, File 465 C (1935-43), Health Insurance Questionnaire—General Summary and accompanying correspondence for June-August 1942. 53 LAC, Department of National Health and Welfare, RG 29, Vol. 1063, File 502-1-1, Part 8, Letter dated 30 June 1942, G. L. Bates to J. J. Heagerty and letter dated 4 July 1942 from J. J. Heagerty to G. L. Bates. 54 LAC, RG 29, Vol. 1063, File 502-1-1, Part 8. Memorandum re: Meeting of Provincial Ministers in the Daly Building, Ottawa, 21 September 1942, p. 2-3. 55 Naylor, Private Practice, Public Payment, p. 106-7. 56 Charles Webster, The National Health Service: A Political History, new edition (Oxford: Oxford University Press, 2002), p. 7-10. 57 Library and Archives Canada, William Lyon Mackenzie King Diaries, 1893-1950, 12 January 1943, MG26-J13, http://king.collectionscanada.ca. Accessed 30 April 2008. 58 King Diaries, 22 January 1943. King stated: “In the Cabinet, most of the time was taken up…listening to presentation of the arguments underlying a draft bill prepared by the Department of Pensions and Health for health insurance. Presentation made by Dr. Higgerty (sic) and Mr. Watson of Finance Department. Both made excellent presentation. Clark gave arguments against. What was said by both parties bore out what I had previously said to the Cabinet, namely that the matter could only be properly considered and understood by members of the House. The one question to be most important for years to come. Crerar was very reactionary.” 59 Slater, War Finance, p. 177-219. 60 Taylor, Health Insurance and Canadian Public Policy, p. 17-20.

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61 “Marsh Reveals Feverish Week Drafting Plan,” Globe and Mail, 17 March 1943, p. 9. The Globe editorial, “Professor Won By Columns,” dated 20 March 1943 rather mischievously pointed out that Marsh’s report had received more press coverage than Heagerty’s effort. “Whether the furor it caused was due to the fact that Mr. Mackenzie’s health bill meant the spending of only a mere $256,000,000 while Dr. Marsh’s plan goes to a cool billion, the psychologists will have to tell….” 62 Kenneth C. Cragg, “Social Security Plan, Health Bill Proposed,” Globe and Mail, 17 March 1943, p. 1, 7. 63 Taylor, Health Insurance and Canadian Public Policy, p. 20-1. 64 Naylor, Private Practice, Public Payment, p. 115-18. 65 Naylor, Private Practice, Public Payment, p. 118-20. 66 LAC, Canadian Council on Child Welfare. MG 28, I 103, Box 345. Health Insurance— Canada, Hospitals and Health Insurance. A Presentation to the Special Committee on Social Security of the House of Commons by the Canadian Hospital Council, April 1943, Bulletin No. 43. 67 Canada. Health Insurance; report of the Advisory Committee on Health Insurance, p. 518-59. See also Peter Neary, Introduction in Peter Neary and J.L. Granatstein, eds., The Veteran’s Charter and Post-World War II Canada (Montreal and Kingston: McGill-Queen’s University Press, 1998) p. 5-13. 68 The Public Health Aspects of the Proposed National Health Insurance Scheme for Canada, Canadian Journal of Public Health, 34 (1943): 147-51. See also MG 28 I 10, Vol. 52, File 465C (Correspondence 1935-43), Letter dated 21 Jan. 1943 from Bruce R. Power to George Davidson with memorandum from CLIOA to Heagerty Committee. 69 LAC, MG 28, I 103, Box 345, Health Study Bureau, Health Can Be Planned, Four broadcasts on Health Planning, from National Farm Radio Forum Broadcasts, over CBC National Network, 6-27 December, 1943, p. 9-22. 70 Within the federal cabinet, some ministers such as Angus L. Macdonald were concerned that the Heagerty proposals were not only too expensive but that they would also cost both the federal and provincial governments too much and were too centralizing. See T. Stephen Henderson, Angus L. Macdonald: A Provincial Liberal (Toronto: University of Toronto Press, 2007), p. 122-26. In addition, King and the Cabinet were ambivalent about a federal-provincial conference at this time because of the failure of the 1941 discussions and the demands of the war. 71 Taylor, Health Insurance and Canadian Public Policy, p. 34. 72 LAC, MG28 I 103, Box 345, Workers’ Educational Association Research Bulletin No. 11, What’s Cookin’! A Witch’s Brew or A National Tonic? (Toronto, 1943-44), p. 11. 73 Naylor, Private Practice, Public Payment, p. 120-22; Taylor, Health Insurance and Public Policy, p. 34-6; and Antonia Maioni, Parting at the Crossroads: The Emergence of Health Insurance in the United States and Canada (Princeton: Princeton University Press, 1998), p. 66-81. 74 Study Health Insurance, Globe and Mail, 7 October 1943, p. 2. See also Statements are Expected from Ottawa, Globe and Mail, 22 November 1943, p. 3 in which CP reports that King is expected to announce economic policy and “how far Canada should go with social security.” Family allowances have become part of the social security package and the draft health insurance material is being discussed in the department and Cabinet prior to being sent back to the House committee on social security. 75 LAC, Department of National Health and Welfare, RG 29, Vol. 1061, File 500-3-1, Part 3, Interim Report of the Committee on Health Insurance Finance, 28 December 1943, p. 8. 76 LAC, RG 29, Vol. 1061, File 500-3-1, Part 3; Taylor, p. 36-37. 77 LAC, http://king.collectionscanada.ca, 13 January 1944. Accessed 30 April 2008. 78 Slater, War Finance, p. 199-201. See also Alvin Finkel, “Paradise Postponed: A Reexamination of the Green Book Proposals of 1945,” Journal of the Canadian Historical Association, 4 (1993): 120-42; and LAC, http://king.collectionscanada.ca, 25 January 1944 for King’s report on the Cabinet meeting in which the health section of the 1944 Throne speech was discussed. “It was clear that every member of Council and Mackenzie himself in his own mind saw that it would be impossible to simply promise to give

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federal money to the provinces without something in the nature of a general understanding in regard to all social legislation being reached. Also Higgerty’s (sic) talking out of turn as to what is going to be done has helped ruin the whole business. It is a most outrageous thing for a civil servant to have done.” Accessed 13 March 2008. David J. Bercuson, True Patriot: the Life of Brooke Claxton, 1898-1960 (Toronto: University of Toronto Press, 1993). Taylor, Health Insurance and Canadian Public Policy, p. 40. Taylor, Health Insurance and Canadian Public Policy, p. 37. Naylor, Private Practice, Public Payment, p. 124-27. LAC, RG 29 Vol. 1063, File 502-1-1, Part 10, Letter dated 12 February 1944 from J. Boyle to I. Mackenzie. LAC, MG 28 I 10, Vol. 52, File 465 (1942-49), “The French Press,” Montreal Gazette, 6 July 1944. St. Laurent Papers, St. Laurent à Emile Bouvier SJ (13 March 1944) cited in Bothwell, The Health of the Common People, p. 212. LAC, MG 28 I 103, Box 345, Labour News, IV, 27 March 1944, 1-4; 10 April 1944, 1-4; 8 May 1944, 3-4; House of Commons, Session 1944, Special Committee on Social Security, Minutes of Proceedings and Evidence, No. 7, 26 April 1944 (Ottawa: Edmond Cloutier, King’s Printer, 1944), Appendix; Memorandum on the Draft Bill Respecting Health Insurance, Public Health, Etc. Submitted to the Social Security Committee of the House of Commons, 31 March 1944 by the Canadian Congress of Labour, p. 209-18 and Appendix B, Brief of the Canadian Association of Social Workers on the Draft Health Insurance Bill, p. 219-24. Neary and Granatstein, eds., The Veteran’s Charter, p. 237-38. Ian A. Mackenzie, “Health Insurance,” Canadian Journal of Public Health, 35 (1944): 21333. Taylor, Health Insurance and Canadian Public Policy, p. 37. Neary and Granatstein, Appendix, p. 239. The government released a poll about Canadians’ reaction to family allowances on 2 August 1944. Eighty-one percent of Quebeckers thought it was a good idea compared to 57% of the rest of Canadians. Given the Liberal Party power base in Quebec and King’s desire to aid families whose economic interests had been threatened during the war, family allowances were a less controversial means of improving the economy than health insurance. See Nancy Christie, Engendering the State: Family, Work and Welfare in Canada (Toronto: University of Toronto Press, 2000), p. 249-309 and note her comment on p. 286: “The inner cabinet of the King government had gravitated to family allowances rather than to other social security measures such as health insurance, because their popular appeal in relieving poverty and stimulating postwar abundance was the perfect disguise for the federal government’s drive to preserve its wartime taxing powers.” Taylor, Health Insurance and Canadian Public Policy, p. 38-45. Taylor, Health Insurance and Canadian Public Policy, p. 45-46. LAC, RG 29 Vol. 1063, File 502-1-1 Part 10, Memorandum Re: Statement on Health Insurance by Dr. Ollivier dated 29 November 1944 from J. J. Heagerty to General G. B. Chisholm. LAC, MG 28 I 10, Vol. 52 File 465 (1942-49), Facts and Figures Weekly, 25-31 May 1945. LAC, RG 29, Vol.1063, File 502-1-1, Part 11, Memorandum dated 13 June 1945 from J. J. Heagerty to G. B. Chisholm. LAC, RG 29 Vol. 23, File 21-2-1. Correspondence from M. R. Bow, C. W. MacMillan, C. F. W. Hames and P. S. Campbell to G. B. Chisholm. Taylor, Health Insurance and Canadian Public Policy, p. 48-57; and Finkel, Paradise Postponed, 141-42. Slater, War Finance, p. 221-55.

4 The Liberal Party and the Achievement of National Medicare P. E . BRYDEN

To understand the origins of government-funded medical care in Canada it is impossible to ignore the role played by successive administrations in Saskatchewan. Historians of that province have rightly emphasized the development of ideas of health insurance from their roots in agrarian populism and farmer militancy, through the organization of the municipal doctors scheme and the Swift Current model, to the now-legendary clash between Saskatchewan doctors and the state in the summer of 1962.1 Broader examinations of health insurance in the Canadian context have also paid close attention to the Saskatchewan model.2 This emphasis on the events in Saskatchewan, and in particular on the three-week strike by physicians following the passage of the Saskatchewan Medical Insurance Plan, is not surprising. The battle seemed particularly pitched in the prairie province, with clear heroes and villains—at least in retrospect—and widely reported coverage of events that allowed a national and even international audience to follow the action. The result of this attention to Saskatchewan, however, has been to ignore some of the other landmarks along the road to Medicare. A national program of health insurance was not achieved until 1968, itself the result of more than a decade of struggle within the federal Liberal party, first for control of direction of the party and then for control of the cabinet. The battle was certainly not as public as that fought between the Lloyd government of Saskatchewan and the striking doctors, but it was just as fierce. *** The national health insurance system in Canada had a particularly long germination period, which perhaps explains why relatively little attention is paid to the final years leading up to its implementation. The Liberal Party was hobbled or blessed, depending on the circumstances, with a commitment to health insurance dating back to the leadership

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convention of 1919, and so the idea itself can be traced at least that far.3 There had been plenty of earlier interest in various forms of more localized health insurance. For decades prior, for example, individual communities had been pooling their resources to cover collective medical costs in an early form of health insurance.4 Mackenzie King, upon whom the leadership fell in 1919, claims to have first thrown out the idea in his magnum opus Industry and Humanity, although the same could be said of most of the policy decisions undertaken by his government in the next 30 years—and beyond! But before those ideas can take root and grow into actual pieces of legislation, they must find an agreeable conjunction of interests, and the Canadian environment proved less conducive to health insurance than the 1919 statement suggested. The British Columbia government undertook the first serious attempt at state health insurance in the 1930s. The effect of the Depression on farmers and the resource-sector has been well-documented, but physicians servicing these constituencies also suffered from the patients’ inability to pay. In some ways, the time seemed ripe for the introduction of at least provincially administered health insurance programs. Investigations were undertaken in all the western provinces during the 1930s. In BC, the Liberal government of Duff Pattullo sought imaginative solutions to the Depression, including the introduction of state-sponsored health insurance to cover the costs of caring for the growing number of indigent citizens. The doctors were at first delighted at the prospect of being paid for their services, but organized opposition soon began to develop. The Canadian Medical Association (CMA) was opposed to the constraints the BC legislation would impose on the choice of physician and its political power, combined with the declining fortunes of the Liberals in BC, led to the shelving of the legislation permanently in 1936.5 Provincial action in the field of health would have to wait until after the war. The Rowell-Sirois Commission, undertaken in the dog days of the Depression and reporting in the early stages of World War II, noted the possibility of a national government assuming responsibility for expensive social security legislation like health insurance, although stopped short of actually recommending its implementation. The division of powers—with provinces responsible for most services but sharing the valuable tax dollars with the federal government—was the chief concern of the Commission. The interests of the day, and therefore those included in the Report, were most pressingly the provision of unemployment insurance, a system for equalizing the differences across the provinces, and a reconfiguring of the tax system to better reflect the distribution of responsibilities.6 But as the bleakest days of war in the spring of 1940 passed, and Canadians began to think seriously about how their lives would be

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reconstructed in its aftermath, governments also began to consider health insurance more seriously. Mackenzie King’s Liberal government struck an advisory committee on health insurance, appointing in 1942 J. J. Heagerty, Director of Public Health Services, as chair. The Heagerty Report, as it came to be called, took into consideration the views of the medical community as expressed by the CMA during the British Columbia negotiations, but fell into the trap of not adequately addressing the concerns of other groups like those representing agricultural and labour. Once again, the various interests involved in the implementation of health insurance failed to align properly, and as a result, legislation failed to materialize.7 Health insurance was still a desirable goal for the federal government when it met with provincial representatives to hash out a national plan for postwar reconstruction. But the Green Book proposals presented at the Dominion-Provincial Conference on Reconstruction in 1945-46 tied the costly social security policies to a shift in tax powers that would see the provinces hand over control of the direct tax fields. Although this had been the approach followed during wartime, the coming of peace heralded to many a return to greater autonomy for the provinces. The premiers were unwilling to accept the tax arrangements, and so the social security offered by King’s government fell off the table.8 Health insurance would again wait for a more agreeable political climate. North American economic prosperity following World War II meant that some of the financial impediments to implementing national health insurance had been eliminated. The federal government was thus able to begin a slow and steady move towards full health insurance by first introducing health grants, followed a decade later by hospital insurance.9 These were baby steps. Clearly, the environment was not quite right for the implementation of full health insurance, despite there having already been important advances at the provincial level. In the mid1950s, premiers from British Columbia, Saskatchewan, Manitoba, and Ontario had all urged the federal government to provide some leadership in the field of health insurance, where there was “unquestionably a great deal of misunderstanding and confusion.”10 Ontario’s Conservative Premier Leslie Frost laid out before the first ministers five alternatives for moving the state into the health care field, ranging from coverage of components such as home-care to full hospital coverage. But in pushing forward the intergovernmental agenda, and functioning as something of a spokesman for the other premiers, Frost was careful to propose a staged movement toward hospital insurance—itself only a step in the progression toward a full Medicare system.11 Even this proved difficult to achieve, with both Ontario and the federal government at one time or another doubting the details of the hospital insurance proposal. Nevertheless, hospital insurance made its appearance on the national political

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landscape in 1957, and slow but steady postwar progress can be seen to be being made toward the ultimate goal expressed by the Liberal convention in 1919. Three things happened in the decade after the introduction of the Hospital Insurance and Diagnostic Services Act, 1957 that made it feasible for the Liberal Party of Canada to consider finally fulfilling its health insurance promise. Two of them—the successful introduction of health insurance in Saskatchewan, and the report of the Hall Commission on health services—have rightly received the most attention.12 Less attention has been paid to the power struggle within the national Liberal party itself, which occurred both in Opposition and again once they achieved power in the mid-1960s. These battles were necessary not only to create an environment within which the Liberals could consider health insurance, but also in determining what form that insurance would ultimately take. The third factor, then, in explaining the timing of the final national push to implement full health insurance, was the Liberal losses in the elections of 1957, 1958, and 1962, and the necessary reconceptualization of their policy priorities. The initial shock of having lost power in 1957 was followed quickly by the more devastating electoral defeat of 1958 under the new leadership of Lester Pearson. After 22 years in power, the Liberals were unaccustomed to opposition, and many embarked on a period of partisan introspection. Numerous party members took a turn at trying to figure out what had gone wrong. The old guard tended to think the electoral misfortunes were because the party had veered from its “management” priorities and had tried to promise too much to a cynical electorate. The new recruits to the party, including people like Tom Kent and Walter Gordon, pointed instead to the need to develop those promises into concrete policy solutions. Over the course of six years in opposition, it was the new guard that came to prominence. A renewed commitment to national health insurance took shape for the opposition Liberals in a number of different ways. Following the lead of other parties in opposition, the Liberals sponsored a non-partisan “thinkers conference” designed, in part, to infuse the party with new ideas. The Kingston Conference, as it came to be known, invited participants “to discuss the great national issues and to argue about what government policy should be with respect to these issues.”13 Among those issues was social security, where the discussion was expected to address the “reconciliation of individual liberty and responsibility, control over the public purse and taxation levels and the demands of a people getting used to the idea of a welfare state.”14 Two of the papers given at the Kingston Conference dealt specifically with health insurance. Wendell Macleod, the Dean of Medicine at the University of Saskatchewan, delivered a discussion paper on “Basic

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Issues in Hospital and Medical Care Insurance.” In it, he identified the issues that were even more pressing than how to administer and finance an insurance scheme, namely “what are the health expectations of the Canadian people? How are these likely to change in the foreseeable future? Are prevailing assumptions and conceptions sound? For example, in the various segments of our society what are the gaps between health expectations and health needs?”15 His was a broad inquiry into the state of society and the place of health care provision within it. The inclusion of a Saskatchewan practitioner in this conference suggests that there was a general sense in central Canada that the prairie province had important advice to dispense regarding health care. Macleod’s paper, however, ended up being more philosophical than prescriptive. Tom Kent’s paper, on the other hand, was designed to offer more pointed policy proposals for discussion. In “Towards a Philosophy of Social Security,” he built on the theme that “freedom is not just the absence of constraint but, equally, the opportunity to act” by outlining an 11-point agenda for action. It included Medicare, whereby the federal “government should pay the individual’s medical bills on a sliding scale related to income” and sickness insurance providing “the same level of income-maintenance for sick people as for those who are unemployed for other reasons.”16 Kent’s goal was to stimulate discussion. One participant noted that Kent’s “full-scale attack” was “very well received by the majority” although criticized by Frank Underhill for “importing … Fabian socialism to a cold climate.”17 Regardless of the reception, however, Kent’s paper clearly became a talking-point. In order to ensure that the Kingston Conference ideas developed into positive policy goals, the Liberal Party established a policy committee that would massage the discussion points into resolutions. These then would be voted on at the party’s Liberal Rally to be held early in 1961. The point of the Rally was “to stir up a general feeling of enthusiasm throughout the Party.”18 Walter Gordon was one of the members of the policy committee, and therefore instrumental in ensuring that ideas turned into workable policy alternatives. On the left of the party, he had been “very much impressed” with Tom Kent’s proposals, and asked him “to put forward some specific suggestions about pensions and other forms of social security.”19 The Liberal “Plan for Health” was unveiled at the Liberal convention—the “Rally”—of January 1961. It offered a government-sponsored scheme for covering hospital, physician, drug and rehabilitation fees, according to an agreed-upon scale of fees. Precisely how such a program would be financed was left up in the air, although the plan floated a method “similar in principle to the present treatment of family allowance and old-age pensions” by which everyone received the benefit but the wealthiest essentially had the increase taxed back.20 The plan

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was a bit vague on specifics, but it was certainly successful in attracting attention at the Rally. Seventy people jammed the plenary session to join in the discussion about health insurance and by the end of the convention, a nine-point plan for health, based very closely on the original discussion paper, was endorsed by the party membership. Yet it was still not sufficient to take to the electorate. The plan needed tweaking: in dealing with an issue that divided people, the Liberals needed to be careful not to alienate the centre while appealing to the reformers or vice versa. Pearson was clear about what would need to be done before the scheme could be unveiled for the public. Specifically, other interested parties needed to be consulted, including both the committee currently investigating health insurance in Saskatchewan and the Canadian Medical Association, and the question of how the plan was to be administered needed to be more explicitly addressed. 21 Included in the group charged with making the health plan electionready were both Boyd Upper, who “got the impression that little of this material will catch the attention of the voter,” and Tom Kent, who was staking his future in the Liberal party on the electorate’s readiness for changes in the delivery of health and other social services.22 Between the Liberal Rally in January 1961 and the party’s return to power in April 1963, it was the progressive, more interventionist approach to social policy that gained prominence in the Liberal platform. Boyd Upper’s first attempt at drafting a memorandum on health services contained a number of features that the more reformist elements in the party found unacceptable. Universal availability was not to be weakened, as Upper had proposed, with the requirement of registering for the program. It was desirable, although not necessarily wise from a legislative standpoint, to avoid surcharges, another feature of the Upper plan. Furthermore, the reformers were clear that the Liberal agenda would not be driven by the objectives of the CMA, or by provincial priorities. Despite protestations that the Upper memorandum was “excellent,” by the time Kent and Gordon had finished with it, it was a much more pointed statement of federal intentions in the health insurance field than the original document had envisioned.23 Significantly, it was the reformers, and not the more cautious people like Boyd Upper, who were key to revamping the Liberal fortunes. Although it was difficult for the Liberals to content themselves with opposition after so many years of governing, the years between 1957 and 1963 were absolutely imperative for the development of social policies in general, and renewing a real commitment to national health insurance in particular. Electoral defeat brought home to party members too accustomed to power the need to revamp the Liberal platform. With first a thinkers’ conference, and then a partisan convention, the Liberals were able to generate new social policy ideas or, in the case of

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health insurance, resurrect an old social policy idea and give it new life. Party officials like Kent and Gordon were then able to shape the resolutions into actual strategies to be employed in election rhetoric and beyond. By ensuring that the policy proposals had the support of the grassroots of the party, the officials were able to establish a place in electoral strategy for expensive programs such as national health insurance. Even after leaving office, with the achievement of Medicare already under his belt, Pearson was able to point to “the building of our Party in opposition; getting a new foundation and a new superstructure” as the accomplishment “that gave [him] more satisfaction than anything else as a political achievement.”24 Without the period in opposition, it is doubtful whether health insurance would have made it onto the Liberal agenda. Having won the struggle to direct the electoral approach of the Liberal party in opposition, the reformers could hardly rest on their laurels. The challenge of governing was vastly different from that of getting into power, and it was questionable whether those advisors and activists who had brought the Liberals to electoral success in 1963 would be the ones who would be dominant once the party reclaimed the reins of power. Some, like Tom Kent, continued to function in an advisory capacity. Whether that advice would continue to be acted upon, however, remained to be seen. Others, like Walter Gordon, sought elected office, and thus continued to fight for social reform from the cabinet room rather than the backrooms. While joined by other reformers, like Maurice Lamontagne, Judy LaMarsh and Allan MacEachen, there were powerful cabinet colleagues who argued for policies of restraint. Before national health insurance could become a reality, therefore, another internal power struggle was bound to ensue. Despite the enthusiasm Liberals of all ranks had expressed for a national health insurance scheme, it was not the social policy with which they opened their return to government in 1963. Instead, a universal pension plan had moved to centre stage following its popularity on the floor of the Liberal Rally. The grassroots support, plus a sense in the halls of power that it would be more straightforward to implement than a health insurance plan, led to the inclusion of pension reform in the list of first steps to be taken by the new Pearson government. As Judy LaMarsh, the new minister of National Health and Welfare, later noted, pensions were “the thing to start with … because [the program] would be self-funding and we didn’t know how much money there would be to start Medicare.”25 Furthermore, by 1963 Saskatchewan had already introduced health insurance on the provincial level, and had been met with a hostile medical community that promptly went on strike. The province was only just beginning to recover from the doctors’ strike; history had not yet cast the government as the dragon-slayer in

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this epic battle, and it was far from clear that the public was fully behind health insurance in Saskatchewan, let alone across the rest of the country. The Liberals in Ottawa chose a wait-and-see approach on health, while pressing ahead on their other social policy goal in the pension field. Lessons learned during negotiations over pensions had an enormous effect on the shape of the national health insurance. Between 1963 and 1965, when the Liberals began negotiations with provincial premiers over health insurance, the pension scheme was unveiled by the federal government and then substantially revised in light of the appearance of a much more attractive plan in Quebec. Provincial governments proved sophisticated in their own policy planning, and unwilling to simply endorse a federal social program without debating questions of constitutional jurisdiction. The experience of attempting to introduce a social program that had clear provincial implications had a profound effect on the manner in which the Liberals approached health care negotiations. Although health raised a number of questions that were absent from the pension debates, there was enough similarity between the two programs that the strategies employed the second time around could benefit from the experience of the first round. Despite clear evidence to the contrary, the new Liberal government seemed taken aback by the degree to which provincial governments had investigated pension reform. The national Liberals were certainly aware of the Advisory Committee on Portable Pensions that had been established by Premier Leslie Frost in Ontario in 1960, and continued its work under the new government of John Robarts. The Ontario Premier, despite being Conservative, had written to then Opposition Leader Mike Pearson in early 1962 that “I learn with much pleasure of your proposals to develop a contributory social security scheme for the aged.” More than pleased, apparently—he was ready to see Pearson move into the prime minister’s office: “the government of Ontario would concur in and facilitate proper and reasonable plans by your government resulting in a contributory social insurance program becoming a reality.”26 But the plan that was taking shape in Ontario was very different from the one the federal Liberals imagined. The chief distinction between the two schemes was that Ontario’s portable, compulsory old age pension program would be run by the insurance industry; Ottawa’s plan was to establish a government-sponsored program. Clearly, the two levels of government were on a collision course. George Gathercole, the chair of Ontario’s pension committee, fully backed by the insurance industry, demanded that the federal scheme conform to the shape of the Ontario plan.27 Equally stubbornly, the federal government prepared to force its own scheme onto reluctant

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provinces at a series of intergovernmental conferences. The first, in the fall of 1963, was clearly “dominated” by Ontario, as the federal delegation struggled to keep the upper hand. Federal officials tinkered with the pension proposals in the face of Ontario’s well-conceived plan. The next major meeting, in the early spring of 1964, witnessed a bombshell from Quebec: the Quebec government had also devised a pension scheme which it would be implementing shortly and was considerably more generous than the one Ottawa was offering and more attractive in all ways to the Ontario scheme.28 Following this disclosure, Pearson and the Liberals were forced to backtrack, reshape the Canada Pension Plan in line with the Quebec Pension Plan, and begin an important re-evaluation of their approach to social policy. Timing was everything. The group of left-leaning policy planners who had pushed health insurance to the front of Liberal consciousness while in Opposition were no longer quite as powerful as they used to be. The reformist cabinet ministers—notably Walter Gordon in Finance and Judy LaMarsh in Health and Welfare—had had their wings clipped, the former after a crisis in his first budget, the latter because of the gruelling pension debate. Those people behind the scenes like Tom Kent saw their influence wane, too, as the realities of government empowered those more likely to advise caution. So despite a strong commitment to health insurance in 1963, just one year later the resolve was shaken. The doctors’ strike in Saskatchewan did not force action in Ottawa; nor did the investigations into private health insurance schemes in Ontario, Alberta and British Columbia. Only one thing could push the Liberals into action, and that was the report of the Hall Commission. When Volume 1 was released in the summer of 1964, and, amazingly, advocated a government-sponsored system of full health insurance, the Liberals could sit on their promises no longer. Hard-learned lessons in other fields would now determine the manner in which national health insurance was implemented. Different people took different lessons from the first year or so of Liberal government. Kent thought that the federal government needed to lay out its plan for health insurance and then begin negotiations with the provinces; the experience of negotiating with the provinces over pensions had taught him the wisdom of being prepared. As he later explained to the Prime Minister, while the Conservatives thought “we ought to have worked out a national [pension] plan by agreement,” the reality was that “it would have taken an indefinite time to get anywhere if we hadn’t faced the provinces with firm proposals.”29 Kent argued for doing the same thing regarding health. Gordon, on the other hand, argued that “given the other complications we are going to have with the provincial governments”30 in finalizing pensions, 1965 would be too

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early to take on health insurance. He also had “reservations about using Federal-Provincial relations as an excuse for an election,” which he feared would happen if the next election was delayed. Essentially, Gordon thought the need for a united Liberal front on the health question was a good reason to head back to the polls quickly, hoping for a solid majority and the Parliamentary strength necessary to silence the conservatives in the party.31 Probably under pressure from her cabinet colleagues, LaMarsh went ahead with a different approach, and began soliciting the views of the provinces in the spring of 1965.32 Better to know what might lie ahead than to be caught completely off-guard as had been the case with pensions. Although preliminary discussions with provincial bureaucrats demonstrated a remarkable divergence of views, the prime minister was still optimistic in the summer of 1965 that moving forward with Medicare would indicate a “willingness to co-operate with the provinces.”33 There might be differences of opinion over strategy, but the federal government still seemed firmly committed to its health insurance program. Whatever their views on the legacy of the pension debates, each member of the Pearson team was undoubtedly guided by the past experience as they confronted the new demands of health insurance. The pension debate had made it clear that, in social policy formation, the federal government should underestimate the provincial agendas at its peril, and avoid constitutional wrangles as much as possible. These lessons were not lost on the architects of national health insurance, whether at the elected or bureaucratic level. The new Assistant Deputy Minister of Finance, A. W. Johnson, a recruit from the CCF administration in Saskatchewan, had as much to do with the federal government’s approach to health insurance as anyone. And in designing the approach that the Liberals would pursue, Johnson looked not just to his former experiences in Regina, but also to the lessons of the pension negotiations. While the politicians wrangled over timing—when to begin health negotiations, when to call an election—the officials in the Department of Finance struggled to design a strategy regarding health insurance. The department was well-equipped for such investigations with seasoned deputy minister Bob Bryce at the helm, and bureaucrats Al Johnson and Tommy Shoyama of the “Saskatchewan Mafia” under him. It should not have come as a surprise, then, for Johnson to solve the riddle of “financing Medicare” but it was still “the kind of solution that, once you have heard it, you kick yourself for having failed to think of.”34 According to Johnson, the manner in which the federal government had approached social policy financing in the past had been found wanting from provincial perspectives. “The essential features of a sharedcost programme,” he wrote to Bryce, was that

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the Federal Government devises a programme and announces it (with varying degrees of advance consultation with the provinces)…; the participating provinces sign an agreement which provides for federal cost-sharing payments to them in return for undertaking to administer a programme which conforms with certain conditions…; the programme is administered by the provinces…; [compensation] takes the form of Federal payments to the provinces…; the Federal government does a programme and a financial audit to ensure that the agreement is being adhered to…; sanctions are imposed by the Federal Government if it discovers the provinces are not adhering to the conditions spelled out in the agreement; [and finally] citizens of non-participating provinces are taxed to finance the programme in the same way as are the citizens of the participating provinces.

Each of the provinces had, at one time or another, been critical of “the unilateral federal initiative, the detailed conditions of the agreement, the detail of the audits, and the imposition of sanctions on the basis of Federal judgment alone.”35 The pension negotiations had tapped into some of this latent provincial discontent with the federal government’s approach to social policy. Johnson had an alternative, however. Instead of the complicated mechanism that had been employed in the past, he proposed that the provinces “not be required to sign an agreement; instead they would simply have to enact legislation which established a plan in conformity with the principles enunciated by the Federal Government after, and as a consequence of, consultation with the provinces.”36 Bryce had a few comments, in particular regarding how this system would work in concert with a formula for equalization, but in essence, this was to be the federal approach to health insurance: establish principles, and partially fund the program if provincial governments enacted legislation conforming to those principles. In its very simplicity, it promised to avoid the confrontations that characterized the pension negotiations. The health principles that the Liberals offered had also evolved markedly since they were discussed at the Kingston Conference, and had become clear and straightforward. At the first ministers meeting called for mid-July 1965, following cabinet’s approval, Pearson unveiled the federal offer. Pass legislation that establishes an insurance scheme that covers a comprehensive range of physicians’ services, is universal in its coverage, is publicly administered, and is portable, and the federal government will pay half of the national cost of covering such programs.37 The provinces were left to consider the federal proposal. It was the first time since taking office that the national Liberals had acted in a calm, confident manner with regards to the provinces; it had taken years of discussion to get to this point, but by the summer of 1965, Pearson’s team was ready to take on national health insurance. Shortly thereafter, he was also ready to take on the Conservatives, and called an election for the fall.

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The man most responsible for the election timing was Walter Gordon, Chair of the Campaign Committee, and ever-weakening Finance Minister. He wanted an election in order to rid the current Parliament of all those who were unconvinced of the necessity of an expanding social welfare net. The problem was, however, that when the Liberals were returned with another minority government, the conservatives in the Party were even more powerful. And Gordon, who accepted responsibility for the poor electoral showing, was even weaker. He offered the Prime Minister his resignation from cabinet, which Pearson felt he had “no choice but [to] accept.”38 This unexpected shift in fortunes, this reversal of the relative power of the left and the right of the Liberal party, had important consequences for the achievement of Medicare. Despite having announced a strategy that was simple, straightforward and in many ways unassailable, the rise to prominence of more fiscally conservative Liberals—like Mitchell Sharp—gave reluctant provinces—like Ontario— a chance to stymie the achievement of the plan as it had been originally conceived. With its own health insurance system already in place, the government of Saskatchewan was the only one that stood to gain immediately from the implementation of the national scheme. Other provinces were thus in a far better position to influence the final shape that Medicare would take. In Ontario, for example, two or three meetings occurred each week to discuss the developments on the federal front and to hash out a provincial response. At first, what appeared to be federal resolve put the provincial politicians in a difficult position as far as establishing an alternative. Premier John Robarts worried that “Ontario was in a delicate position. Because of the November 8th Federal election,” he warned, “the Federal Government might want to jockey Ontario into a position of opposing Medicare.”39 Provincial Health Minister Matthew Dymond focused his objections on the fact that TB sanatoria and mental health facilities seemed to be excluded from the federal offer. Chief Economist Ian Macdonald pointed to the need to “treat Medicare costs as part of the overall picture of health costs” when calculating the federal financial contribution.40 But no one suggested chipping away at the actual conditions laid down by Ottawa. The new post-1965 Liberal government had some new faces in the relevant departments, but in the early months there seemed to be little indication that the commitment to Medicare was waning. Although Judy LaMarsh was demoted from Health and Welfare to Secretary of State, the new minister responsible for seeing Medicare to conclusion was Allan MacEachen, a left-leaning Liberal who appeared in favour of the program as it had been designed. Putting Mitchell Sharp in Finance and Robert Winters in Trade and Commerce suggested a shift to the

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right in money matters, but in terms of the cabinet’s commitment to Medicare in 1965, there seemed little evidence of this conservatism. Regardless of what was happening around the cabinet table, however, following the November election the door seemed to open for provincial critiques of the national Medicare proposals. Sensing weakness in Ottawa, or at least a wavering of support for health insurance as the old reforming power horses of the Liberal party slipped away, provincial premiers and health ministers went on the offensive. The election of the Union Nationale in Quebec in 1966 immediately unsettled intergovernmental relations, if only because Premier Daniel Johnson was an unknown quantity. But both old and new alike chimed in with complaints about the federal Medical Care Act. When the premiers met at their annual interprovincial conference in the summer of 1966, they agreed to “request a Federal-Provincial Conference, at the top level, on Medicare…. This matter should be dealt with as a financial question in conjunction with the whole matter of federal-provincial financial arrangements.”41 What this meant from Ontario’s perspective was that “the provinces are not in a position to embark on major new expenditure programs next year.” Thus, while meeting the federal target date of 1 July 1967 for passing health insurance legislation would “be premature,” it was still hoped “that a clear agreement should be reached on the targets for federal and provincial participation in Medicare schemes during the course of the five year period.”42 When, by mid1966, provinces still had not announced their intention of legislating on full health insurance, it appeared that there were shortcomings with the federal criteria. More time would be needed, according to the bureaucrats in Finance and happily endorsed by their minister, to bring the provinces on side.43 The start date for Medicare in Canada was delayed until 1 July 1968. This delay indicated a weakening of the federal resolve, and the provinces became even more critical of the federal proposal. Ontario openly condemned the federal role in subverting provincial priorities. According to provincial Finance Minister Charles MacNaughton, “further improvements in provincial medical care programmes should have lower priority than housing, education and urban development. If the Federal Government is prepared to make financial contributions to the provinces toward the financing of medical care, Ontario should be able to apply its share of such federal contributions to housing.” Finance ministers from all of the other provinces—including Saskatchewan— voiced concerns about the costs of introducing legislation. There might be “political” support for health insurance, but provincial treasuries were already running low.44 The continuing debate within the federal cabinet on whether to press ahead with the already-revised start date of 1 July

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1968 gave cash-poor provincial premiers an opportunity to raise serious questions about the cost, constitutionality, and precedent of a national health insurance program. Pearson’s 1965 cabinet was very different than the group of ministers he had gathered around him in 1963. They might not have immediately pounced on Medicare, but with a declining economic outlook, it was destined to be one of the first policies to be questioned. Just a year into the second minority government, Liberal fortunes seemed to be falling, in part because it had lost touch with its own “progressive wing.” Gordon was invited to return to cabinet to try to address these issues, but before he agreed to do so, he secured Sharp’s agreement that they would discuss issues in advance and attempt to minimize disagreements in cabinet.45 It was clear that Sharp was the cabinet colleague most likely to present difficulties for the left-leaning Gordon. However careful the preparatory work, Gordon did not function well in the new environment. By the fall of 1967, he was complaining that “the Liberal Government has given the impression of becoming increasingly conservative in its attitudes. In the process, we have given the public a confused impression of what we stand for. The more conservative elements in the cabinet, both because of their numbers and the portfolios they hold, exert a dominating influence, one that tends to be deadening and unimaginative.”46 The cabinet was rapidly moving towards a crisis. Those who counselled delay—and potentially even elimination—of the federal Medicare scheme were led by Sharp; both Gordon and MacEachen were reported to be “insisting that there can be no delay.”47 With “conflicting and contradictory statements” circulating about the future of Medicare, it was looking like it would be one of the first casualties of the battle in cabinet.48 Finally, the Prime Minister himself stepped in. Calling for an end to cabinet wrangling, Pearson pressed for a decision on health insurance in January 1968. There was an extended cabinet debate on the pros and cons of proceeding with a 1 July 1968 start date for the Medical Care Act, during which cabinet ministers on both the left and the right weighed in with their thoughts. Sharp took the opportunity to explain that had a commitment not been made to Medicare, “he would be strongly opposed to going ahead” at the present time. He raised the fact that when the commitment to health insurance had been made, the economy was considerably brighter than it was in the winter of 1968. He left little doubt that his vote would be cast against doggedly sticking to the 1968 deadline.49 Others, including Walter Gordon, Manpower and Immigration Minister Jean Marchand, Allan MacEachen, and Treasury Board President Edgar Benson, were equally determined to follow through on the federal government’s commitment.50 When a decision

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was finally reached in the next day or two, the 1968 deadline remained. On which side the Prime Minister had cast his vote remains unclear: “while noting that all members of the government would be expected to support the government’s position unequivocally,” the cabinet minutes note, “the Prime Minister expressed regret at the failure of some Ministers to be more flexible with regard to a formula for phasing-in the Medicare program, or for otherwise obtaining more provincial participation.”52 Regardless of the internal divisions and provincial criticisms, however, the criteria for federal funding remained the same as had been conceived by Al Johnson. There had been moments when it seemed certain that health insurance would again be shelved by the Liberals, but there was to be no repeat of a half-century earlier. Once the provinces slowly came on board, national health insurance had become a reality. The most important factors in the achievement of national health insurance could be found within the Liberal Party itself. Having first established the desire to enter into this new field of social policy—a desire, admittedly, borne out of electoral necessity—the Liberals then looked to their own past in shaping their approach to the implementation of health insurance. What lessons could be gleaned from the exhausting process of negotiating a national contributory pension scheme? As it happened, the experience of dealing with the provinces over pensions proved crucial in designing a strategy for dealing with health. The last hurdle was an internal one, as more fiscally cautious Liberals rose to positions of power in cabinet, leaving the social policy planners weakened. But when the Prime Minister announced that Medicare was to commence forthwith, the way was finally clear. Dealing with their own strengths and weaknesses, their own angels and albatrosses, both inside and outside the party, proved to be the central challenge for the Liberals in the achievement of a system of national health insurance. NOTES 1 See Harley Dickinson, “The Struggle for State Health Insurance: Reconsidering the Role of Saskatchewan Farmers,” Studies in Political Economy, 41 (Summer 1993): 133-56; Joan Feather, “Impact of the Swift Current Health Region: Experiment or Model?” Prairie Forum, 16, 2 (Fall 1991): p. 225-48; Aleck Ostry, “Prelude to Medicare: Institutional Change and Continuity in Saskatchewan, 1944-1962,” Prairie Forum, 20, 1 (Spring 1995): p. 87-105; Robin F. Badgley and Samuel Wolfe, Doctors’ Strike: Medical Care and Conflict in Saskatchewan (Toronto: Macmillan, 1967); E. A. Tollefson, Bitter Medicine: The Saskatchewan Medicare Feud (Saskatoon: Modern Press, 1963); and C. Stuart Houston, Steps on the Road to Medicare: Why Saskatchewan Led the Way (Montreal and Kingston: McGill-Queen’s University Press, 2002). 2 J. L. Granatstein, Canada: 1957-1967: The Years of Uncertainty and Innovation (Toronto: McClelland and Stewart, 1986), p. 169-97; and Malcolm G. Taylor, Health Insurance and

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5 6

7 8

9 10 11 12

13 14 15

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Canadian Public Policy: The Seven Decisions That Created the Canadian Health Insurance System and Their Outcomes, 2d ed. (Montreal and Kingston: McGill-Queen’s University Press, 1987), p. 69-104, 239-330. Alvin Finkel, Social Policy and Practice in Canada: A History (Waterloo: Wilfrid Laurier University Press, 2006), p. 105. C. David Naylor, Private Practice, Public Payment: Canadian Medicine and the Politics of Health Insurance, 1911-1966 (Kingston and Montreal: McGill-Queen’s University Press, 1986), p. 31-32. Naylor, Private Practice, p. 58-89. Report of the Royal Commission on Dominion-Provincial Relations; for a recent evaluation of the working of the commission, see Barry Ferguson and Robert Wardhaugh, “‘Impossible Conditions of Inequality ’: John W. Dafoe, the Rowell-Sirois Royal Commission, and the Interpretation of Canadian Federalism,” Canadian Historical Review, 84, 4 (December 2003): 551-83. P. E. Bryden, Planners and Politicians: Liberal Politics and Social Policy, 1957-1968 (Montreal and Kingston: McGill-Queen’s University Press, 1997), p. 4-5. See Alvin Finkel, “Paradise Postponed: A Re-examination of the Green Book Proposals of 1945,” Journal of the Canadian Historical Association, new series, Vol. 4 (Ottawa 1993), p. 120-42; Marc J. Gotlieb, “George Drew and the Dominion-Provincial Conference on Reconstruction, 1945-46,” Canadian Historical Review, 66, 1 (1985): 27-47; and P. E. Bryden, “Beyond the Green Book: Ontario’s Approach to Intergovernmental Negotiations, 1945-1955,” in Nancy Christie and Michael Gauvreau, eds., Cultures of Citizenship in Post-war Canada, 1940-1955 (Montreal and Kingston: McGill-Queen’s University Press, 2003), p. 133-62. On these developments, see Paul Martin, A Very Public Life: Volume II: So Many Worlds (Toronto: Deneau, 1985), p. 27-75. Opening Statement by Leslie Frost, Canada, Federal-Provincial Conference, 1955: Preliminary Meeting (Ottawa: Queen’s Printer, 1955), p. 19. Taylor, Health Insurance and Canadian Public Policy, p. 105-60. On the Hall Commission, see Frederick Vaughn, Aggressive in Pursuit: The Life of Justice Emmett Hall (Toronto: The Osgoode Society for Legal History, 2004), esp. chap. 5; and Dennis Gruending, Emmett Hall: Establishment Radical (Toronto: Macmillan, 1985). Queen’s University Archives (QUA), Tom Kent Papers, Box 6, File: Study Conference, September 1960. “Study Conference on National Problems,” 29 June 1960. QUA, Kent Papers, Box 6, File: Study Conference, September 1960, “Study Conference on National Problems,” 29 June 1960. Library and Archives Canada (LAC), Lionel Chevrier Papers, MG 32 B16, Vol. 12, File: Nat’l Problems, 1. J. Wendell Macleod, “Basic Issues in Hospital and Medical Care Insurance,” Queen’s University, 6-10 September 1960. Tom Kent, A Public Purpose: An Experience of Liberal Opposition and Canadian Government (Kingston and Montreal: McGill-Queen’s University Press, 1988), p. 82-83. QUA, Kent Papers, Box 6, File: Study conference, September 1960. R. M. MacIntosh, “The Kingston Conference,” 4 October 1960. LAC, Lester B. Pearson Papers, MG 26 N2, Vol. 27 File: 391—National Rally. Walter Gordon to Boyd Upper, 24 April 1961. QUA, Kent Papers, Box 1, File: Correspondence, September to December 1960. Gordon to Kent, 4 October 1960. LAC, National Liberal Federation Papers, MG 28 IV 3, Vol. 889, File: Health Insurance. “Plan for Health,” Liberal Rally statement, January 1961. LAC, Pearson Papers, MG 26 N2, Vol. 114, File: Liberal Health Plan. Pearson to Boyd Upper, 7 February 1961. LAC, Pearson Papers, MG 26 N2, Vol. 27, File: 391—National Rally, Upper to Walter Gordon, 30 March 1961. LAC, Pearson Papers, MG 26 N2, Vol. 114, File: Liberal Health Plan. Kent to Upper, 15 February 1961.

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24 LAC, Pearson Papers, MG 26 N5, Vol. 46, File: Pearson Years, Rolls 113-118; Pearson interview with Chris Young, 11 June 1970, Roll 115. See also Tom Kent, “Reformism,” in Norman Hillmer, ed., Pearson: The Unlikely Gladiator (Montreal and Kingston: McGill-Queen’s University Press, 1999), p. 168-71. 25 LAC, Peter Stursberg Papers, Vol. 15, File: LaMarsh, Judy. Interview, 28 May 1975. 26 QUA, Kent Papers, Box 2, File: correspondence, June 1963. Robarts to Pearson, 6 February 1962. 27 Archives of Ontario (AO), George Gathercole Papers, MU 5332, File: Portable Pension Correspondence. Gathercole to J. J. Connolly, 1 May 1963. 28 See, for example, Claude Morin, Quebec versus Ottawa: The Struggle for Self-Government, 1960-1972 (Toronto: University of Toronto Press, 1972); and Kenneth Bryden, Old Age Pensions and Policy-Making in Canada (Kingston and Montreal: McGill-Queen’s University Press, 1974). 29 QUA, Kent Papers, Box 3, File: 1-12 October 1965. Kent to Pearson, 5 October 1965. 30 LAC, Walter Gordon Papers, MG 32 B44, Volume 16, File: 11. Gordon to Pearson, 27 January 1965. 31 LAC, Gordon Papers, Vol. 16, File: 11. Gordon to Pearson, 30 June 1965. 32 LAC, Department of National Health and Welfare Papers, RG 29, Vol. 1058, File: 5001-12, Pt. 3. LaMarsh to Provincial Ministers of Health, 9 April 1965. 33 LAC, Privy Council Office Papers, RG 2, Series A-5-a, Vol. 6271, Cabinet conclusions, 7 July 1965. 34 Kent, A Public Purpose, p. 366. 35 LAC, Department of Finance Papers, RG 19, Vol. 4854, File 5508-02. Pt. 1, Johnson to Bryce, 16 July 1965. 36 Department of Finance Papers, Vol. 4854, File 5508-02, Pt. 1. Johnson to Bryce, 16 July 1965. 37 AO, Robarts Papers, RG 3 Series A-13-1, Box 134, File: Medical Insurance, Health, January-December 1966. “Implementation of the Medical Services Insurance Act in the Light of the Proposals Made at the Federal-Provincial Conference, July 1965.” 38 LAC, Gordon Papers, Vol. 16, File: 11. Gordon to Pearson, 9 November 1965 and Pearson to Gordon, 11 November 1965. 39 AO, Robarts Papers, RG 3-26, Box 492, File: Federal-Provincial Conference of Ministers of Health, Federal Government, 23 and 24 September 1965. “Meeting re: Medicare Conference of Federal and Provincial Ministers of Health,” 14 September 1965. 40 AO, Robarts Papers, RG 3-26, Box 492, File: Federal-Provincial Conference of Ministers of Health, Federal Government, 23 and 24 September1965. “Meeting re: Medicare Conference of Federal and Provincial Ministers of Health,” 14 September 1965. 41 AO, RG 50-33, Box 10, File: 1966 F-P Tax Agreements—General File. “Seventh Provincial Premiers Conference,” HI Macdonald to D. W. Stevenson and Robarts, 4 August 1966. 42 AO, Robarts Papers, RG 3-26, Box 122, File: Minister, Health, January 1966 - December 1966. Don Stevenson, “Proposal Regarding Ontario’s Stand on Medicare,” 24 August 1966. 43 Mitchell Sharp, Which Reminds Me…: A Memoir (Toronto: University of Toronto Press, 1994), p. 149. 44 LAC, Gordon Papers, Vol. 16, File: 13. “Summary of Views Expressed by Provincial Ministers of Finance on the Subject of Medicare at the 16-17 November Meeting of Finance Ministers,” Cabinet Document #761/67. 45 LAC, Gordon Papers, Vol. 16, File: LBP, “Note of matters to discuss with Mike on 29 December 1966” and Confidential Memo to file, 4 January 1967. 46 LAC, Gordon Papers, Vol. 16, File: 13: “The position of the government at the present time,” 3 October 1967. 47 “Cabinet finds last cuts hardest,” Globe and Mail, 25 October 1967. 48 J. L. Granatstein Xerox collection, Walter Gordon Papers, “Notes for a discussion at Cabinet,” Tuesday, 24 October 1967.

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49 LAC, Privy Council Office Papers, Series A-5-a, Vol. 6338, Cabinet Minutes, 30 January 1968. 50 Granatstein Xerox collection, Gordon Papers, “Re: The Book—Sharp Troubles,” 8 March 1968. 51 LAC, Privy Council Office Papers, Series A-5-a, Vol. 6338, Cabinet Minutes, 1 February 1968.

5 Political Cartoonists Respond to Medicare FELICITY POPE

Debates about health-care policy have been and continue to be a rich topic for editorial cartoonists. The subjects of the debate are competing ideas about Canadian Medicare. By the early 20th century, national health policy was a fact or a subject for debate in industrialized countries. But what kind of plan would Canada adopt? Would it be based on social justice and collective security or on individual freedom and minimal state intervention? What about professional autonomy? How would each province implement federal policy? The cartoons are from the period 1944 to 1986, which covers the implementation of the three major pieces of national health insurance legislation: the 1957 Hospital Insurance and Diagnostic Services Act, the 1966 Medical Care Act, and the 1984 Canada Health Act. They are organized chronologically and grouped by reference to the events leading up to and resulting from the passage of the legislation. I have added short linking passages to each group to place the images into their historical contexts. I also draw the reader’s attention to discussions by other contributors that have a bearing on the cartoons. Seventeen drawings from Canada’s major cartoonists trace the issues surrounding health insurance policy over this pivotal 40-year period. The cartoons are from public collections: Library and Archives Canada, McCord Museum, Saskatchewan Archives Board, Glenbow Archives, and Simon Fraser University. They are a small selection from hundreds of cartoons that cover the events and attitudes of people during the debates surrounding the creation of national Medicare. Chosen mainly for their artistic value, these editorial cartoons are drawn mainly for newspapers and serials. The cartoon is the medium the artist uses to bring his insight and skill (the examples I have found are all by men) to satirize or comment on the essence of the day’s top story. Editorial cartoonists essentially support the direction of the publication; only Duncan Macpherson of the Toronto Star is reported to have

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negotiated his editorial freedom.1 The nature of editorial cartoons—their daily regularity—has the unintentional effect of occasionally giving prominence to a personality of the day who may not be remembered or who enjoyed only a short period in the public eye. Figure 4 of Paul Sauvé, whose premiership of Quebec ended with his early death after four months in office, illustrates the latter characteristic. How do cartoons work? The artist has to produce a visual communication that can be grasped within the few seconds that a viewer might give it in what is essentially a throwaway medium. He does this by framing a little drawing of a single moment, a simple encounter or presentation of easily recognizable people and or objects. The scene will be made intelligible by devices like metaphor or contradiction to turn what may be an abstract idea (e.g., health insurance policy) into an image from daily life. The artist uses a variety of techniques such as captioning, exaggerating the physical features of readily recognizable public figures, or using a stock character in a domestic setting to convey a message. By a nice turn of coincidence, the political cartoonists of health-care policy could tap into a rich vein of doctor and patient caricatures that goes back well into the 18th century, as Carl Zigrosser illustrates through many examples in Medicine and the Artist.2 Canadian and European cartoonists have a history of using medical imagery—a commonly recognized theme from everyday life—in political cartoons, even when the issue being satirized has no medical or health component. In the 1900s, for example, amongst the cartoons published by the Toronto Star were Les Callan’s 1938 cartoon that used a doctor/patient theme to comment on federal-provincial relations, and Duncan Macpherson’s 1974 cartoon that used the idea of a “cure-all” to depict the Conservatives’ economic policy. The cartoonists thus had a wide repertoire of ready-made ideas and themes to draw from when depicting issues of health-care policy: doctors and money at the expense of the patient, doctors and pain, politicians as doctors, policy as medicine, the country as the patient. Doctors in the images shown here were always men until Health Minister Monique Bégin makes her appearance as a doctor in figure 16. The fact that two of Canada’s health ministers were women, first Judy LaMarsh and later Monique Bégin, was a special gift to male cartoonists in the Medicare debate; it enabled them to draw on prevailing stereotypes of women. EARLY MISSTEP TOWARD NATIONAL MEDICARE

Heather MacDougall analyses the political and policy background to the national health-insurance developments in her contribution to this volume. A cartoon from 1944 (figure 1) arises from criticisms made by

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Figure 1. “What’s Cookin’? A WITCH’S BREW OR A NATIONAL TONIC? THE NATION’S HEALTH IS THE CONCERN OF ALL.” K. C., Worker’s Education Association Bulletin, 11 (1944), © Workers Education Association, Library and Archives Canada, e008319605

two groups who had actively supported the concept of national health insurance: the Trades and Labour Congress and the Canadian Federation of Agriculture. They wanted a national plan but not one that was dominated by the medical profession and excluded the voice of the patient. These two groups, who were not represented at the 1941 Dominion Council of Health meeting and had published their own proposals for health insurance, strongly criticized the draft bill tabled by Minister Ian Mackenzie in 1943. They objected to the dominance of the Canadian Medical Association and the lack of consultation with their members.

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This drawing, the cover image of the Workers’ Education Association Bulletin, presents the views of labour and agriculture by an unidentified artist for the Bulletin’s sympathetic readers. The dominant figures are the tiny black-suited physician labelled “Canadian Medical Association” boosted on a block and a manic bureaucrat labelled “Ottawa” energetically stirring the central pot. The two doubtful, irritated farmers in dungarees placed in the background, marked by their dress as workingclass onlookers, are non-participants in a concept that was supported by most Canadians, including them. The cooking metaphor, combined with the idea of provoking and creating something new and uncertain, “a witch’s brew” or “a national tonic,” itself a medical reference, frames the idea and directs how the viewer will interpret the image. PROVINCES AND PUBLIC HOSPITAL INSURANCE

Three cartoons from Saskatchewan, British Columbia, and Quebec depict artists’ and their newspaper readers’ attitudes to public hospital insurance in these provinces. Aleck Ostry’s chapter provides the historical context to the cartoons, with special attention to Saskatchewan. He describes the changes in hospital development and public financing that eventually led to the national Hospital Insurance and Diagnostic Services Act (1957) and the implementation of hospitalization across the country over the next five years. The second cartoon (figure 2) appears three years after the Saskatchewan social democratic government led by Tommy Douglas had begun to enrol all its citizens in a universal plan to provide hospital services. The circumstances and events that made possible such a public policy breakthrough in a relatively poor province like Saskatchewan are described in detail by Stuart Houston and Merle Massie in their chapter on the precursors of Medicare and by Gordon Lawson in his essay on the Health Services Planning Commission in Saskatchewan. By 1950, the hospital insurance plan was working successfully: new hospitals had been built, doctors were well paid, hospital financing was sound, and patients were being treated. The cheerful surgeon reports to an equally cheerful premier that, even though he (doctors) tried to kill it, the plan (made of iron and therefore indestructible) is alive and well. The 30year-old artist Ed Sebestyen had just started his life-long career at the Saskatoon newspaper, which culminated as its executive vice-president. The subject of figure 3 is Premier W. A. C. Bennett’s decision to retain the compulsory nature of the British Columbia hospitalization plan, rather than make it voluntary as he has promised in an election campaign. This political history is briefly recounted in Greg Marchildon and Nicole O’Byrne’s chapter on Bennettcare. Bennett got himself in considerable trouble with the media for trying to downplay the compulsory

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Figure 2. “Sorry T. C. In spite of our efforts … it looks like he’ll live!” Ed Sebestyen, Saskatoon Star-Phoenix, 11 June 1950 Saskatchewan Archives Board, F379-450

nature of the plan by arguing that “voluntary meant only freedom from state prosecution and not freedom to opt out of the plan”—a position that was mocked in provincial newspapers. This is a beautifully drawn image of a sleazy salesman, backed up by Len Norris’s stock smug policeman dangling handcuffs, who enters a house where the owner is cowering under a newspaper announcing that insurance premiums for the British Columbia Hospital Insurance Service (BCHIS) are now compulsory. The BCHIS had had a problematic administrative structure, which W. A. C. Bennett promised to fix when he was first elected in 1952. Despite his aversion to compulsory premiums, they continued until April 1954, when Bennett abolished premiums entirely and instead raised taxes to pay for the program. The artist Len Norris joined the Vancouver Sun as a political cartoonist in 1950, where he made his name as a beloved commentator on how the ordinary citizen coped with political issues such as this. The image contains the details by which Norris became identified: the citizen reacting to a newspaper headline, the bizarre potted plants, the long-suffering wife, and the smug policeman.

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Figure 3. “It’s that persistent insurance man again, with a NEW sales gimmick this time …” Len Norris, Vancouver Sun, 4 December 1953 SFU Library Editorial Cartoons Collection, 1-1953-12-04

The last cartoon relating to hospital insurance (figure 4) dates from the brief four months that Paul Sauvé was premier of Quebec following the death of long-time Quebec Premier Maurice Duplessis. In 1959, the government of Quebec refused to accede to the national hospital insurance plan on the grounds that the plan encroached on provincial jurisdiction. Aline Charles and François Guérard discuss in their chapter the form of public-private partnership between the state and the private (for-profit) hospitals that continued to exist in Quebec even after it joined the national hospitalization plan under the new government of Jean Lesage in 1961. An uncomprehending Paul Sauvé looks to the heavens to find the answer to the question of why one would join a health insurance program while sitting beside a dying patient whose bedside table holds medicine bottles labelled with past Quebec government scandals. Paul Sauvé had in fact given a speech after becoming premier in September 1959, in which he laid out a progressive program that hinted at the massive social changes that were to come under Jean Lesage’s premiership. Clearly, however, the artist identifies Paul Sauvé with the Duplessis regime, depicting him as an idiot who fails to notice the patient’s state. The 30-year-old-artist Normand Hudon worked full time from 1958 to 1961 for Le Devoir, a left-wing Montreal newspaper that had exposed

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Figure 4. “Sauvé: Pourquoi s’joindre au plan d’assurance maladie-santé?” Normand Hudon, Le Devoir, 1959 McCord Museum, M997.63.101

the scandals and corruptions of the Duplessis and the Union Nationale governments throughout the 1950s. His cartoons supported editorial policy during this period; his cartoons of Duplessis often showed a vulture lurking in the frame. This particular cartoon exemplifies Hudon’s economy of line that was so effective in getting his message across. SASKATCHEWAN AND THE DOCTORS’ STRIKE OF 1962

Saskatchewan’s provincial election in 1960 was fought over the issue of introducing a single-payer system of medical care insurance. After its victory, Tommy Douglas’s CCF government took steps to implement universal medical care insurance, but at all stages it was opposed by the College of Physicians and Surgeons of Saskatchewan. This opposition culminated in a province-wide, 23-day doctors’ strike on the day that the Medical Care Insurance Act was to be implemented, 1 July 1962. In his recollections of the event—as a minister under Premier Douglas and subsequently under Premier Woodrow Lloyd—Allen Blakeney provides his unique insights into this bitter period of history. He singles out the partisan media coverage of the strike, notably the distortions of the truth that some newspapers and weeklies used to whip up public

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Figure 5. “Have you any doctors in your car?” Ed Sebestyen, Saskatoon Star-Phoenix, 14 March 1962 Saskatchewan Archives Board, F379-1293

fear. The three cartoons shown here indicate the tone of the media battle that developed over the spring and summer of 1962. Figure 5 dates from the three months before the Medical Care Insurance Act was to come into effect, when doctors in Saskatchewan who opposed Medicare were threatening to leave the province. Here Woodrow Lloyd, Tommy Douglas’s successor as premier, is depicted as a customs officer (an oft-maligned bureaucrat) trying to ensure that no doctors are being smuggled out. The sign “YOU ARE NOW LEAVING SASKATCHEWAN,” coupled with Lloyd as a customs officer, implies that Saskatchewan has become a foreign state where doctors are held against their will. The artist Ed Sebestyen became extremely well known for his popular cartoons on the Doctors’ Strike that appeared in the Saskatoon Star-Phoenix, one of the newspapers that Allan Blakeney identifies for its biased reportage. The cartoon series was later published as Is There a Doctor in the House?3 The 1962 Doctors’ Strike attracted enormous attention from the rest of Canada and internationally. The next pair of cartoons was published in the Toronto Star, a left-leaning newspaper known for its support for social justice, which nevertheless gave Duncan Macpherson freedom from the editorial position to choose his subjects from across the political spec-

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Figure 6. “WOULDN’T YOU RATHER BE DEAD THAN RED?” Duncan Macpherson, Toronto Star, 11 July 1962, © estate of Duncan Macpherson Library and Archives Canada, 1987-38-178

trum. These images give a sense of the shocking scare-mongering tactics that anti-Medicare forces used—tactics that were once again on display during the more contemporary debate on Obamacare in the United States. Outside Saskatchewan, the press was more critical of the 23-day Doctors’ Strike and its supporters who loosely connected the term “communism” with Medicare to instil fear and suspicion in peoples’ minds. In this cartoon Duncan Macpherson uses his humble “everyman” figure to represent Saskatchewan, meekly holding his hand out for medicine, as Ross Thatcher, Liberal opposition leader in Saskatchewan and critic of Medicare, taunts him. On 12 July a mass rally in Regina of the Keep Our Doctors (KOD) organization delivered a petition to Premier Lloyd urging the government to suspend the Act. Duncan Macpherson’s pen became sharper in this drawing with his depiction of the self-centred, possibly blind man wearing many hats (labelled chambers of commerce, town councils, College of Physicians and Surgeons, anti-NDP government) anonymously being offered another hat—a Ku Klux Klan hood. This image makes a

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Figure 7. “PLAN MUST SATISFY ALL (mainly me!).” Duncan Macpherson, Toronto Star, 13 July 1962, © estate of Duncan Macpherson Library and Archives Canada, 1987-38-180

frightening connection between the anti-Medicare forces and the violence and racism associated with this infamous secret society. The wording on the placard “Plan Must Satisfy All” can be seen in photographs of the rally. FINAL PUSH FOR UNIVERSAL MEDICAL CARE INSURANCE

The six cartoons in this section present a wide range of policy, opinion, mood, and decision in the path towards the adoption and implementation of the national medical care insurance system. The years from 1962 to 1970 include complicated debates within the Liberal Party of Canada, about the type of system that would be proposed. P. E. Bryden’s article is the key to interpreting the historical context within which these cartoons were drawn. Interwoven in her history of the Liberal Party during this period is the subject of federal-provincial relations that enables the viewer to make sense of the cartoon about John Robarts’s plan for Ontario, based on subsidizing private insurance companies rather than Saskatchewan-style Medicare, where the government acted as a single payer, as described by Greg Marchildon in the introductory chapter.

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Figure 8. “L’assurance-santé et les partis politiques.” Normand Hudon, La Presse [?], 1962 McCord Museum, M997.63.257

Figure 8 was drawn after the 1962 federal election when Medicare was being hotly debated, all the more after the Saskatchewan government had implemented its plan on 1 July 1962. Here the four federal party leaders indicate their positions regarding Medicare: ranging from total health insurance (Tommy Douglas, now leader of the federal New Democratic Party), aiming higher (Lester Pearson, leader of the Liberal Party—the official opposition), relying on existing insurance companies (Réal Caouette, Social Credit) and awaiting the result of the Hall Commission (John Diefenbaker, prime minister and leader of the Progressive Conservatives). As an indication of where he stands, artist Normand Hudon has transferred the vulture that always hovered in his cartoons of Maurice Duplessis to a new target, Prime Minister Diefenbaker. By November 1964 when the cartoon in figure 9 was published, the Royal Commission on Health Services (known as the Hall Commission after its chair Mr Justice Emmett M. Hall) had tabled its report. The Hall Commission recommended a universal medical care insurance plan along the lines developed by Saskatchewan, putting pressure on the new Liberal government under Lester B. Pearson to provide some national direction.

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Figure 9. “… Palpitation? Heart flutter? … Ever feel a pounding in the chest? … Heart ever skip a beat? … Erratic pulse?” Sid Barron, Toronto Star, 12 November 1964, © estate of Sid Barron Library and Archives Canada, 1989-151-14

Sid Barron, an enormously popular artist, who drew for Maclean’s magazine as well as for the Toronto Star, was known for his detailed gentle social commentaries. Here he enjoys showing the attitude of a physician who sits in front of anti-Medicare propaganda barking out questions at a half-clad, therefore vulnerable patient. Medicare is categorized in the poster behind the doctor as “Another step down the path to a weakwilled, socialistic, panty-waist, defeatist society.” In the lower right corner Barron’s cat, his personal mark, props up his chin as he listens. By the summer of 1965 Lester Pearson was ready to make his government’s proposal for a national health services program to the provinces at the first ministers meeting held from 19 to 22 July. Health Minister Judy LaMarsh had been sounding out the views of her provincial counterparts ahead of time to smooth the way for its eventual passage. Duncan Macpherson presents the Liberal government’s medical care insurance proposal to the first ministers on 19 July 1965 as an act of desperation by a prime minister desperate to win public approval and the

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Figure 10. “Now for my next act.”Duncan Macpherson, Toronto Star, 20 July 1965, © estate of Duncan Macpherson Library and Archives Canada, 1987-38-328

next election (figure 10). Pearson is depicted as a bumbling jester surrounded by his failures. At the last minute, a hand from the wings saves his act with a rabbit in the hat. Pearson was returned to office after the November 1965 election but, despite his promise to proceed with a national scheme for universal medical care insurance, with another minority government. There was intense popular pressure on all political parties in the House of Commons to pass the federal Medical Care Act, finally passed in December 1966. A stumbling block in its progress was the implementation date. While Pearson was out of the country, Mitchell Sharp, a fiscal conservative, acted as prime minister, during which time he pushed for a delay in implementation. Ultimately the Pearson government settled on 1 July 1968 as the implementation date, one year later than the original implementation date, in an effort to strike a compromise between the social progressives and the fiscal conservatives within the Cabinet. During a period when the public felt that the government was wobbling on the implementation of Medicare, artist George Shane (figure 11) shows Mitchell Sharp as acting prime minister, receiving loads of mail supporting Medicare while a “Medicare is communism” lobby of one watches. Shane worked mostly as a freelance cartoonist supplying cartoons for the labour movement. This image was sold to the Cooperative

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Figure 11. “HERE YOU ARE, SIR, … NOBODY WANTS MEDICARE BUT THE PEOPLE!” George Shane, Cooperative Press Association, n.d. [July-December 1966], © George Shane Library and Archives Canada, 1991-26-239

Press Association, the first labour news service in North America. As an artist supporting the labour movement, Shane was acutely attuned to how the anti-Medicare forces continue to connect Medicare with communism. While the federal government was planning its strategy for introducing its Medicare proposals to the provinces in 1965, Ontario was working on its own health services plan, Bill 163, a non-universal plan involving private insurance carriers, in an effort to influence the design of the federal plan. Inspired by John Tenniel’s illustration of the Mad Tea Party, Duncan Macpherson shows (figure 12) how enthusiastically Premier John Robarts, supported by the insurance companies, and Matthew Dymond, Robarts’s health minister, supported by the medical profession, force the unsuspecting citizen (Macpherson’s “everyman” figure) into the teapot. Dymond is recognizable to viewers of the period by his exaggerated curly hair and glasses and his physician’s accoutrement, a stethoscope. Inspired by an illustration from Lewis Carroll’s Alice in Wonderland, this representation of an alliance of business and medicine

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Figure 12. “REALLY, IT’S SUCH A CHEAP PLAN FOR HEALTHY PEOPLE.” Duncan Macpherson, n.d. [1963-65], © estate of Duncan Macpherson Library and Archives Canada, 1987-38-752

suggests a disordered world that does not bode well for the ordinary person. The final cartoon in this group (figure 13) relates to events in Quebec. In the 1970s, the Union Nationale government of Premier Bertrand was on the verge of passing a popular Medicare bill when the provincial Liberals, led by a very young Robert Bourassa, defeated the government. The Liberals then moved quickly to introduce a bill very similar to the preceding one, which was passed in July 1970. Artist John Collins depicts Premier Bourassa as a doctor—carrying the cartoonist’s “UNO WHO” figure in a cage labelled “For Experimental Purposes”—announces in a delightfully cocky manner, “We’re going to be—different.” Since the 1940s, cartoonist John Collins had amused English-speaking Montrealers with his insertion of the humble barreland-bowler-wearing taxpayer “UNO WHO” into many of his cartoons. As a cartoonist, Collins was more of a mild social commentator than a withering satirist. Here he gently suggests the anxiety the Gazette’s con-

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Figure 13. “ENTER THE GUINEA PIG.” John Collins, Montreal Gazette, n.d. [1970], © Library and Archives Canada Library and Archives Canada, 1986-9-574

servative readers feel about how the new Medicare program will affect them. MAKING A JUST SOCIETY

Among the social aims of Pierre Trudeau’s Liberal government was the creation of the “Just Society.” In the early 1970s, governing with a minority government supported by a New Democratic Party opposition, Trudeau’s National Health and Welfare Minister Marc Lalonde released a policy document titled “A New Perspective on the Health of Canadians.” At a time of stagflation—high unemployment and inflation—it was designed to shift the discussion of health and health care from the expensive funding of hospitals, doctors, and illness care to illness prevention and the broader determinants of health. The physical characteristics of Prime Minister Pierre Trudeau and his Cabinet, coupled with the subject matter of the document, is too good to

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Figure 14. “IT JUST ISN’T A GOOD TIME, MARC, TO TELL THE VOTERS THEY’RE OUT OF SHAPE, DRINK AND EAT TOO MUCH AND FIT FOR AN EARLY GRAVE!” Andy Donato, Toronto Sun, 3 May 1974, © Andy Donato Library and Archives Canada, 1993-169-348

miss (figure 14). Andy Donato’s brilliant drawing provides an unsurpassable match of subject, caption, and representation. The cartoon was published just before this minority Parliament ended. After, in July 1974, Trudeau was re-elected with a majority. The Lalonde Report—as it became known—would come to be highly regarded outside Canada. SAVING MEDICARE

Economic problems resulting in wage and price controls in the late 1970s, and conflicts with both the provinces and the medical profession endangered the very principles of Medicare. As federal funding to the provinces began to slow and as provinces looked for savings, some physicians began to bill their patients extra fees, and some hospitals and medical clinics began to charge user fees. In 1979, Emmett Hall was asked by the short-lived Conservative government of Joe Clark to examine Medicare in practice and its legislative basis, and to report on its state.

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Figure 15. No title Tom Innes, Calgary Herald, 6 September 1980 Glenbow Archives, M8000-678

Tom Innes’s cartoon (figure 15) was published after the second Hall Report was presented when the Liberals were back in government. It shows a doctor character wearing a button labelled “MDs” who recoils as Hall offers a spoonful of the “Hall Report” from the “medicare” bottle while saying, “Come now … Take your medicine!” Hall’s check-up report on Medicare, released three days earlier, recommended abolishing both “extra-billing” of patients by physicians and the imposition of “user fees” by hospitals and medical clinics. There is a strong sense here that the doctor is behaving like a child who has to be persuaded to take his medicine by the kindly old man. By 1980, the artist Tom Innes had been editorial cartoonist at the Calgary Herald for almost 30 years. Medicare continued to be hotly contested in the early 1980s; it was proving an extremely expensive program but one that had attracted organized public support. In July 1983 the Department of National Health and Welfare under Minister Monique Bégin published a position paper titled “Preserving Universal Medicare” that outlined the Canada Health Act that was presented to Parliament in December 1983. It affirmed the existing principles of Medicare and also recommended adding a fifth principle of accessibility. This cartoon was published days after the position paper about the future of Medicare was presented. In Alberta, physicians charged an

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Figure 16. No title Tom Innes, Calgary Herald, 27 July 1983 Glenbow Archives, M-8000-1297

extra “balance billing” to make up their incomes. Here, artist Tom Innes uses a doctor-patient image to make the point that funding cutbacks to the provinces will hurt the provinces. The pathetic patient asks the intimidating doctor (Monique Bégin), who is holding a gigantic hypodermic syringe labelled “Fund cutbacks”—a reference to cutbacks in federal health transfers to the provinces. To the patient’s question concerning side effects, the doctor replies, “Pain … Pure unadulterated pain!” Innes makes excellent use of the powerful imagery embodied in the hypodermic syringe, particularly since he can place it in the hands of a powerful woman, a scene drawn from many a male nightmare? After the Canada Health Act was made into law, all provincial governments had to stop the practice of extra billing and user fees within three years in order to get their share of federal transfer money fully restored. The medical profession responded dramatically with strikes in Quebec and Ontario. The Ontario government introduced its new Health Care Accessibility Act in December 1985, which ended user fees and extra billing, affecting some 20% of the medical profession who had opted out of the provincial plan. The government’s attempts to negotiate a settlement with the Ontario Medical Association failed in June 1986 when the doctors went on strike.

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Figure 17. No title Merle Tingley, London Free Press, 26 February 1986, © Merle Tingley Library and Archives Canada, 1987-55-37

This cartoon was published during the attempted negotiations with the Ontario Medical Association that ended in strike action by the medical profession. Liberal Premier David Peterson is depicted as a snake charmer playing “Ban extra billing” to two defiant snakes representing organized medicine in Ontario. The strike, lacking popular support, caused massive damage to the medical profession’s reputation. CONCLUSION

How did Canada’s cartoonists depict publicly funded health care? As professional artists they clearly brought energy and imagination to the subject. Eight artists used a medical reference as a framing device: doctor and patient (four), doctor as activist, bedside visit, hospital and laboratory setting. The doctor, both metaphorical and actual, is depicted variously controlling and meddling (figures 1, 12, 13), questioning and intimidating (figures 6, 9, 16), and in other images being instructed by a lay figure (figure 15) or reporting as a subordinate to a provincial premier (figure 2). The taxpayer / ordinary man is shown as a dying, vulnerable, grovelling, humble patient or as an anxious, puzzled, bullied person.

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The cartoonists present a very male world, an accurate reflection of gender imbalance in politics, the media, and the medical profession in the period 1944-86. The only two women shown are Len Norris’s drawing of a wife (figure 3) and Tom Innes’s drawing of Monique Bégin (figure 16)—both depicted as commanding presences. Duncan Macpherson’s work is shown four times. He is a superb artist who could draw on a deep well of general knowledge to illuminate his subject. Two of his cartoons (figures 6, 7) satirize the 1962 Doctors’ Strike that attracted widespread interest nationally and abroad. They are powerful and shocking images, chilling rather than comic, of the closed minds of people blinded by ideology and bigotry. The 17 cartoons shown in this chapter, selected from hundreds available, indicate the attitudes, emotions, and differing regional expressions that Canadians felt during the debates over national health insurance. These debates provoked anxiety and uncertainty which was exacerbated in times of unemployment and inflation. At the same time, many Canadians welcomed universal health insurance because life before Medicare was still a recent memory. ACKNOWLEDGMENTS

The author wishes to thank the anonymous reviewers for their helpful comments and Greg Marchildon for his patience and support throughout the preparation of this paper for its original publication and during its revision. This paper grew out of research in preparation for a virtual exhibition about the history of Canadian Medicare undertaken for the Canadian Museum of Civilization in 2007. NOTES 1 Peter Desbarats and Terry Mosher, The Hecklers: A History of Canadian Political Cartooning and a Cartoonists’ History of Canada (Toronto: McClelland and Stewart, 1975), p. 243. 2 Carl Zigrosser, Medicine and the Artist: 137 Great Prints, Selected with Commentary, 3d ed. (New York: Dover Publications, 1970). 3 Ed Sebestyen, Is There a Doctor in the House? A Case History, in Cartoons, on Saskatchewan’s Medical Care Plan (Saskatoon: Star-Phoenix, no date).

6 After Medicare: Regionalization and Canadian Health Care Reform TERRY B OYCHUK

INTRODUCTION

Canadian health policy witnessed three overlapping transitions in the postwar era. The first, roughly from the close of World War II to 1971, was marked by the steady expansion of federal grants-in-aid for provincially administered health services and successive political victories for universal hospital and medical insurance in both provincial and federal parliaments. National health insurance brought in its wake a second transformation, beginning in the early 1960s and continuing through the 1970s. This was the dramatic growth and reconstruction of ancillary health services: community health clinics, mental health services, nursing homes, home care, public health and prevention services, specialpurpose public housing, etc. The third, ongoing transition in Canadian health policy began in the mid-1970s. The release of the Lalonde Report and the advent of the Established Programs Financing Act represented its points of departure. Therapeutic skepticism, a diminished faith in the contributions of acute care to health and well-being, and the restoration of provincial flexibility in health-care financing and administration are the hallmarks of this third transitional period. The reconfiguration of ideas, institutions, and interests embedded in Canadian health policy have provided a permissive context for the resurgence and reinvention of localized health administration in the last four decades. Every provincial government has experimented with creating regional or district health authorities with broad jurisdiction over the delivery of health services, and, with the exception of Alberta and Prince Edward Island, have elected to sustain them as progressive innovations in health-services administration. Regionalization does not represent a commitment to local self-governance as the ultimate end of health policy, though even so, precepts of community involvement, consumer participation, and the like have anticipated—and to a certain extent provided a rationale for—increasing reliance on local authorities for admin-

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istering health care. Nor has regionalization greatly diminished the importance attached to acute-care services in provincial health budgets, although it has striven for a more equitable balance of investments in health and social services and improved coordination between these two branches of health promotion. Regionalization has thus far brought practical definition to a more limited agenda—establishing new forms of accountability and efficiency in the financing and provision of health care—the logic of which has surfaced from the realities of strained public finances, dire predictions of burgeoning demands for acute-care services, and of the perceived lessons drawn from federal and provincial experience with underwriting health services. This chapter develops in three parts. The first considers the changing institutional environment of Canadian health policy since the mid-1970s. By “institutional environment” I am specifically referring to the ideological, fiscal, and technological forces that have set the national context for health-policy deliberations. These elements underwent important transformations in the era of Medicare. Rapid development of communication and transportation technologies in the broadest sense, and technological advances more specific to health care, have vastly expanded the ways in which health services may be monitored, supervised, organized, and delivered. Ideologically and fiscally, the dynamics of federalprovincial relations have reaffirmed the basic tenets of federal intervention into health-care financing: universality, comprehensiveness, accessibility, and public administration. But Canadian governments have also acknowledged accountability, efficiency, and effectiveness as cardinal virtues governing health policymaking. These novel rationales for justifying policy, added to the original guiding principles of Medicare, have created new opportunities for innovation in health-care financing and organization. Part 2 describes the regional organization of health services in Canada from the mid-1960s to the 1980s. The purpose here is twofold. The first is to provide historical and analytical benchmarks for contrasting newer and older approaches to health-services districting, with particular attention to incipient models of regionalization in Quebec and Saskatchewan. Reviewing the experiences of these two provinces offers an illustrative, not exhaustive account of the origins and accomplishments of early experiments with regionalization. An overview of the historical development of regional health policies in every province is beyond the scope of this study, but the evidence from select provinces indicates that regional health authorities operated largely within the confines of the allied health-services sector and tended toward fragmentation and poor coordination during their formative stages. Current attempts at regionalization represent a concerted effort to overcome the characteristically centrifugal drift of the old, while advancing social services models of health-care financing and delivery. The second motive for surveying

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the evolution of regional health-care administration is to trace the origins of provincial endorsements of regionalization as a medium of health reform. Understanding how Quebec and Saskatchewan came to embrace regionalization as a vehicle for making the health-care system more accountable, affordable, and effective provides a window of insight into the lessons that the provinces have drawn from their historical experience with health-services districting. Part 3 provides an overview of the defining moments and features of policymaking in the 1990s. The discussion here illustrates how the architecture of health-care districting has balanced the complex objectives of health reform. Correspondingly, I take up some of the paradoxes embodied in the health regions model. Administrative rationalization has taken precedence as the object of reform across the nation: the creation of district health boards charged with coordinating the work of several branches of the health-care establishment—hospitals, nursing homes, clinics, home-care agencies, and other sundry health agencies operating within their boundaries. The democratic pretexts of health districting emphasizing localized, participatory governance of health regions have given way to technocratic standards of accountability in the transition to health-services integration—deference to the expertise of provincial ministries in setting the agenda for local reform. Implementing the wellness paradigm that emerged from the decades-long conversation between federal and provincial governments on the priorities of health services has proven to be the slow boring of hard boards but appears to have reaffirmed the historical importance of adequate primary care in Canada. Ultimately, regionalization appears to have taken its place in the historical evolution of Medicare as an enduring, yet ambiguous and contested institution—as with Medicare itself—and one that will serve as an important medium of health reform in Canada for the foreseeable future. THE EVOLVING NATIONAL CONTEXT

The context of Canadian health policy underwent a transformation in the 1970s and 1980s in two overlapping, complementary streams. The first movement, beginning in the 1970s, represented a departure from the consensus that had underpinned national health insurance in at least two respects—one ideological, and the other fiscal. Ideologically, federal and provincial governments began to rethink the contributions of acute-care services to health and well-being. Fiscally, the original costsharing formula joining together federal and provincial spending on health insurance fell prey to extensive criticism and eventual dissolution. The second movement came in the 1980s. It coincided with the growth of health services research in Canada, associated technological advances in health-care delivery, and progress in the statistical and evaluative sci-

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ences. The appearance of cadres of university-based health-services researchers in the social and medical sciences brought greater clarity and definition to critiques of medical organizations and practices. These same experts often generated dismal scenarios of the impact of aging cohorts on an unreconstructed health-care system. Criticism of the acutecare sector also arrived in tandem with the increasing sophistication of community-based and outpatient health services. The joining of these two streams created an opportunity for reinventing the administration of Canadian health services. Health Care in Question The early 1970s witnessed national health insurance’s ultimate assimilation into Canadian political life, and paradoxically, the incipient transformation of its ideological and fiscal underpinnings. The beginnings of a decisive shift in Canadian thinking about the relative contributions of medical and hospital care to health came with the release of the Lalonde Report, A New Perspective on the Health of Canadians.1 Lalonde stressed the importance of environmental factors and lifestyle choices on health as opposed to acute-care services. The report was the first of several to question implicitly or explicitly the preference given to medical and hospital care in provincial health budgets. The report owed some of its influence to gathering skepticism of medical care growing out of the accumulation of cross-national data on health-care spending and health indicators. It was easier to call into doubt the value of acute-care services with demonstratively weak evidence of a correlation between longevity, disability, and infant mortality on the one hand, and acute-care spending on the other, among the advanced industrial democracies. It was also easier to condemn the flaws of Canadian health policy than to specify in convincing detail what sort of arrangements should take their place. Lalonde raised questions but fell short of outlining a comprehensive set of practical adjustments to federal and provincial policy that would establish a proper balance between preventative, environmental, and acute-care branches of health promotion. One obstacle to achieving such a balance lay in the provisions of federal hospital and medical insurance acts. The 50:50 cost-sharing formula of federal grantsin-aid for universal health insurance sought to reconcile two conflicting objectives. The first was giving the provinces the strongest possible incentive to enact public health insurance: raise provincial taxes to meet federal requirements or have provincial residents pay federal taxes to support universal programs in other provinces. The second aim was to have the provinces internalize enough of the costs of universal insurance to become responsible purchasers of health care. To the extent that federal funding succeeded in the first instance, it weakened provincial discretion in substituting other health services for hospital and medical care.

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The Established Programs Financing Act of 1977 represented an important milestone along the road leading to more provincial flexibility and a new generation of health policy. The familiar pattern of Canadian federalism following in the wake of Established Programs Financing—the yielding of more tax points to the provinces, recourse to less-restrictive federal block grants to the provinces, and equalization guarantees culminating in the Canada Health and Social Transfer—gave the provinces more discretion in allocating funds among branches of the health-care establishment. This broad retreat from federal oversight of provincial health and welfare services had key exceptions, of course: federal specifications for universality, comprehensiveness, portability, and public administration for hospital and medical insurance. The Canada Health Act of 1984 reaffirmed these principles, contrary to the general trend in intergovernmental relations favouring more provincial autonomy. But to enforce these principles, the federal government resorted to withholds rather than shoring up fiscal inducements, as it had in the past. The emphasis on sticks over carrots was embodied in federal penalties assessed against user fees and balance billing. Thus, Canadian health-care policy remained wedded to the original intent of federal grants-in-aid of hospital and medical insurance but has allowed the provinces to satisfy those criteria within a wider scope of fiscal effort: spend down, spend up, or spend differently. Reducing or reallocating provincial spending would no longer bring automatic reductions in federal spending. Toward a New Model of Health Care: Wellness, Social Engineering, and Localism The 1970s had witnessed an ideological shift—from unqualified faith in the value of acute-care services to a rediscovery of prevention and health promotion—and new cost-sharing agreements among the federal and provincial governments. The former offered a rationale for reorienting provincial health policy, and the latter, opportunities to reprioritize health spending. Developments in the 1980s and early 1990s strengthened the reform impulse and saw the rise of public debates that favoured localized administration as a modus operandi for channelling health-policy reform. Three emergent movements put Canada on the path to health-care reform. The first was the proliferation of health-care analysts, social forecasting, and attendant controversies over the likely impact on the demand for health care of a burgeoning elderly population. Second, the technological sophistication of health care grew in Canada and most other OECD countries, as well as the scope and finesse of research on the appropriateness and effectiveness of health services. And third, the federal government moved beyond the vague critique of Canadian health care entailed in the Lalonde Report and endeavoured to sharpen the debate over the future of health policy with the 1986

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release of Achieving Health for All. The combined thrusts of these developments crowned social engineering as the leitmotif of health policymaking in Canada and de-emphasized reliance on medical and hospital care in health promotion. The emergent focus on managing the social determinants of health introduced a new vocabulary for talking about health care in Canada and prioritized in spirit the development of organizations compatible with this new ethos. The Canadian health-care system, as constituted in the 1970s and 1980s, took on the pejorative label “sickness system” in public debates. With lessening frequency the causes of health and wellbeing were identified with hospital wards and doctors’ offices in Canada. A “wellness paradigm” that located good health in the attributes of individuals, families, neighbourhoods, communities, schools, and workplaces rose to the fore. The favoured vehicle for promoting health gravitated toward community-based health services—those services oriented toward promoting healthy lifestyle choices and calculated adjustments to the immediate social networks in which individuals live out their daily experience. The logic of health-care reform increasingly revolved around notions of “local-ness” in the 1980s. A perceived crisis in Canadian health policy in the 1980s began with debates over the future of health care for the elderly. The upward shift in life expectancy in the postwar era, the rapid expansion of institutionalized care for the aged in the same period, and the anticipated mushrooming of the elderly population in the opening decades of the 21st century served as one catalyst for widening the debate over the funding and organization of Canadian health care.2 Providers groups, on the one hand, most notably the Canadian Medical Association, responded to projections for increased demand for health care among the elderly with calls for hikes in public spending or expanding the scale and scope of private funding for health care.3 Contrarily, health-care researchers called into the question the assumption that demographic shifts required further investments in acute care. Further, they shed doubt on the appropriateness of providers’ response to the needs of the elderly.4 What policymakers need do, so went the critique, is de-institutionalize and de-medicalize health services for the elderly. Provincial governments sided with de-institutionalization. No provinces proposed increasing hospital and nursing-home beds or expanding the ranks of practising physicians as cornerstones of health-care policy as they had in the past. Technological advances in medical care also created a permissive context for building down the acute-care sector. The American experience has been particularly instructive. The advent of certificate-of-need laws governing capital investment in hospitals during the 1970s, and then the introduction of Medicare’s prospective reimbursement schedule for hospital care in the mid-1980s dramatically increased investment in out-

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patient facilities in the United States and correspondingly significantly reduced the length of hospital stays. The attendant push toward day surgery and supporting advances in less invasive diagnostic and surgical procedures saw hospital bed vacancies rise in the United States. Lessons drawn from American hospitalization patterns were not lost on Canadian observers. Diagnostic, surgical, and convalescent services have correspondingly been re-designated and reorganized as outpatient services in Canada.5 Other technical advances—in particular, the refinement and expansion of the evaluative sciences—have weighed in on the side of those who envisage pruning acute-care services without observable harm. The rapid growth of health-services research among public and then private insurers in the United States, combined with public funding for outcomes research and formulating clinical practice guidelines, surpassed anything of its kind in Canada in the 1980s and 1990s. The outcomes movement had nevertheless established several beachheads in Canada in the 1980s. The preliminary findings and conclusions of outcomes research in both Canada and the United States have generally supported allegations of excessive medical treatment and hospitalization.6 Health-services research has served as a critical legitimating device to build down the acute-care sector through claims to expert knowledge developed independently of health-care professionals and organizations. A third major contributing force to the de-medicalization movement came with the 1986 release of Achieving Health for All.7 The federal report sought to recreate the symbolic terrain of health-care politicking in Canada. Rather than mount a comprehensive critique of the acute-care sector, Achieving Health consciously made little mention of medical and hospital care. It was an attempt to establish a forward-looking blueprint for provincial health policy, however little fiscal power the federal government had at its disposal to impose new norms on the provinces. Nevertheless, the report did much to redefine the problem of health in a way that marginalized acute care, and the document became a touchstone for provincial deliberations following in its wake. Achieving Health defined health in social and psychological terms and extolled the virtues of health promotion and prevention. As distinct from medical engineering with its attendant focus on coping with ill health, the report looked to social engineering as a new model for health promotion in Canada. It suggested that the imperatives of public policy should be the creation of a social order conducive to good health. It thus introduced a new criterion into policymaking: all policies should be assessed in terms of their contributions to health. To imply, as Achieving Health did, that transforming people’s health requires transforming society raises the difficult issue of the appropriate scope of public policy—to be discussed later in this chapter. More relevant to the purposes at hand, the report

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made a distinction between health-promotion mechanisms and implementation strategies that gave added credence to health services reorganization on a local level. Achieving Health identified self-help and mutual aid as two of three key mediums of health promotion. The former concerned individual lifestyle choices, and the latter, everyday social networks. Self-help would require that Canadians’ beliefs, values, and behaviours assimilate what is known about the influence of personal habits on good and ill health, ostensibly through better health education in every conceivable setting: homes, schools, workplaces, recreation, etc. Mutual aid made more explicit reference to social support networks described as critical to preserving and promoting personal well-being: families, neighbourhoods, voluntary associations, self-help groups, etc. To develop the full potential of these health-promotion mechanisms, Achieving Health exhorted direct, public participation in health-services planning at the community level to give institutional expression to this new paradigm. It further named community health services as the appropriate conduit, providing, as it were, “a natural focal point for coordinating services such as assessment, home care, counselling and the valuable work of volunteers,” along with the entire spectrum of social services.8 Local accountability and coordination had moved to the centre stage in Canadian health-care debates. To reiterate, the ideological, fiscal, and technological foundations of Canadian health policy underwent considerable change since the introduction of national health insurance. In broad outline, the Canadian experience mirrors that of other affluent democracies where the costs and efficacy of health care came under intense scrutiny. However much retrenchment has provided the overarching theme for policy development in Canada and abroad, policy responses have varied greatly. In the United States and the United Kingdom, for example, establishing new forms of market competition in health care became the chosen medium for promoting patient control over health care and for improving the efficiency of health services.9 In Canada, policy debates have likewise favoured decentralization of health-care governance, more individual participation in securing health and health care, and better value for money. These same arguments have not located sovereignty in markets, but reaffirmed democratic control of health services. Canadian reforms have preferred voice to exit, to appropriate Albert Hirschman’s classical distinction.10 This notion of local control over health resources had several reinforcing logics in Canada. The health-promotion paradigm so described above contributed one argument. The growing documentation of unnecessary and ineffective care in the acute-care sector contributed yet another. The perceived need to rein in health-care spending in general

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and the associated desire to promote less-invasive and less-intensive care for the elderly as a substitute for comparatively expensive, institutional health services also buttressed calls for elevating locally organized, community health services to the forefront of health policy. And more broadly, the growing recognition of the need to provide a wellintegrated continuum of care so as to smoothly move all patients, not just the elderly, out of acute-care settings to less costly community-based settings gave added force to the notion of localizing health-services coordination. THE EVOLVING PROVINCIAL CONTEXT

Provincial governments have long resorted to varied forms of regional governance, administration, and provision in health care. National debates over health reform that promoted regionalization drew inspiration from, and accelerated, provincial initiatives to expand and reconstruct health and social services in the 1960s, 1970s, and 1980s—policies that had greatly extended the reach and importance of district-level health-care administration. Though regionalization has appeared in many guises, and broad generalizations about regional health organizations would invite lengthy qualifications, a much simplified description would yield the following properties: provincially funded and organized, appointed as opposed to elected governing boards, and functional segmentation within and among various branches of the health services. By the 1980s, the provinces were collectively primed for a thorough re-examination of the successes and failures of regionalized health services, and as such, they became a receptive audience for national proposals that envisaged comprehensive, yet localized solutions to the problems of health-care financing and organization. Unlike the United States, where county governments have often served as basic units of administration, funding, and provision of publicly sponsored health services, provincial governments have generally looked upon local governments as unequal to the task of organizing health services on a district or precinct basis. The provinces have commonly withheld from municipal governments intermediate roles in organizing and governing health services, with the exception of public health measures.11 In their place came provincially appointed boards drawing largely from local, interested parties, either as purveyors or consumers of districted services. Or, in the case of hospitals and the various special-care homes, the governing boards of these institutions were thought to serve equivalent representative and administrative functions. In developing provincially funded health services, the provinces have normally introduced special-purpose health districts that crisscrossed or amalgamated the boundaries of several local governments. The

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regional boards also tended to pillarize health delivery, since stepwise regionalization had been the prevalent form of health-services districting. That is, the provinces tended to regionalize health services in a sequential manner along functional lines: mental health services, home care, nursing home care, community health services, etc. The following discussion briefly recounts the evolution of health districting in the provinces of Quebec and Saskatchewan to illustrate previous manifestations of regional health-care administration. The principal critiques of health districts as constituted in the 1960s and 1970s concerned their failure to establish a continuum of care either by securing mutual accommodations among providers or through unified administration and budgeting. Further, local accountability rarely obtained; vertical linkages to provincial health departments and horizontal linkages among providers were the rule. Health districts exhibited a common pattern of fiscal dependence on the provincial ministry, nominal supervision, and little formal accountability to local constituencies. Notwithstanding these perceived shortcomings, the experience of older regional bodies provided the basis for a new synthesis of concepts and practices that would augur well for the reconstruction of health districts. Quebec Quebec made the first attempt in the national health insurance era to implement comprehensive, district-level health administration in Canada. The Quebec experiment with district health councils represented a comparatively advanced effort to rationalize health-care delivery at the local level, relative to the more ad hoc development of primary, secondary, and tertiary health services in the other provinces. The concept of regional health administration in Quebec made its debut in the Castonguay-Nepveu Commission reports in the late 1960s and early 1970s.12 The Commission recommended the creation of regional health authorities with a mandate to (1) integrate primary, secondary, and tertiary health services into a single, unified administrative framework to ensure continuity of care in the province, and (2) give institutional expression to a new model of health care, that of social medicine, which gave equal recognition to the social, environmental, and biological determinants of health. The practice of social medicine detailed in Castonguay-Nepveu envisaged interdisciplinary health teams comprising physicians, social workers, and allied therapists focused on prevention, to make recourse to specialized hospital and medical services one of last resort. The implementation of health-services districting in Quebec strayed from the ideals of Castonguay-Nepveu.13 The provincial government’s desire to pacify physicians and hospitals made health-care reform in Quebec assume the more familiar pattern of policymaking incremen-

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talism as opposed to the thorough reconstruction called for in Castonguay-Nepveu. The desire to elevate social medicine and preventive services found comparatively mild expression in the creation of local community service centres (CLSCs) and departments of community health (DSCs). CLSCs and DSCs were grafted onto the acute-care sector and became new segments of an otherwise fragmented healthcare system. CLSCs embodied the principles of social medicine but fell short of recruiting a majority of physicians into this avant-garde of medical practice. They did, however, contribute to the spread of private polyclinics or group medical practices. While the DSCs uprooted public health services and located them near or inside hospitals, there is little to suggest they injected a prevention ethos into the strongholds of highly specialized, secondary and tertiary health care. Notwithstanding these efforts, it was, rather, in the realm of decentralization where the major thrusts of Castonguay-Nepveu witnessed more impressive gains. The creation of regional social service and health councils (CRSSSs) in the early 1970s and their subsequent development placed Quebec in front of the other provinces on the road to regionalizing health-care administration. The regional councils held modest responsibilities upon their inception: to advise the ministry on administrative, financing, and planning issues while providing a venue for consultation and collaboration among local health-service agencies. By the early 1980s, the councils had in stages gathered unto themselves significant administrative powers. CRSSSs first assumed control over planning, budgeting, and evaluating the allied health services—mental health, home care, ambulance, and other community-based services—powers later extended to review and approve the programs and financing of health-care establishments such as hospitals and nursing homes. The various administrative commissions operating under the auspices of the CRSSSs developed programs for joint-purchasing supplies for health-care agencies, extensive plans for resource-sharing trained on curbing duplication of technology, equipment, and personnel, and made strides in coordinating once disparate services so as to provide effective continuity of care.14 By the 1980s, Quebec’s regional councils constituted the most advanced experiment in district-level health administration in Canada. Saskatchewan: Regionalization Lost and Found Saskatchewan health districts came full circle in the postwar era—from the birth of the health regions concept, to its abandonment and eventual resurrection. When Tommy Douglas came to power at the beginning of the CCF’s nearly 20-year reign in the province, his newly minted Health Services Survey Commission envisaged the creation of a health-care system comprising 14 health regions. Each district would operate a com-

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prehensive health service for local residents under one coordinate authority. These regional health governments were to offer a full spectrum of preventative and curative services, with community health centres (salaried group medical practices) as the cornerstone of the new model health care.15 The only surviving remnant of the first-ever attempt at comprehensive health planning in the province was Swift Current Health Region No. 1, one of two pilot regions created in the 1940s and later dismantled in the 1960s with the introduction of provincial medical insurance. Organized medicine’s opposition to expanding salaried group practice and local resistance to reorganization vitiated the health regions model. The emerging ethos governing health-services delivery uniquely attributed to the province the required expertise and capital to plan health-care financing and delivery. Sequential, as opposed to comprehensive regionalization became the predominant form of provincial health initiative in the 1960s and 1970s in the drive to reconstruct and expanded the allied health services. Mental health services were first to come under the rubric of provincially funded and organized districts in the mid-1960s. Saskatchewan spearheaded the movement to de-institutionalize the mentally ill in Canada with the planned development of mental health districts (MHDs). MHDs built and administered regional clinics and developed other community-based services to reduce admissions to provincial asylums. Following them came regional Ambulance Boards, and most notably, Home Care Boards (HCBs) in the 1970s. The HCBs greatly expanded the scale and scope of domiciliary health and social services. The reappearance of health-services districting contributed to an emerging patchwork quilt of health programs operating under the auspices of the provincial ministry. The launching of these programs represented the attainment of a laudable objective: the creation of a complete spectrum of health services, at adequate levels, throughout the province. Incremental extensions to provincial funding of these diverse services had nonetheless culminated in a growing frustration with provincial administration. Both the costs of health care and poor coordination among the various branches of the health-care establishment had inserted themselves into the centre of health policy debates by the early 1980s. As for costs, provincial formulas for arriving at yearly estimates for health-care spending rewarded increased use by using past utilization as baselines. Prospective budgets were not tempered with any transparent criteria governing appropriate utilization. Thus hospitals, special care homes, and home care all witnessed hikes in utilization when, in theory, the addition of provincial supports for home care should have lightened the caseloads of hospitals and nursing homes. Baseline budgeting gave rise to another hallmark of health-services provision in the province: inconsistent patterns of use from locality to locality. Such vari-

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ance suggested that utilization rates did not accurately reflect underlying needs for services, but were the artifacts of the idiosyncratic preferences of local health-care professionals and institutions. Coordination problems were as serious as mounting costs. The provincial health department had become balkanized from within along functional lines: medical, hospital, nursing home, mental health, public health, and home care services. Each service had its division within the department with little evidence of communication among them. Even in the presence of an expressed desire for cooperation among the diverse branches, the administrative barriers to coordination were formidable. The units of administration in each case were incompatible. Regional boards did not have common geographical boundaries for each districted service, whereas the institution served as the unit for administration for hospital and special home care, and in the case of medical care, individual physicians. The lack of any shared geographical referents among health-care providers, regionalized health services boards, and local governments made for administrative complexity, and ultimately poor coordination. Demands for improved coordination appeared with the provincially backed expansion of the long-term care sector. Long-term care and community-based services had developed on an ad hoc basis with partial provincial subsidies, and then in the late 1970s and early 1980s, the province expanded funding to broaden access and establish a more even, adequate distribution of services. Soon after, the ministry and the health-care associations began to exhort local providers to create regional coordinating committees to better integrate acute, institutional, and community-based services, given the obstacles to effective coordination within the ministry. From the early 1980s onward, hospitals, special care homes, home care boards, and public housing authorities in the localities responded by establishing assessment and placement agencies (APAs). These were public, non-profit agencies, jointly funded by area healthcare providers. APAs employed social workers and nurses who performed field assessments of prospective beneficiaries of any long-term care or community-based service and then passed on recommendations for appropriate care to respective applicants and providers. APA recommendations were not necessarily binding on either party, but the agencies nonetheless made great strides toward creating an integrated continuum of care by providing a clearinghouse for information for both. A process for assessing and prioritizing client needs and matching them with available services had come together for the first time. By the mid-1980s, a consensus had emerged within the ministry and the Saskatchewan Health-Care Association (SHCA), the umbrella organization representing providers of most institutional and communitybased services, that the future of health-care administration rested on

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decentralizing coordination and supervision of health services.16 The ministry and the SHCA had drawn inspiration from the well-received implementation of the APAs in the localities and from the associated successes of case management for allocating long-term care. The perceived need to provide a seamless continuum of appropriate care had elevated the concept of regionalized coordination to the forefront of public deliberation over the direction of Saskatchewan health care. The SHCA exhorted the province to establish a more formal and permanent framework for coordinating and integrating health services on a regional level that stood to benefit from the goodwill and experience of the local APAs. The provincial response was to commission a study to provide the province with options for reinventing health-care administration on a district or regional basis. So named for its principal architect, R. G. Murray, the Murray report strayed beyond the comparatively modest scope of inquiry attributed to it by its sponsors. The SHCA and the provincial government were initially concerned with bringing the long-term care sector out of disarray. It was here that the potential benefits of regional coordination and integration were most apparent. Neither party contemplated a wholesale re-prioritizing of health-care financing and organization. The timing of the Murray report would disappoint these expectations. The release of Achieving Health for All prefaced Murray, and an unanticipated synergy emerged between provincial demands for comparatively mild administrative reform and the federal government’s more sweeping proposals for a new health-services paradigm that favoured local, civic participation in health-care decision-making. The Murray report became a lodestone, attracting as it did and incorporating many distinct strands of reform that demonstrated some degree of consistency. Murray was no longer confining itself to the matter of administrative rationalization and regionalization. Health districting had become a chosen instrument for realizing broader ambitions: the promise of bringing health services under local, democratic control; giving institutional expression to a wellness paradigm; and providing an organizational vehicle for improving the knowledge base surrounding the appropriateness and effectiveness of health services.17 Future Directions laid a good deal of the foundation for deliberations over contemporary reform in Saskatchewan. Since it subscribed to the guiding principles of Achieving Health for All, Future Directions created one of those rare moments of federal-provincial agreement in a policy domain otherwise riven with discord. Achieving Health and Future Directions went much farther in each other’s company than either could have alone. Relative to the cacophony over federal cost-sharing, these two reports suggested a consensus in inter-governmental forums on the

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future of health reform in Canada. Future Directions and like-minded commission reports that surfaced in most of the other provinces in the late 1980s and early 1990s marked the point of departure for a new stage of deliberation and institution building across the nation.18 ACCOUNTABILITY, EFFICIENCY, AND EFFECTIVENESS

As the evolution of health-care districting in Saskatchewan and Quebec shows, regionalization in both provinces was first identified with provision—establishing an adequate minimum of services throughout each province. It increasingly became a vehicle for health-care administration and coordination, whether through voluntary efforts as demonstrated in Saskatchewan or through the more elaborate, formal mechanisms in Quebec. In the late 1980s and early 1990s, a third generation of health policies bent on refining and extending the role of regional health administration seemed imminent. The newer versions of regionalization would advance the efforts of previous ones to improve continuity of care and to better coordinate a broad range of health and social services. Apart from realizing greater efficiencies in health care by accelerating administrative reforms, regionalization held out the promise of a new era of accountability. It could serve as an instrument for civic participation in health policymaking and for enlarging the capacities of provincial governments to monitor health services and set health-care priorities. The overall effectiveness of the Canadian health-care system would also stand to benefit from new approaches to regionalization, serving as conduits for health promotion as presaged in Achieving Health for All. In the last two decades, the immediate task of institution building has not assigned equal weight and importance to all these laudable objectives. No one of these goals necessarily implies the others, however much Achieving Health and Future Directions were inclined to see elective affinities between them and advertise them as a coherent, integrated set of reforms. In providing regional health districts with stable points of reference for their continued operation, the provinces necessarily gave priority to administrative reorganization and provincial accountability. The rationale underlying the sequencing of district reforms was relatively transparent. Administrative reform was the key to all others. Only when the districts had assumed greater responsibilities for managing and budgeting health services within their jurisdictions would they acquire the means to accomplish other reform objectives. District accountability to the provinces would have no basis but in a working machinery of financial accounting and administrative hierarchy for monitoring health services in the localities. To give practical definition to a wellness paradigm would require broad authority to allocate resources among district health services to channel resources from acute to pre-

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ventative care. Elevating democratization above administrative rationalization might compromise provincial accountability and the objectives of the wellness paradigm. The health districts, if primarily brought under local and democratic control, would not inevitably converge on the model envisaged by the provinces. Administrative reorganization, provincial accountability, and a wellness approach were to be the starting points of local deliberations, not the uncertain outcome of districtlevel politics. Accountability Incipient debates over regionalization embodied unresolved tensions between two competing norms of accountability. The democratic version attributed surpassing importance to registering and acting upon locally derived preferences. The administrative version privileged district responsibility for collecting and transmitting information to provincial ministries of health, specific and accurate enough to allow these departments to modify province-wide policies, plans, and budgets. How these disparate models of accountability would limit the scope of one another was unclear at the outset of reform. In Quebec, for example, it appeared that the civic model might assume great importance. With the 1989 release of Improving Health and Well-Being in Quebec, the stage was set for re-evaluating the accomplishments of the regional social service and health councils.19 The ministry’s white paper upheld the basic tenets and strategic recommendations of Achieving Health, in particular, the importance assigned to citizen involvement in setting health-care priorities. In this new light, the representative functions of existing regional social service and health councils (CRSSSs) were found wanting. In the province’s estimation, the local constituencies that the councils had come to represent were providers, not patients.20 CRSSSs had leaned heavily on the expertise and representation of health professionals and institutions in all phases and aspects of their deliberations and administration. All professions and organizations selectively collect, manage, and publicize information to buffer them from environmental threats to their autonomy, survival, and growth. Whether this is done consciously or is the collateral product of other implicit motivations and behaviours matters less. Health-care providers in Quebec did not likely constitute the exception that proves the rule, or at least the provincial government assumed as much. In sum, the province concluded that the councils had become captive to health-care providers. The lesson of Quebec’s experiment with regionalization was that providers could dominate local agenda-setting in the absence of any countervailing power, if administrative coordination of health services became the primary object of regional governance. Such countervailing power might appear in two guises: one democratic, and the other

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technocratic. The civic route to balancing the influence of health-care providers would have regional boards brought under popular control. Across the nation, provincial governments considered institutionalizing new forms of civic participation, born of optimism about the willingness and capacity of citizens to grasp the objectives of reform and to propel them forward. But what starts out as a strategy for mobilizing consent can also end up enabling resistance. Democratization can slow reforms by institutionalizing the right to oppose them, or by bringing out groups with an axe to grind. As such, the provinces have commonly opted not to ground reform in the shifting sands of localized health politics. The representative functions of regional health boards have alternatively been deferred, scaled back, or modified, and the civic thrust of health reform has given way to concepts of transparency—the right of Canadians to be informed of the workings and performance of their health-care system.21 The technocratic route to countervailing power would require regional boards to acquire information and intelligence about the appropriateness and effectiveness of health care independently of the claims and information originating with providers. In Quebec, the CRSSSs had not given much effort to cultivating alternative approaches to gathering and evaluating data about health services under their supervision. Operating without basic tools of assessment—extensive investments in epidemiological knowledge chief among them—the councils had depended primarily on the kinds of information and knowledge that health-care agencies were willing to make available. Concerted efforts to overcome this knowledge deficit were perhaps destined to displace localized, civic images of accountability with provincialized, administrative ones. District accountability to the provinces—the creation of standardized systems for collecting and reporting data to the ministries for evaluating the performance of the health districts, of determining regional budgets, and of modifying health policies and planning—became the more immediate object of health reform. Regional health districts have nevertheless generated new avenues for representation and deliberation, even if the long-term implications of these intermediaries for health-care governance in Canada remains an open question.22 Given the high profile of health issues in federal and provincial elections, it seems unlikely that Canadians will come to view district assemblies and forums as the primary vehicle for registering their preferences on health policy in the public realm. Though not subject to thorough democratic control, district health boards have institutionalized and bolstered lay participation in local health-care governance. Provincial appointments to district boards have created opportunities for enlarging representation from marginalized populations with distinctive health concerns and needs that are generally over-

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looked in broader deliberations over health policy.23 Lay participation in district affairs has also counterbalanced to some extent the influence of provincial ministries of health and local health-care providers, even though it introduces added complexity and turbulence into regional governance.24 Efficiency Regionalization has long been understood as a promising instrument for improving the appropriateness of health care in Canada. The search for greater efficiency has historically placed a heavy premium on administrative reorganization—the formation of unified, localized supervision over diverse branches of the health-care establishment, excepting physician services. Decentralization held out the prospect of yielding immediate dividends from realizing unexploited economies of scope and scale in health-care administration: ensuring better continuity of care as well as more easily bridging the formidable divides between intensive, costly services and more extensive, but less expensive ones. Apart from the short-term benefits of health-services integration, the long-term dividends would be drawn from shifting the overall balance of resources devoted to curative and preventative services, institutional and community-based care, and health and social services. As such, regionalization carried new methodologies for the budgeting of health care. It provided a window of opportunity for introducing forms of prospective budgeting that pegged allocations to estimates of underlying needs for health services, rather than taking existing service patterns as baselines for future appropriations. Calibrating funding to the demographic profiles of health districts spurred the elaboration of increasingly sophisticated measures and models for determining the appropriate use of health services, subject to ongoing revisions consistent with advances in health-services research. Canadian governments, as with others, are banking on expert knowledge to better guide public spending on health and social services in the quest for more profound and lasting efficiencies in health-care delivery. Saskatchewan became an early exemplar of these new approaches to promoting efficiencies in the health-care system. There, reforms began with the passing of the Health Districts Act and the formal establishment of regional health districts in 1993.25 The following year the province disbanded the governing boards of publicly owned health corporations in the province—hospital and nursing home boards, the home care boards, the mental health boards, the ambulance boards, the public health departments of local government—and regrouped them under the direct supervision of the district boards. The province also empowered regional authorities to negotiate the service contracts of non-profit and for-profit agencies operating within existing networks of publicly

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funded health and social services. Correspondingly, the province reorganized the health department to complement district responsibilities. With the immediate charge of administering and overseeing health services passing to the districts, the ministry reassigned the majority of its administrative staff to the regional authorities. This leaner department redirected its efforts to providing strategic programmatic and planning guidance,26 developing and disseminating technical expertise on information management,27 and budget review. Growing out the movement toward information-based management came accountability increasingly rooted in the application of expert knowledge, epidemiology, and demography in the early stages of reform, for determining health-care needs and budgets. The province historically allocated moneys to health-care providers on the basis of past utilization with all the attendant disadvantages noted earlier. With the establishment of the districts, the province no longer distributed funds directly to specific facilities, agencies, or programs, and further, the districts could not resort to aggregating budget requests from supervised health agencies and then pass along these estimates for provincial approval. Rather, the province mandated population-based funding for the regions.28 This was a variation of prospective budgeting based on elaborate formulas that control for population size, adjusted for age, sex, and other indicators of health status and needs. The fiscal leverage of the province remained undiminished with the introduction of population-based funding. Health district authorities had no powers to tax. The province raised the needed revenues and determined the global budgets for each health district, in a process that largely absented health-care providers from direct deliberations over allocations. Provincially mandated budgeting methodologies required district authorities to conduct a yearly census and continuing needs surveys and assessments.29 The districts have been designated as data-gatherers for the province. The incipient logic of health-services budgeting under regionalization has been to convert, to the greatest extent possible, programmatic issues into technical ones through appeals to bodies of knowledge embedded in fields of health-services research—epidemiology, biostatistics, econometrics, and so on. While population-based budgeting has accompanied significant improvements in the health services infrastructure in Canada, it has been subject to powerful cross-currents that have blunted the thrust of reform. The temptation to relieve tensions over health reform and to defer painful or politically hazardous transitions by infusing more money into the system has proven difficult to resist.30 The return of a robust economy and expanding government revenues in the late 1990s and early 2000s, lingering public suspicion of regionalization as a cost-

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cutting expedient, and popular demands for prioritizing government spending on surgical and diagnostic services to shorten waiting lists for acute care have diluted the impact of new methodologies for budgeting health services, notwithstanding government pronouncements reaffirming the importance of a wellness approach to health reform.31 Effectiveness Provincial reforms thus far have sought to recreate governance: formal decision-making processes, budgeting, and administrative supervision. Changes devoted to improving the overall effectiveness of the healthcare system remain a live concern. Implementing a wellness approach to health promotion, a long-envisaged objective of health reform, is nevertheless a laborious task. Moving too quickly to de-institutionalize health services and give priority to community-based care can generate unwanted dislocations and discontinuities of care in the near term. Incrementalism has prevailed in the transition period. The wellness paradigm—with its emphasis on primary health services, social medicine, public education, and building social support networks—bespeaks lengthy, time-consuming investments in both institution building and what is now commonly referred to as social capital. It is both a social and socializing process, and a comparatively slow one relative to administrative reform. The prospects for institutionalizing the wellness paradigm also seem less certain than other reforms. It is doubtful how far the provinces can travel in the direction of social medicine with reforms exempting traditional fee-for-service medical practice. The provinces have generally temporized on medical reform to avoid confrontations with doctors that threatened to stall progress on regionalization. Many provinces have experimented with plans for reconstructing medical practice along the lines of Quebec’s local community service centres: capitated or salaried medical practices integrated into multidisciplinary health teams. But provincial planning thus far has emphasized relatively modest steps in this direction, suggesting a transitional period of many years, beginning after the consolidation of current reforms and assuming the wellness paradigm will not have lost any of its ideological force or institutional momentum. Whether social medicine will simply become a competing alternative to conventional fee-for-service medicine or the dominant pattern of medical practice through provincial determination is yet to be seen. Thus far progress on shifting resources from illness to wellness services appears modest.32 Moreover, to invest total faith in the wellness paradigm may eventually lead to hopes betrayed. The optimism of the national health-insurance movement—attributing to the acute-care system the power to eradicate disease and disability—may have lost much

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of its lustre in Canada. Does the same fate await the preventionist cause? Or is there a compromise on the horizon that gives balanced recognition to both? Part of the answer lies in whether provincial leadership can determine with greater precision the contributions of the acute-care system to health and well-being, and further, grapple intelligently with the paradoxes and limits of health promotion. It is true that medical engineering has yet to devise ways of fundamentally altering the course of most degenerative, chronic diseases that proximately account for most deaths. To judge the performance of acutecare services solely on the basis of mortality and morbidity rates may not bring us closer to understanding the value of medical and hospital care. If the consensus has it that social and environmental conditions largely determine life expectancy and health status, then it does not follow that the performance of acute-care services can be evaluated according to these indicators. They say little about the contributions of health care to quality of life, the extent to which acute-care services relieve pain and suffering and keep people active. Knowledge of this kind is in short supply. No country has so far demonstrated revolutionary advances in closing this information gap, though increasingly, health-services researchers are turning their attention to these kinds of questions. Absent more definitive answers, arriving at practical decisions about the appropriate balance between preventative services and those acute-care services devoted to rendering the lives of the sick more tolerable may come very slowly. The health-promotion paradigm itself has to face difficult questions about the appropriateness and effectiveness of managing the social determinants of health. Health-promotion campaigns of the past lead to immediate, visible health gains. The public health movement of the late nineteenth century, trained on purifying water supply, regulating sewage, enforcing safe building codes, and subsequently, vaccinations and immunizations, etc., posted measurable improvements in the general health of the population. Present-day extensions of health promotion, on the other hand, project themselves into the realm of the social— as opposed to the environmental—that directly touches upon things personal and private. Further, they often call for immediate sacrifices in the short run in exchange for more diffuse and less visible benefits in the distant future. Many of these efforts must go forward without the assistance of settled controversies about which changes to individual and social behaviours yield the greatest improvements in health status. And even in those instances of consensus over behaviours that promote good health, the social sciences cannot offer conclusive evidence about how to best go about inducing them. There is the ever-present possibility that the social engineering approach to health will collapse under the weight

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of unrealistic expectations, as did the medical engineering model of yesteryear. An important assumption of the wellness paradigm is that an equal distribution of health should be the aim of health policy. Since formalizing universal access to medical and hospital care under Medicare did not equalize the health status of Canadians, the health-promotion paradigm suggests that extra efforts must be made outside the boundaries of the acute-care system to right the balance. Thus, as long as health inequalities persist, it could be said that a proactive wellness paradigm will maintain its raison d’être. Historical experience does not generally support the notion that health promotion can narrow these differences, however noble the aim. For example, public education campaigns designed to combat smoking, drug abuse, and poor eating habits suggest that the educated and wealthy more commonly internalize these messages and make the appropriate lifestyle changes. Health promotion runs the risk of reaffirming long-standing inequalities of health status.33 CONCLUSION

The concept of regional governance has evolved in tandem with the changing institutional environments of Canadian policymaking over the past half-century, beginning with concerns for adequate provision of health services and ending with the movement for accountability, affordability, and effectiveness. The primary achievements of recent efforts to reconstruct health-services districting have been administrative and technical (top-down), and it remains to be seen whether the democratic and social aims of reform (bottom-up) will assume a greater importance in the long run. Health-district planning has been carried out largely in terms of imposing provincially determined norms and standards upon the regional authorities. The guiding rationality has been found in technique—devising formulas, standards, and priorities derived from a growing corpus of findings in health-services research. Nevertheless, district policy will also be made through a process of institutionalizing dialogue between the provinces, health district boards, and local constituencies rather than through the application of technique.34 The future of health policy will also revolve around reaching accommodations among the competing values that inhere in social and medical models of health promotion. The outlines of the new synthesis are not entirely apparent, but the long-term success of health districts will rest on defining health problems realistically in terms of the capacity of the acute-care system and community-based services to address them. Notwithstanding these enduring dilemmas of health reform in Canada, regionalization has become a major catalyst for addressing present needs to improve the

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performance of the health-care system in most provinces, while reaffirming Medicare’s historic commitments to universal access to hospital and medical care. NOTES 1 Canada, Health and Welfare Canada (HWC), A New Perspective on the Health of Canadians: The Lalonde Report (Ottawa: HWC, 1974). 2 Canadian Medical Association (CMA), Task Force on the Allocation of Health Care Resources, Health: A Need for Redirection (Ottawa: CMA, 1984); Woods Gordon Management Consultants, Investigation of the Impact of Demographic Changes on the Health Care System in Canada (Prepared for the Task Force on the Allocation of Health Care Resources, 1984). 3 CMA, Working Group on Health System Financing in Canada, Toward a New Consensus on Health Care Financing in Canada (Ottawa: CMA, 1993). 4 Robert G. Evans, “Illusions of Necessity: Evading Responsibility for Choice in Health Care,” Journal of Health Politics, Policy and Law, 10, 3 (1985): 439-67; and more recently, see Robert G. Evans, Kimberlyn M. McGrall, Steven G. Morgan, Morris L. Barer, and Clyde Hertzman, “Apocalypse No: Population Aging and the Future of Health Care Systems,” Canadian Journal on Aging, 20, S1 (2001): S160-S91. 5 The stripping away of the hospitals’ previous monopoly over sophisticated health-care technologies in the United States has not been replicated in toto in Canada. While there is a well-defined movement in Canada to locate aftercare of hospital-based procedures to the home and intermediate care agencies, the technological pre-eminence of Canadian hospitals goes largely unchallenged. The provinces have typically placed rigorous controls on capital investments in freestanding clinics and practices bent on duplicating the technological prowess of the hospitals. Provincial payments under the medical care acts similarly discourage physicians from performing procedural as opposed to cognitive services. Canadian hospitals carry on as repositories of high technology, but these same technologies have already greatly diminished the custodial role of Canadian hospitals. Every province posted reductions in public hospital beds in the 1980s and 1990s. Canadians have done with fewer hospitals and hospital beds, but the surviving hospitals remain vital institutions. 6 David Eddy and John Billings, “The Quality of Medical Evidence: Implications for Quality of Care,” Health Affairs, 7, 1 (1988): 19-32; Roger D. Feldman, John A. Nyman, Janet Shapiro, and Colleen M. Grogan, “How Will We Use Clinical Guidelines? The Experience of Medicare Carriers,” Journal of Health Politics, Policy and Law, 19, 1 (1994): 7-26; Sandra Tanenbaum, “Knowing and Acting in Medical Practice: The Epistemological Politics of Outcomes Research,” Journal of Health Politics, Policy and Law, 19, 1 (1994): 27-43. 7 Canada, HWC, Achieving Health for All: A Framework for Health Promotion (Ottawa: HWC, 1986). 8 Canada, Achieving Health for All, p. 10. 9 Donald Light and Annabelle May, Britain’s Health System: From Welfare State to Managed Markets (New York: Faulkner & Gray, 1993); Paul Starr, The Logic of Health Care Reform (New York: Penguin, 1992). 10 Albert O. Hirschman, Exit, Voice, and Loyalty (Cambridge, MA: Harvard University Press, 1970). 11 Terry Boychuk, The Making and Meaning of Hospital Policy in the United States and Canada (Ann Arbor, MI: University of Michigan Press, 1999). 12 Quebec, Royal Commission of Inquiry on Health and Social Services, Report, vols. 1-4 (Quebec: Queen’s Printer, 1967, 1970). 13 Marc Renaud, “Reform or Illusion? An Analysis of the Quebec State Intervention in Health,” in David Coburn, Carl D’Arcy, and George Murray Torrance, eds., Health and

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16 17 18

19 20 21

22

23

24

25 26

27

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Canadian Society: Sociological Perspectives (Markham, ON: Fitzhenry and Whiteside, 1981), p. 369-92. Roger Gosselin, “Decentralization/Regionalization in Health Care: The Quebec Experience,” Health Care Management Review, 9 (1984): 7-23. Saskatchewan, Health Services Survey Commission (HSSC), Report (Regina: HSSC, 1944); Saskatchewan, HSSC, Report (Regina: HSSC, 1945); see also Gordon Lawson’s contribution to this volume. W. A. Riddel and G. A. DeCorby, The Saskatchewan Health-Care Association, 1918-1993 (Regina: Saskatchewan Health-Care Association, 1993). Saskatchewan, Commission on Directions in Health Care, Future Directions for Health Care in Saskatchewan (Regina: Commission on Directions in Health Care, 1990). Alberta, Premier ’s Commission on Future Health Care for Albertans, The Rainbow Report: Our Vision of Health (Edmonton: Premier’s Commission on Future Health Care for Albertans, 1990); British Columbia, Royal Commission on Health Care and Costs, Closer to Home (Victoria: Crown Publications, 1991); Manitoba, Manitoba Health, Quality Health Plan for Manitobans (Winnipeg: Manitoba Health, 1992); New Brunswick, Commission on Selected Health Care Programs, Report (Fredericton: Commission on Selected Health Care Programs, 1989); Nova Scotia, Royal Commission on Health Care, Towards a New Strategy (Halifax: Royal Commission on Health Care, 1989); Ontario, Premier ’s Council on Health Strategy, Towards a Strategic Framework for Optimizing Health (Toronto: Premier’s Council on Health Strategy, 1991); Prince Edward Island, Task Force on Health, Health Reform: A Vision for Change (Charlottetown: Cabinet Committee on Government Reform, 1992); Quebec, Ministère de la Sante et des Services Sociaux (MSSS), Improving Health and Well-Being in Quebec: Orientations (Quebec: MSSS, 1989) ; Quebec, MSSS, The Policy on Health and Well-Being (Quebec: MSSS, 1992); Quebec, MSSS, A Reform Centered on the Citizen (Quebec: MSSS,1990); Saskatchewan, Saskatchewan Health (SH), A Saskatchewan Vision for Health (Regina: SH, 1992). Quebec, MSSS, Improving Health and Well-Being in Quebec. Quebec, MSSS, A Reform Centered on the Citizen. Canada, Commission on the Future of Health Care in Canada, Building on Values: The Future of Health Care in Canada (Ottawa: Commission on the Future of Health Care in Canada, 2002), p. 63. Ken Rasmussen, “Regionalization and Collaborative Government: A New Direction for Health System Governance,” in Duane Adams, ed., Federalism, Democracy and Health Policy in Canada (Montreal and Kingston: McGill-Queen’s University Press, 2001), p. 23970. Duane Adams, “The White and the Black Horse Race: Saskatchewan Health Reform in the 1990s,” in Howard A. Leeson, ed., Saskatchewan Politics: Into the Twenty-First Century (Regina: Canadian Plains Research Center, 2001), p. 267-93. Damien Contandriopoulos, Jean-Louis Denis, Ann Langley, and Annick Valetter, “Governance Structures and Political Processes in a Public System: Lessons from Quebec,” Public Administration, 82, 3 (2004): 627-55. Saskatchewan, Statutes, The Health Districts Act (Regina, 1993). Saskatchewan, SH, Guidelines for Developing an Integrated Palliative Care Service (Regina: SH, 1994); Saskatchewan, SH, A Guide to Community Health Centres in Saskatchewan (Regina: SH, 1993); Saskatchewan, SH, A Guide to Core Services for Saskatchewan Health Districts (Regina: SH, 1993); Saskatchewan, SH, Health District Development Guide (Regina: SH, 1992); Saskatchewan, SH, Planning Guide for Saskatchewan Health Districts: Part I, Strategic Planning (Regina: SH, 1993); Saskatchewan, SH, Planning Guide for Saskatchewan Health Districts: Part II, Facilities Planning (Regina: SH, 1994); Saskatchewan, SH, Planning Guide for Saskatchewan Health Districts: Part II, Program Planning (Regina: SH, 1994); Saskatchewan, SH, Supporting Wellness: Supportive Services in Saskatchewan; A Policy Framework (Regina: SH, 1994); Saskatchewan, SH, Users’ Guide to the Health Districts Act (Regina: SH, 1993). Saskatchewan, SH, Annual Report, 1993-1994 (Regina: SH, 1994).

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28 Saskatchewan, SH, Introduction of Needs-Based Allocation of Resources to Saskatchewan District Health Boards for 1994-5 (Regina: SH, 1995). 29 Saskatchewan, SH, Health Needs Assessment Guide for Saskatchewan Health Districts (Regina: SH, 1993). 30 Adams, “The White and the Black Horse Race”; Claude Constanguay, Mémoires d’un révolutionnaire tranquille (Montreal: Éditions Boreal, 2005) p. 274. 31 Saskatchewan, SH, The Action Plan for Saskatchewan Health Care (Regina, SH, 2001); Saskatchewan, SH, Caring for Medicare: Sustaining a Quality System (Regina, SH, 2001). 32 Gregory P. Marchildon, “Regionalization and Health Services Restructuring in Saskatchewan,” in Charles M. Breach, Richard Chaykowski, Sam Shortt, France StHilaire, and Arthur Sweetman, Health Services Restructuring in Canada: New Evidence and New Directions (Montreal and Kingston: McGill-Queen’s University Press, 2007), p. 3357. 33 For more on the social class determinants of health and well-being, see Robert G. Evans, Morris L. Barer, and Theodore R. Marmor, eds., Why Are Some People Healthy and Others Not? The Determinants of Health of Populations (New York: Walter de Gruyter, 1994); Leonard A. Sagan, The Health of Nations: True Causes of Sickness and Well-Being (New York: Basic Books, 1987). 34 Contandriopoulos et al., “Governance Structures and Political Processes in a Public System.”

PART TWO Individual Provincial Histories of Medicare

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7 Four Precursors of Medicare in Saskatchewan C . S TUA RT H OU S TO N A ND MERLE MA SS IE

INTRODUCTION

In 2004, when 1.2 million Canadians voted in a Canadian Broadcasting Corporation competition to choose the Greatest Canadian of All Time, the audience chose Tommy Douglas, who was also known as the “Father of Medicare.” What most people do not know is that Douglas and his team built on the phenomenal successes of several bold rural initiatives that were in place before he came to power in June 1944. These initiatives led to the phenomenally successful Swift Current Health Region (HR#1) two years later, and were important precursors of provincial Medicare in 1962. These bold initiatives came out of the region hardest hit by the Depression—Palliser ’s Triangle in the southwest Dry Belt of Saskatchewan.1 Following the stock market crash in 1929, producers around the world endured record-low commodity prices and decreased international demand, which together led to widespread rural poverty.2 Historians acknowledge that Saskatchewan was the hardest-hit province, and the southwest Dry Belt region endured the worst of it. Extreme drought exacerbated the crash in real farm income, and was compounded by grasshoppers, cutworms, saw-flies, army worms, wheat stem rust, and the ever-present dust. The stories from that region were heartbreaking.3 Many people responded to the dire situation by abandoning their farms and going to the cities or escaping to dust-free northern parkland or forest fringe homesteads.4 Those who did not leave knew what it was to suffer, and to have insufficient money to purchase hospital services or a physician’s care. As the drought receded and wartime brought more affluence, with a reordering of priorities and a willingness to try new social experiments, four key municipalities led the way in promoting new initiatives in health care reform. Health care reform was a complicated issue because it had to bring together several (sometimes conflicting) interests: hospital, laboratory,

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Figure 1. Map of Health Region #1. Prepared by Carol Beaulieu.

and nursing services; doctor’s services; municipal and provincial governments holding the purse-strings; and, of course, the policy-makers and politicians setting the legislative framework at the local and provincial level. Above all, the concern was for the patient. To make matters worse, the care available in each community varied widely, from cottage hospitals staffed by midwives and nurses to municipal hospitals built by taxes and from a doctor’s rented office to a room in the doctor’s home. To bring all these interests into alignment and agreement was no easy task, but a small group of men, the forerunners of Medicare, were able to present bold ideas and leadership that appealed to stakeholders and succeeded against all odds.5 The four contiguous rural municipalities (RMs) of Miry Creek, Pittville, Webb, and Riverside, located near Swift Current in the heart of the Palliser Dry Belt (figure 1), became the incubators of precursor health plans that offered both complete medical and hospital care. This essay will examine those early plans, and follow the people, ideas, discussions and solutions that vaulted them to prominence, and led to the eventual visionary success of the Swift Current Health Region (HR #1), which in turn provided 16 years of experience before Medicare became province-wide. MUNICIPAL MEDICAL AND HOSPITAL PLANS

The two most commonly proposed medical care schemes were medical

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plans which paid doctors and hospital plans which paid for a limited hospital stay. Saskatchewan boasted the first municipally-paid doctor in North America. In 1915, RM Sarnia at Holdfast developed a new tactic to keep their doctor, Henry Schmitt, from succumbing to the blandishments from neighbouring Craik when the Craik doctor joined the Army. In desperation, the RM Sarnia council voted tax money to pay Dr. Schmitt a retainer to keep him from moving.6 While few people at the time appreciated the ground-breaking significance of Sarnia’s action, the next year, Dr Maurice Seymour, the Commissioner of Health in the Department of Municipal Affairs,7 acting with uncommon dispatch, helped to draft an amendment to the Rural Municipality Act in 1916. This amendment, another first for North America, allowed an RM to use land tax money to pay a medical doctor or to build a local, or “union,” hospital.8 A second type of plan originated with Matt Anderson, reeve of RM McKillop at Strasbourg, who had long wished to initiate a health plan similar to that in his native Norway. The Municipal Medical and Hospital Services Act, known as “the Matt Anderson Act,” was passed in March 1939. This act permitted payment of both medical and hospital services via a personal tax. Anderson also persuaded a group of Regina doctors to accept 50% of the Saskatchewan College of Physicians and Surgeons schedule of fees as payment in full.9 The 1939 Act was then amended the next year10 to allow a group of physicians to enter into medical services agreements with municipalities. Almost immediately, five other RMs joined this plan, whereby the patient first consulted the local salaried municipal doctor, but had freedom of choice of specialist once referred to Regina. The health insurance plan organized by Regina doctors, initially named Medical Services Incorporated (MSI), acted as paymaster for specialists beginning 1 October 1940.11 Although fee-for-service payment through the Rural Municipality Act had been possible since the 1940 amendment, almost all the 92 RMs which operated under this Act paid their resident local doctor a salary, effectively pushing patients to go to that doctor.12 In March 1943, only 13 RMs, 3 towns, and 8 villages operated under the less-restrictive Municipal Medical and Hospital Services (“Matt Anderson”) Act, and 118 provided hospitalization.13 All had limiting restrictions. THE FOUR MUNICIPAL PRECURSORS OF THE SWIFT CURRENT HEALTH REGION PLAN

In the late 1930s and early 1940s, four precursor medical plans in the Swift Current area broke out of the standard salaried municipal doctor molds. Each of the four innovative RMs offered its residents comprehensive coverage without limitations, with local control and freedom of choice of doctor. This was a local form of “prepaid health insurance”

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with mild overtones of “socialized medicine”; it took root and flourished in this rural area before the election of T.C. Douglas. RM Miry Creek

The first example was the unique hospital plan pioneered at RM Miry Creek under Reeve Charles Haydon, who emigrated to Canada from Liverpool, England. During World War I, he received a medal for bravery as a medic and stretcher-bearer in the trenches. His wife had worked in the Cancer Hospital in London, England. On 1 January 1937, the year after the Abbey Cottage Hospital closed, RM Miry Creek began its hospital plan, whereby a resident of that municipality, through an additional land tax levy equal to half the amount of the normal municipal taxes, was entitled to hospitalization anywhere in Saskatchewan.14 This plan lasted until HR#1 came into existence on 1 July 1946. The Miry Creek medical plan was added in July 1943 (table 1), paying for visits to any Saskatchewan doctor.15 The RM Miry Creek council knew that the Rural Municipality Act, under which they operated, did not allow indiscriminate payments to doctors anywhere, but “decided to carry on and take their chances,” as will be outlined below. RM Pittville

In 1937, Pittville hired Dr. A. L. Caldwell who lived in Cabri, immediately to the north, to provide medical care for all residents of the RM for $2700 per year.16 On 1 February 1941, RM Pittville for the first time issued hospitalization and medical services cards to all ratepayers, tenants and families. The fee was $8 per adult.17 Revenue fell far short of expenses in the first year, so the fee was raised to $10 per adult for 1942 and $15 for 1943, with a maximum of $30 per family.18 In January 1943, William J. Burak was hired by RM Pittville as its secretary-treasurer.19 When Dr. Caldwell joined the Canadian Army late in 1941, it was “immaterial” to the Pittville council whether their residents saw the salaried RM Riverside doctor at Pennant or the new doctor in Cabri or one of six or so doctors in Swift Current.20 Hence, by April 1943, RM Pittville paid the medical bills if their residents went to “any doctor, any place.”21 One Pittville patient had medical bills paid at the Montreal Neurological Institute, and another at the Mayo Clinic in Rochester, Minnesota.22 Such payments to doctors anywhere in Saskatchewan, and even beyond, were “contrary to the Rural Municipality Act,” as Burak was told in Regina, where RM Pittville council sent him to explain matters to Dr. R. O. Davison, chairman of the Health Services Board at the Department of Health.23 Burak returned with only a promise that “necessary amendments to the Rural Municipality Act will be made in order to make the scheme legal.”24 Doctor and hospital bills were paid immediately upon receipt in the

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Four Precursors of Medicare in Saskatchewan Table 1. Four Municipal Health Plans in Southwest Saskatchewan Name and Number of Rural Municipality (RM)

RM Pittville (#159)

RM Webb (#138)

RM Riverside RM Miry Creek (#168) (#229)

Village or town address

Hazlet

Webb

Pennant

Abbey

Medical health officer

A.L. Caldwell

J.A. Matheson

W.A. Hargrove

None

Hospital / medical levy

3 mills

Name of reeve

R. Stock

James Macleod

Carl Kjorven

Charles Haydon

Name of secretarytreasurer

G.H. Martin

S. Robertson

C.E. Campbell

F. McDonald

Date plan first established

2 Mar. 1939

12 Apr. 1942

23 Oct. 1944

2 Apr. 1942

Bylaw number

67

86

111,112

79,80

Date of RM vote

3 Apr. 1939

31 Mar. 1944

20 Nov. 1944

15 June 1942

Date plan in force

15 Apr. 1941

15 Apr. 1944

7 Dec. 1944

1 July 1943

Premium per adult

$8

$10

$12

$15

Maximum premium per family

Not stated

$50

$24 + $3/child $30

Doctors paid through

RM office

MSI/GMS

Pittville method

Pittville method

Choice of doctor

yes

yes

yes

yes

1.5 mills (hosp)

RM Pittville office.25 Burak freely admitted that the plan was not strictly legal, yet he promoted it as a template for a regional health plan.26 Burak was “a mover and a shaker,” even “a firebrand” as one observer designated him.27 His ambitious plans were in no way impeded by waiting for changes in the letter of the law. Impetuous, Burak blazed ahead, damn the consequences—and brought into being a full health care plan.

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RM Webb

Stewart Robertson emigrated from Scotland in 1920 and in turn tried farming and managing a general store, before accepting a job as the secretary-treasurer of RM Reno in the hamlet of Vidora.28 Robertson moved on to RM Webb in 1940.29 At RM Webb he was instrumental in introducing medical care reform, even though he saw his municipal council’s first two attempts to introduce a medical care scheme fail.30 Robertson and the council tried again and presented two bylaws—one for a hospital plan, one for a medical plan—to a municipal vote on 31 March 1944 when both finally passed, 291 in favour and only 53 opposed.31 Under Robertson’s watchful eye, in contrast to the other three Swift Current area medical plans, RM Webb took the cautious legal route and became one of 13 RMs that functioned under the 1939 “Matt Anderson Act.” Fee-for-service payments were made through MSI to medical doctors locally and in larger centers in two provinces. From the beginning, and contrary to the practice at RM McKillop, both local and distant doctors serving RM Webb residents were paid fee-for-service, at 75% of the schedule of fees.32 RM Riverside

Carl Kjorven, reeve of RM Riverside, gave years of service to the cause of better regional health care. His dedication was motivated by the deaths of two of his children, one-year-old Ella and four-year-old Clifford, during the same winter in the early 1920s.33 Kjorven attributed both deaths to inadequate medical care. He was never bitter about the deaths, but “be damned if he was going to let the same thing happen to anyone else’s kids.”34 RM Riverside, under Kjorven’s tenure, voted to begin their Pittville-style health plan, whereby patients could go to any doctor, anywhere, some five months after the Douglas government came to power and shortly after the Sigerist Commission on Saskatchewan health care tabled their report. Implementation was swift. The council meeting of 23 October 1944 passed the necessary bylaws and the electors voted 90% in favour on 20 November. The council held their next meeting on 6 December and the Riverside health plan came into effect at midnight that night!35 As Joan Feather has said, “The comprehensive health plans in these municipalities not only served as models for programs later adopted by the region, but they also provided experienced leadership for the region’s organization.”36 DOUGLAS AND SIGERIST

T. C. Douglas, on assuming power in June 1944 as the first social democratic premier in North America, began working in step-like fashion, as finances permitted, towards his goal of eventual province-wide

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Medicare.37 The day after his election, Douglas phoned Henry Sigerist at Johns Hopkins University in Baltimore and asked him to chair a committee to plan Saskatchewan’s health care for the future. Sigerist arrived in September 1944 and conducted province-wide hearings for three weeks. These hearings allowed rural health planners to present their initiatives, showing Sigerist that Saskatchewan was a province ready for bold new ideas. One of the longest presentations to the Sigerist commission was from Bill Burak, detailing the comprehensive coverage, freedom of choice, and local control of the RM Pittville health plan. Nearly two years later, HR #1 followed the RM Pittville template to a large extent, such as allowing free choice of doctors, and using a personal tax to generate necessary revenue, but adding a property tax which produced a further 25% of the funding.38 Sigerist presented his formal report on 4 October 1944.39 This became the blueprint for progress towards Medicare that was followed for more than 30 years.40 One of his urgent suggestions was a care plan for widows, mother’s allowance recipients, the blind, and indigent pensioners, groups requiring high per-capita services; amicable dealings with the medical profession resulted in the inauguration of the Social Assistance Plan on 1 January 1945. This plan relieved much of the financial burden for municipalities, as did the later step to province-wide hospitalization two years later on 1 January 1947. Another response to Sigerist was the Health Services Planning Commission (HSPC), created in November 1944, which proposed on 15 February 1945 that the province be organized into health regions with local control and autonomy. The plan also called for salaried (as opposed to fee-for-service) general practitioner service,41 although this continued to be a point of contention and debate. Dr. Mindel C. Sheps, Secretary of the Health Services Planning Commission, presented a Memorandum on Organization of Health Regions to T.C. Douglas, Premier and Minister of Health, on 20 April 1945. She recommended that a health region be initiated on receipt of resolutions from any ten municipal councils,42 and also recommended “provision of public health services in at least two regions.”43 She did not foresee the unstoppable momentum that would be unleashed during her visit to Swift Current only four months later. THE BURAK BLITZ AND THE FORMATION OF THE SWIFT CURRENT HEALTH REGION

On 31 July 1945, regulations concerning the creation of Health Regions under the Health Services Act were published in the Saskatchewan Gazette.44 Immediately, RM Pittville petitioned to establish a health region in the southwest. One presumes that this area was chosen in part

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because Pittville was the first to apply, on behalf of the entire area, and secondly, because here drought and deprivation had led residents to create a comprehensive care plan to benefit all stakeholders and spread the burden of health and sickness.45 Douglas sent Dr. Mindel Sheps to visit Swift Current on 18 August 1945.46 She conveyed Douglas’s desire that the Swift Current region become the demonstration unit for a “public health district,” for preventive medicine only, a field in which Saskatchewan lagged behind the rest of Canada. Burak attended the meeting and proposed instead a full hospital and medical plan, following the Pittville template—and was then named Chair of the one-man “Health Region Organization Committee.” At his own expense, Burak visited weekly newspapers and municipal councils, and mailed out mimeographed information bulletins to every RM, town and village in the area.47 He estimated that “complete medical, surgical and hospital services” could be provided for about $9 per person per year.48 Burak then chaired a meeting on 15 September 1945, attended by T. H. McLeod and Dr. Orville Hjertaas of the Saskatchewan Health Services Planning Commission and representatives from 48 RMs, towns, and villages. At this meeting, the reeves of RM Riverside and RM Big Stick, Carl Kjorven and Walter Melrose, were elected to assist Burak.49 By 1 November the requisite petitions from 10 RMs, the government-stipulated minimum, had been received.50 On 26 November 1945, during the annual province-wide rural municipal elections, residents of the southwest voted 71% for Burak’s more comprehensive plan. This overwhelming voter support was no doubt made possible by the improved economy now that the Depression was over, and the wish to spread the burden of disease and disability widely across the community as the RMs of Pittville, Webb and Miry Creek had demonstrated was possible. On 11 December 1945 a Saskatchewan Order-in-Council formally established Swift Current Health Region (HR #1).51 The first meeting of the HR #1 board assembled in Gull Lake on 17 January 1946, on 4 April the legislature passed the Health Services Act, and on 7 May the Swift Current Health Region board opened an office in Swift Current.52 An “experiment unique in North America,”53 HR #1 came into force on 1 July 1946, two years and five days in advance of Great Britain’s National Health Service plan.54 The Swift Current Health Region offered a children’s dental plan, apparently the first in North America; it also offered full hospitalization six months before provincewide hospitalization came into effect 1 January 1947; and it offered full medical care insurance combined with free choice of doctors, empowering patients to engage in a new way with their health care. When HR #1 was formed, Burak was not appointed as its secretary, nor even considered for the position, for which there were eleven appli-

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cants.55 Bitterly disappointed, Burak resigned from his position at the RM Pittville office on 27 May 1946, a month before “his” health plan came into being.56 Earlier, on 9 February 1946, the RM Pittville council, suspecting that Burak was being discriminated against because of his Ukrainian heritage, lent support on Burak’s behalf by writing members of the HR #1 Board “a letter giving information re W. J. Burak’s activities connected with the health region.” The letter had no effect. Burak moved permanently out of the Swift Current area, serving in turn as a municipal secretary at Ogema, Aberdeen, and Hafford.57 SUCCESS OF THE SWIFT CURRENT HEALTH REGION

Bill Burak’s whirlwind campaign in 1945 brought a full medical care plan—both hospital and medical services—into being in southwest Saskatchewan. Success was even sweeter because earlier experiments elsewhere in rural Saskatchewan had either failed or died in the planning stage.58 Regional support for a sanitary officer for the Weyburn region had lasted only one year. A health district in the Gravelbourg area, with a full-time medical health officer, and one-half of the costs assumed by the provincial government and the Rockefeller Institute, lasted only three years, 1929-32. At best, plans for Yorkton, Weyburn, Estevan, and Moose Jaw did not get beyond the planning stage.59 Success of HR #1 depended on a number of factors. The timing was right. Grain prices were on their way up. Rain was beginning to fall again. Dust storms and grasshoppers were less of a menace. There was feed for the cattle and horses. The exodus to new farming areas in the Peace River country of Alberta and to the mixed forest of northern Saskatchewan had ceased. World War II produced a labour shortage as men and women went off to war; war production, the postwar baby boom, and the need for food induced economic growth. But perhaps even more than economic and local conditions was the famous co-operative spirit of rural Saskatchewan people, their innovative nature, and the “integrity, pragmatism and openness of all concerned.”60 This was coupled with their desire to overcome the dire medical and social problems induced by the Depression. These qualities meshed with Tommy Douglas’ threefold legacy of idealism, prairie pragmatism and tenacity previously identified by Greg Marchildon.61 Pragmatism personified the leadership of HR#1. Stewart Robertson, in his 21 years of service as what today would be called Chief Executive Officer of HR #1, was known as a canny, frugal Scot. His first secretary, Pat Cammer, gave three reasons for HR #1’s success: “its autonomy; a mutual trust between the doctors and the Regional board; and Robertson’s ability to manage the Region’s purse as if it was his own.”62 Robertson’s subsequent appointment to the Saskatchewan Medical Care Insur-

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ance Commission in 1962 was another indication of his reputation. Carl Kjorven had already given many years of service as councillor (193036), reeve of RM Riverside (1937-51), and as the initial chair of HR #1. “Influential and highly regarded,” a superb chairman of meetings, he gained a reputation as “the great persuader.”63 He was famous for “calming ruffled feathers with his quiet diplomacy.”64 Charles Haydon had been a councillor of RM Miry Creek, 1927-36; reeve, 1936-52, and represented RM Miry Creek on the Cabri Municipal Hospital Board from 1929 to 1951. His 30 years of public service are an indication of both his dedication and his abilities. He was on the initial board of HR #1 in 1946, then spent his last seven years as chair after Carl Kjorven retired.65 In HR #1 there was little opportunity for failed communication.”66 For years, Dr. Vince Matthews, Stewart Robertson, and Dr. Casimir Wolan, the doctors’ representative for financial matters, would have coffee together most mornings at the Venice Café in Swift Current.67 There was a spirit of trust and a willingness to work out problems. 68 The administration of HR#1 exemplified local and participatory approaches to public policy on health care at its best. These were coupled with a sense of fiduciary responsibility; each year through 1953, the HR #1 plan lived within its budget under the “ceiling principle.”69 Similarly, the province-wide Social Assistance Plan was “policed” by the medical profession to ensure an equitable division of earnings.70 Scrimping and penny-pinching were carried to a fine degree; when utilization went up, the doctor ’s unit payment went down.71 “The doctors “could be much tougher on an over-billing member than any government agency.”72 Nurses often worked overtime without extra remuneration, and in remote facilities they were on what we now know as 24/7 call, as were nearly all rural MDs. HR #1’s infant mortality rate, once one of the highest in the province, fell to 11.4 per thousand live births, the lowest in Saskatchewan.73 Part of the explanation lies in the change from almost universal home deliveries, sometimes in a shack with an earthen floor, to the antiseptic sanitary regimen of the small hospital. With the cost barrier levelled first in the Swift Current region, many women came to hospital for childbirth for the first time.74 The Douglas government had originally envisioned a demonstration region with a focus on preventative health. The pioneers of the Swift Current region reached for something more—the seamless integration of preventive medicine with medical care.75 Dr. Vincent L. Matthews, the medical health officer for HR#1, also acted as accounts assessor and statistician for the regional board. He kept his eye on both health and the bottom line. The result was effective, practical, affordable, and sustainable health care provided at a local level. Patients felt empowered with a sense of ownership. The Board felt accountable to the people.

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The reeves of the two northernmost RMs, Riverside and Miry Creek, Carl Kjorven, and Charles Haydon, provided continuity and dedication. They stayed on to provide guidance to HR #1 through its best years.76 The doctors and nurses supported the plan and demonstrated a willingness to sacrifice. Local control, a defining feature of the four precursor plans, continued in HR #1 from its organization in 1946. This local control was lost with eventual province-wide implementation of public medical care insurance in 1962, although freedom of choice of doctor was maintained. The CCF government was the undeniable beneficiary of what the precursors of Medicare had pioneered. ACKNOWLEDGMENTS

Joan Feather, Lester Jorgenson, Leah Robertson Koldingnes, and Katherine Robertson Galloway, provided helpful information. We are grateful to the administrators of six rural municipalities: Barbara Griffin at RM McKillop #220; Terry Erdelyan and Nola Zinn at RM Pittville #169; Connie Sorenson and Shelly Thierman at RM Webb #138; Debbie Shaw and Sharon Swan at RM Riverside; Cindy Genert and Kim Lacelle at RM Reno, as well as Jan Stern who gave Lester Jorgenson access to RM Miry Creek minutes on our behalf. Gordon Lawson’s perceptive comments spurred Dr. Houston to do additional research into minutes of the four most active municipalities near Swift Current; Gordon has since contributed a number of corrections and suggestions. Bill Waiser and Andre Gerard have helped direct the reconfiguration of the manuscript. Greg Marchildon provided essential support and guidance throughout the preparation of this paper. NOTES 1 James H. Gray, Men Against the Desert (Saskatoon: Western Producer Prairie Books, 1967). 2 Bill Waiser, Saskatchewan: A New History (Calgary: Fifth House, 2005), p. 280. 3 W. A. Mackintosh. Economic Problems of the Prairie Provinces (Toronto: Macmillan, 1935); Elizabeth Mooney, “Great Depression,” Encyclopedia of Saskatchewan (Regina: Canadian Plains Research Center, 2005); Seymour Martin Lipset, Agrarian Socialism (Garden City, New York: Doubleday Anchor, 1968); Gray, Men Against the Desert. 4 T. J. D. Powell, “Northern Settlement, 1929-1935,” Saskatchewan History 30 (1977): 8198; and John McDonald, “Soldier Settlement and Depression Settlement in the Forest Fringe of Saskatchewan,” Prairie Forum 6 (1981): 35-55. 5 Joan Feather, “From Concept to Reality: Formation of the Swift Current Health Region,” Prairie Forum 16 (1991): 59-80; and Joan Feather, “Impact of the Swift Current Health Region: Experiment or Model?” Prairie Forum 16 (1991): 225-48. 6 Stuart Houston, Steps on the Road to Medicare (Montreal: McGill-Queen’s University Press, 2002), p. 28-30. 7 Stuart Houston, “Maurice MacDonald Seymour: A Leader in Public Health,” Annals of the Royal College of Physicians and Surgeons of Canada, 31, 1 (1998): 41-3. 8 The Rural Municipality Act of 1909, R.S.S. 1909, c.87 and an Act to amend the Rural Municipality Act, S.S. 1916, c. 21; C. S. Houston, “A Medical Historian looks at the

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10

11 12 13

14

15

16

17 18 19 20 21 22 23 24 25 26 27

28 29 30

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Romanow Report,” Saskatchewan Law Review 66 (2003): 539-47. The Rural Municipality Act was revised in 1932 to allow two or more municipalities, or portions thereof, to pay a doctor a salary. Revisions to the Town and Village acts in 1934 allowed a per capita tax to pay a physician. Duane John Mombourquette, “A Government and Health Care: The Co-operative Commonwealth Federation in Saskatchewan, 19441964,” MA thesis, University of Regina, 1990, p. 17. Matthew S. Anderson and Harold A. Longman, Bold Experiment (Regina: Commercial Printers, 1969); and Matthew S. Anderson, Bold Experiment: A Pioneer’s Vision of Health Care (Regina: Your Nickel’s Worth Publishing, 2005). Gordon S. Lawson, “The Co-operative Commonwealth Federation, Health Care Reform and Physician Remuneration in the Province of Saskatchewan, 1915-1949,” MA thesis, University of Regina, 1998, p. 26. Stuart Houston, “Matt Anderson’s 1939 Health Plan: How Effective and How Economical?” Saskatchewan History 57, 2 (2005): esp. 8-9. Lawson, “Commonwealth,” p. 26. Brief by Saskatchewan Association of Rural Municipalities (SARM) to Sigerist Commission, 25 September 1944, p. 3, Saskatchewan Archives Board, R251, no. 10. Quoting from the SARM presentation to the bipartisan Hogarth Select Committee in March 1943. Minutes, RM Miry Creek, 1 August and 5 December 1936; 2 April 1937. RM minutes were abstracted in current RM offices, and the writers are grateful to have received such warm hospitality and access. RM Miry Creek followed the RM Pittville plan. Jorgenson, “Rural Municipality of Miry Creek No. 229 and Health Region No. 1,” in Bridging the Centuries (Miry Creek History Book Committee, Abbey, Saskatchewan, 2000), p. 52-8. This was less than half of Caldwell’s income, because he served most of the people in two other RMs—Riverside and its municipal office village, Pennant, plus the larger town of Cabri, plus RM Miry Creek, and its office village, Abbey. Minutes, RM Pittville, 4 January 1941 and 1 February 1941 when the wording was revised. Minutes, RM Pittville, 7 February 1942 and 5 December 1942. Minutes, RM Pittville, 2 January 1943 and Minutes, special meeting of RM Pittville, 23 January 1943. Letter, William Burak to Stewart Robertson, 2 December 1943, in RM Pittville correspondence. Letter, Burak, 2 December 1943. Brief, Wm. J. Burak to Sigerist Commission, 26 September 1944, p. 2. Letter, Burak, 2 December 1943. The amendment half-promised by Davidson never did materialize. Brief, Burak to Sigerist Commission, p. 3. Burak told Sigerist his plan was simplicity personified. Letter, Burak to Robertson, 2 December 1943. Pat [Ditner] Cammer, “Some Memories of the Beginnings of Health Region #1,” presented 3 June 1993 at Health Region #1 Remembrance Celebration, Swift Current; typescript, p. 5-6. Minutes, RM Reno: Special Meeting, 25 August 1934; regular meeting, 1 September 1934. His starting salary was $1500 per year; Minutes, RM Webb, 3 June 1940. First, ratepayers rejected the proposed health plan in a vote on 24 November 1941, presumably because most feared higher taxes would result. The reeve and councillors then introduced bylaws for a hospital and medical plan (Bylaws 83 and 84, with first, second and third readings on 4 October, 1 November, and 18 December 1943), but both bylaws were challenged under the Controverted Elections Act. RM Webb Minutes. Minutes, RM Webb, Bylaw No 86, 7 February and 31 March 1944. Perhaps because of

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33 34 35 36 37

38 39 40 41 42 43 44 45 46 47 48

49

50

51 52 53 54

55 56

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the Controverted Elections Act controversy earlier, Dr. R. O. Davison, chair of the Health Services Board in Regina, approved the wording of Bylaw 86 before it was put to the vote. A second letter from Davison, 24 May 1944, approved the payment details, retroactive to inception of the RM Webb plan on 15 April 1944. RM Webb correspondence: Agreements with MSI, 1 June 1944, re Regina specialists; Minutes, RM Webb; Drs. Stirrett and Irwin at Swift Current, 31 March 1944; Dr. Matheson at Gull Lake, 15 April 1944; Calgary Associate Clinic, 10 April 1945; and Drs. Burroughs and Magid in Swift Current, 5 November 1945 and 23 March 1946. Otto Kjorven, “Carl Kjorven family,” in Through the Years (Cabri: Cabri History Book Committee, 1984), p. 457-58. Pat Cammer, “Some memories,” p. 5-6. RM Riverside became the third RM to follow the Pittville plan. Feather, “From Concept,” p. 71. We consider “social democratic” more accurate than “socialist” since his foremost biographers admit that “He carried a remarkably light load of ideological dogma.” Thomas H. McLeod and Ian McLeod, Tommy Douglas: The Road to Jerusalem (Edmonton: Hurtig, 1987), p. 312. Houston, Steps, p. 83-84. Health Services Survey Commission, Report of the Commissioner, Henry E. Sigerist, to the Minister of Public Health, 4 October 1944 (Regina: King’s Printer, 1944). Houston, Steps, p. 69-74. Lawson, “Commonwealth,” p. 102-4. M. C. Sheps, “Memorandum on Organization of Health Regions,” Health Services Planning Commission, Department of Health, Regina, File 14-6-7, p. 2, SAB. Sheps, “Memorandum,” p. 6. Order-In-Council 1020/45, 13 July 1945. Regulations under the Health Services Act. The Saskatchewan Gazette, 31 July 1945. Minutes, RM Pittville, 4 August 1945. An almost identical letter was sent to the Minister by RM Riverside (Minutes, 29 August 1945). This date, 18 August 1945, for the forthcoming meeting was announced in the Minutes of RM Riverside, 4 August 1945. William J. Burak, Health Region Organization Committee, 3-page and 2-page mimeographed circular letters, 23 August and 30 August 1945. The figure of $9 was based on the first two years’ experience with the RM Pittville plan, but was supported by the national figure of $9.50 provided by J. J. Heagerty, Report, Advisory Committee on Health Insurance (Ottawa, 1943). Somewhat contrary to the Burak campaign, the Town of Gull Lake expressed caution in a letter to T. C. Douglas on 25 September 1945: “That this Council oppose the establishment of a health unit in this Region, pending a decision as to the method of Financing.” Saskatchewan Health Commission, file 14-6-7, Department of Health. SAB. Burak sent a triumphant telegram to Premier T. C. Douglas on 16 September 1945: “I have ten petitions to ask you to establish health region here there are few matters I would like to discuss with you could I have an appointment some day this week preferably tuesday or thursday if possible wire collect.” Saskatchewan Health Services Commission, File 14-6-7, Department of Health, Regina. SAB. This Order-in-Council effectively made the Pittville plan both obsolete and legal. Carl Kjorven, printed copy of radio address, June 1946. Property of Hans Korven, Carl’s son who dropped the “j” from the family surname. Feather, “From Concept,” p. 75. The date of inception of the United Kingdom scheme was 5 July 1948. Report on the Enquiry into the Cost of the National Health Service (London: Her Majesty’s Stationery Office, 1965), p. 30, 32, 46, 292. Letter, Stewart Robertson to members of HR #1 Regional Board, 26 March 1946. Minutes of special meeting of RM Pittville, 27 May 1946.

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57 C. Stuart Houston, “William J. Burak,” Encyclopedia of Saskatchewan (Regina: Canadian Plains Research Center. 2005), p. 136-37. 58 Feather, “From Concept,” p. 60-1. 59 Feather, “From Concept,” p. 60-69. 60 Houston, Steps, p. 64, 85, 86, 125. 61 Greg Marchildon, “The Douglas Legacy and the Future of Medicare,” in Bruce Campbell and Greg Marchildon, eds., Medicare: Facts, Myths, Problems, Promise (Toronto: James Lorimer and Company, 2007), p. 57. 62 Cammer, “Some memories,” p. 9-11. 63 Cammer, “Some memories,” p. 2-4. 64 Swift Current Sun, July 1967, on the occasion of the Kjorven’s 50th wedding anniversary. 65 “Charles and Carrie Haydon,” Bridging the Centuries (Miry Creek History Book Committee, 2000), p. 260-61. 66 Pat Cammer, “Memories,” p. 5. 67 Houston, Steps, p. 86. 68 Maureen Matthews, “The Origins of Medicare,” (CBC Ideas, broadcast 5 December 1990), transcript, p. 6. 69 Feather, “Impact,” p. 231. 70 Houston, Steps, p. 75-76. 71 The success of HR #1 demonstrated “the importance of fiscal authority and autonomy.” B. E. “Woody ” Freamo, Saskatchewan Medical Quarterly, 27, 4 (1963): 250. 72 Houston, Steps, p. 76. 73 Swift Current Health Region, Winds of Change (Swift Current: Swift Current Health Region, 1966), p. 55. 74 Wendy Mitchinson, Giving Birth in Canada (Toronto: University of Toronto Press, 2002), p. 173-75. 75 Houston, Steps, p. 82. 76 Matthews, “The Origins,” p. 10.

8 The Road Not Taken: The 1945 Health Services Planning Commission Proposals and Physician Remuneration in Saskatchewan GOR D O N S . L AWSO N

The instrumental role of the Saskatchewan Co-operative Commonwealth Federation (CCF) government of 1944-64 in the development of Canadian Medicare has overshadowed the interpretations of many historians that the universal medical services plan introduced in Saskatchewan in 1962 was not what the CCF had intended when it first came to power in 1944. In his classic study of the Saskatchewan CCF, Seymour Martin Lipset states that the “party leaders originally envisaged a medical system in which all doctors would work on a salaried basis….”1 Frequently based on Lipset’s work, subsequent historical accounts of the establishment of Saskatchewan and Canadian Medicare often cite a Saskatchewan CCF commitment to a salaried medical service.2 The 1962 doctors’ strike has also overshadowed what existing historical accounts of the step-by-step development of Saskatchewan Medicare from 1944-62 indicate was a less dramatic, but equally formative, conflict concerning physician remuneration in 1945. In early 1945 the government’s Health Services Planning Commission (HSPC) devised a medical services plan for rural Saskatchewan that envisaged the expansion and development of the existing municipal doctor system into a salaried general practitioner service. Existing accounts maintain that Premier Thomas Clement (Tommy) Douglas (1904-1986) and his cabinet considered implementing the HSPC proposals despite the opposition of the College of Physicians and Surgeons of Saskatchewan (SCPS), but in negotiations during 1945 Douglas, in C. David Naylor’s words, “gave way” to the medical profession.3 This article seeks to determine why the Douglas government did not follow the HSPC 1945 recommendations for a salaried medical scheme. The significance of this policy decision in the development of Canadian Medicare was recognized by Malcolm G. Taylor: What if Premier Douglas had acted on the advice of his Health Services Plan-

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ning Commission to introduce a medical care program, with general practitioners paid by salary.… Had that policy option been implemented, it is obvious that, in some parts of Canada, at least, the design of the delivery system might well have been vastly different.4

Indeed, some scholars assert that the CCF government’s concessions to organized medicine in the mid-1940s led to the entrenchment of feefor-service (FFS) payment in Canadian Medicare.5 Despite its relevance to contemporary medical reform debates and initiatives,6 this crucial policy decision has been discussed only in passing by historians of Canadian Medicare. Historians offer three interpretations as to why the CCF did not follow the 1945 HSPC recommendations for the establishment of a salaried medical service in rural Saskatchewan. First, Taylor states that organized medicine’s opposition to salary remuneration and their threat that such a policy would compel doctors to leave Saskatchewan, and deter others from setting up practice in the province, led the Douglas government to reject the HSPC proposals for salaried state medicine. 7 However, Taylor’s account of the Premier’s negotiations with the SCPS on 21 March 1945 suggests that the province’s salaried municipal doctors were not opposed to the HSPC proposals. Taylor intimates that the municipal doctors’ representative on the SCPS negotiating committee, Dr. R. K. Johnston, was not against a salaried scheme: There was one discordant voice in the College delegation, that of Dr. R. K. Johnston, a municipal doctor. He reported, as chairman of the Municipal Doctor Committee, that in a survey he had conducted, seventy one municipal doctors “were almost 100% for a practise consisting of municipal contract work [salary] and outside practise [fees for major surgery], and that on the whole they favoured the municipal work as it was now operated.” But his voice was lost in the committee committed, as it was, to fee-for-service.8 (brackets by Taylor)

In view of the extent of salaried medical practice in Saskatchewan in the mid-1940s, one may suggest that if the municipal doctors were not opposed to the HSPC proposals, official SCPS opposition may have been less of a factor in the Douglas government’s rejection of the HSPC’s proposals than is suggested in the established historical accounts, and may even have been surmountable. A second interpretation is offered by Naylor who maintains that Premier Douglas’ “concern was to implement programs of health services as amicably and rapidly as possible.”9 Naylor suggests that this factor, coupled with SCPS opposition and its threat that the HSPC plan would both compel doctors to leave and discourage immigration, exacerbating the province’s existing doctor shortage, led to Douglas’ concessions to the SCPS in 1945.

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A third interpretation is presented by Lipset who suggests that the people of Saskatchewan did not desire a state salaried medical service. Lipset argued that HSPC proposals were not implemented because (a) the electorate did not understand or demand qualitative changes in medical care, and (b) there was a lack of organized pressure groups that supported qualitative changes.10 Contrary to Lipset, Naylor’s account suggests that there were pressure groups in Saskatchewan that supported radical reform. Naylor states that the State Hospital and Medical League (SHML) and the Saskatchewan Association of Rural Municipalities (SARM) supported the CCF salary remuneration policy.11 The SHML was a broad confederation of voluntary and governmental organizations, including homemakers clubs, fraternal societies, church and farm organizations, the Saskatchewan Teachers Federation, co-operative groups, 120 rural municipalities, 6 cities, 24 towns, and 56 villages.12 SARM, in Taylor’s words, was “one of Saskatchewan’s most powerful political forces, representing as it did 302 rural municipalities.”13 These endorsements may suggest that there was significant public support for a salaried medical service in 1940s Saskatchewan. This article assesses the three interpretations in the established historical accounts based on the available empirical evidence. The analysis begins with an exploration of the municipal doctors’ views towards physician remuneration, and the practicality of developing the municipal doctor system into a state salaried medical service. It is argued that the municipal doctor system was not the embryo of a salaried medical scheme; the majority of province’s salaried municipal doctors engaged in extensive private practice and were opposed to the establishment of a full-time salaried service that would entail the loss of their private practice privileges. The article then proceeds to determine the nature and extent of public support for a salaried service in order to test Lipset’s hypothesis that the Saskatchewan electorate did not support the establishment of such a scheme. It is argued that, contrary to Lipset’s assertion, there was considerable public support for the establishment of state salaried medical service in 1940s Saskatchewan. The CCF party’s health care policy is then examined in order to clarify its commitment to salary remuneration. It is argued that the Saskatchewan CCF, unlike the national party, was never committed to, or an advocate of, the establishment of a state salaried medical service as many historians suggest. The article proceeds to provide an historical account and analysis of the Douglas government’s medical reform initiatives and policy statements prior to the unveiling of the 1945 HSPC proposals. It is argued that the Douglas government had rejected a state salaried medical service long before the HSPC unveiled such a proposal in March 1945. Douglas’ meeting with the SCPS on 21 March 1945 to discuss the 1945 HSPC proposals is then revisited. It is argued that the salaried municipal doctor in

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the SCPS delegation, Dr. R. K. Johnston, did not express disagreement with SCPS opposition to the establishment of a state salaried medical service; Douglas reiterated his rejection of such a policy and did not consider implementing the HSPC proposals as several scholars suggest. The subsequent departures from the HSPC proposals are then analyzed. The article concludes with an explanation for why the CCF did not follow the HSPC recommendations for the establishment of state salaried medical service. SASKATCHEWAN’S MUNICIPAL DOCTOR SYSTEM

When the CCF came to power in Saskatchewan in 1944, a substantial number of the province’s doctors were remunerated on a salaried basis. According to a survey undertaken by the Canadian Medical Procurement and Assessment Board (CMPAB)14 in 1943, of the 408 practicing physicians in Saskatchewan, 130 (31.7%) were on full-time salaries and 65 (15.3%) were on part-time salary. As noted by the CMPAB, “this unusually high proportion of salaried physicians” was “due to the wide-spread adoption in the rural areas of the municipal doctor scheme.’15 It was through an extension and development of this indigenous medical system that the HSPC envisaged the establishment of a salaried general practitioner service in rural Saskatchewan. The inability of many rural areas to support a doctor on a FFS basis led to the establishment of Saskatchewan’s salaried municipal doctor system in Saskatchewan between 1914 and 1930. 16 As the system expanded during the 1930s, the scheme was adopted in areas where FFS payment was still viable, including some of the most densely populated and prosperous farm regions in the province.17 By 1943, the residents of 106 rural municipalities or parts thereof, 65 villages and 8 towns received general medical services, including minor surgery and maternity care, from municipal doctors. These 179 communities had a combined population of 204,788 persons, 22.8% of the 1941 population of 895,992 persons and approximately 32% of the rural population. Nine of the 106 rural municipalities with medical care schemes remunerated physicians on a FFS basis. The remaining 97 agreements with rural municipal councils and all of the 73 contracts with villages and towns paid participating physicians a straight salary for general practitioner services.18 In 1943, 63 of 179 rural municipalities, villages and towns with municipal medical care plans also provided coverage for major surgical procedures; 29 surgical contracts were on FFS basis.19 As Naylor notes, many municipal doctors were able to supplement their salaries by performing major surgery on a private FFS basis.20 According to the CMPAB survey of 1943, these schemes involved 113 of the province’s 213 rural-based general practitioners. Seventy-three

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doctors had full-time contracts with one or more rural municipalities. Forty doctors practiced municipal medicine part-time, with contracts with part of a rural municipality, village or town.21 At a glance the 1945 HSPC proposals for the establishment of a state salaried medical service appear as a continuation of the status quo for the province’s full-time municipal physicians, with the exception that they would no longer be paid for major surgery on a FFS basis. However, the established historical accounts fail to recognize that the majority of municipal doctors engaged in extensive private practice. This private practice consisted of both general medical services and major surgery, in addition to the surgical care for their contracting municipality on a private FFS basis. This additional private income, which the municipal doctors referred to as ‘outside practice,’22 was derived from two sources. First, municipal doctors were permitted private practice in the villages and towns situated within the geographical boundaries of the contracting rural municipality.23 Second, municipal physicians both accepted cases from, and engaged in private practice, outside the borders of the contracting municipality.24 Clearly some municipal doctors’ earnings consisted almost entirely of their salaries. Municipal physicians surrounded by other doctors on contract and who did not perform major surgery, or did so on salary, appear to have been entirely removed from private practice.25 However, for many municipal doctors, a substantial part of their income was earned on a private FFS basis, as indicated by a SCPS survey undertaken in 1944. At the SCPS Annual General Meeting in September 1944, Dr. R. K. Johnston of Eston, Saskatchewan, a salaried municipal doctor, reported that of the 71 physicians who replied to a questionnaire sent to all the municipal doctors, 69 stated that they supplemented their salaries with private practice on a FFS basis.26 Johnston’s survey also demonstrated that 70 of the 71 doctors would not be content if their incomes were restricted to their present salary. A majority of these same physicians were satisfied with their present income, i.e., municipal contract plus private practice. This suggests that FFS practice was quite substantial. According to an earlier survey conducted by Dr. J. J. Collins of Ituna, Saskatchewan, also a municipal doctor, in 1941 30% of the average municipal doctor’s gross income of $5302 was earned privately.27 Moreover, the private income of some municipal doctors appears to have exceeded their annual salaries. For example, the rural municipality of Tisdale reported to the 1944 Sigerist Commission that the private earnings of its municipal doctor in 1939 were greater than his $4000 annual salary.28 Thus the municipal doctor should not be equated to a full-time salaried civil servant as envisaged in a state salaried medical service. The municipal doctors attached great importance to both their private

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income and private practice privileges, as evidenced by their efforts in the early 1940s to strengthen and enhance the scheme’s private practice provisions via the introduction of a new “model” contract.29 Indeed, Dr. Collin’s 1941 survey revealed that a majority of the municipal doctors preferred a “totally fee-for-service system.”30 Several surveys undertaken in the late 1930s, 1941, and 1944 indicated that the vast majority of municipal doctors were content with salaried municipal contract practice.31 For example, Dr. J. J. Collins in the summary of his 1941 survey reported: The district or municipality being satisfied, our problem is to determine whether our municipal doctors are satisfied. With some qualifications one might say that they are. Such remarks as these are quite clear on this point—“I like the system very much. Have been a Municipal Doctor for three years and am perfectly satisfied with my contract”—“Thoroughly satisfied after twentyone years in Municipal practice.” Others though voicing no great complaint desire some modification to it.32

Municipal physicians were favourable towards and appear to have desired the continuation of the municipal doctor scheme, provided that they were able to retain their private practice privileges. The province’s private practitioners, in contrast, were opposed to the salaried municipal doctor system. As early as 1934, the SCPS declared that municipal contract practice should be reserved for communities where FFS was not viable.33 This position, congruent with Canadian Medical Association (CMA) policy, was forcefully conveyed to the three government inquiries into the health services in 1943-1944, and in turn the Douglas government. Moreover, during the 1930s organised medicine in Saskatchewan sought to have the municipal doctor scheme eliminated through a statefinanced maternity care scheme that would have provided doctors in rural Saskatchewan with sufficient income to terminate their municipal doctor contracts;34 and several schemes for province-wide FFS contributory medical insurance designed by the Saskatchewan Medical Association (SMA) Special Committee on Health Insurance (1933) and the Regina District Medical Society (1938).35 The SCPS also successfully lobbied the provincial government to permit FFS remuneration in the municipal doctor system in 1941,36 and to permit the first doctor-controlled medical insurance plan in Saskatchewan—Medical Services Incorporated (MSI) to enter into medical service agreements with municipalities.37 Despite SCPS opposition to the municipal contract practice, municipal doctors continued to express their support for the system. Indeed, an address by R. K. Johnston, Chairman of the Municipal Doctor Committee, to the SCPS Annual General Meeting of September 1943, suggests that many municipal doctors disagreed with CMA/SCPS policy that

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salaried contract practice should be restricted to areas where FFS payment was not viable: I have contacted many of the Municipal Doctors to get their views, and without exception, they have told me that they consider Municipal Practice to be the ideal form of practice, patient and Doctor considered…. The Doctor feels free to carry out whatever treatment he may consider best, as only loss of time has to be considered. Eston is one of the most prosperous farming districts in the province; the Municipal doctor scheme was not introduced as a direct relief measure…. Many of you will not agree with what I have said, however, no subject is well dealt with until it has been well discussed.38

In terms of a province-wide medical services scheme, in the early 1940s, many municipal doctors and rural-based private practitioners believed that contributory health insurance on a FFS basis, as advocated by the SCPS, was not viable in many areas of rural Saskatchewan. In this context, many municipal doctors wanted to be able to continue to work on a combined salary and FFS basis within a provincial health insurance scheme.39 They did not, however, support the establishment of a state salaried medical service, as R. K. Johnston’s 1943 address indicates: I have been asked to speak on behalf of the municipal doctors. The Municipal Doctor Plan is now working so satisfactorily in 105 [rural] municipalities in Saskatchewan, and yearly new areas are adopting this form of medical services, so I feel that Health Insurance can be worked equally satisfactorily for both health services. At present municipal contracts allow Doctors to engage in outside practice. I would not concur in any plan of Health Insurance which would take away the element of competition or limit the Doctor in the scope of his practice….40

These sentiments appear to have been representative of the province’s municipal physicians. In a summary of the comments received from the 71 municipal doctors who responded to R. K. Johnston’s 1944 “questionnaire re Health Insurance,” Johnston reported that “Municipal Doctors are not in favour of [salaried] State Medicine” and “although fairly well satisfied with this form of practice [municipal contract plus private practice] preferred FFS remuneration by 60 to 11.41 A survey conducted in early 1944 by the SCPS’ Central Health Insurance Committee, charged with devising a definitive SCPS remuneration policy, also revealed that the majority of municipal doctors preferred FFS payment.42 While the municipal doctor system did not include a majority of doctors favourable to a state salaried medical service, it did, however, facilitate public support for such a delivery system. The municipal doctor scheme was very popular in Saskatchewan. As Premier Douglas observed in early 1945: “no municipality, once having adopted the system has given it up of its own accord.”43 The establishment of a salaried

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medical service based on the province’s existing municipal doctor system was not viewed as “radical,” let alone a departure from the development of medical services in Saskatchewan as the debate on medical reform in 1940s Saskatchewan reveals. THE POLITICS OF MEDICAL CARE REFORM IN 1940S SASKATCHEWAN: “HEALTH INSURANCE” VERSUS “STATE MEDICINE”

In 1940s Saskatchewan there was an understanding among the medical profession, politicians, the press and many lay organizations interested in health care reform that the establishment of a universal medical service scheme in the province entailed a choice between the following two distinct medical services schemes, as articulated by the bipartisan Saskatchewan Legislature Select Special Committee on Social Security and Health Services (1943-44): 1) “health insurance,” with costs met from a fund created by personal contributions and state subsidy, the doctors paid by fee-for-service, capitation or by salary. 2) “state medicine,” a non-contributory system financed entirely by taxation from general government revenues, in which members of the medical profession would become salaried civil servants.44 Both contributory health insurance and salaried state medicine had their advocates and detractors who sought to influence government policy and public opinion as to which of the two schemes should be implemented in Saskatchewan. From the outset of the 1930s, the leadership of organized medicine in Saskatchewan was opposed to “state medicine,” as an address by the President of the SMA in 1931 illustrates: Unless we can meet the problem we demand to have solved there is no doubt a solution will be found in the nature of state medicine….We owe to our profession and to ourselves the duty of finding a substitute that will be just as universal in its application and that will be just as effective but at more reasonable costs and more in line with the traditions of our profession.45

Accordingly, in 1933 the SMA endorsed and sought public and state support for contributory health insurance on a FFS basis in order to entrench “existing practice patterns instead of ‘state medicine.’”46 The popular movement for salaried “state medicine” in Saskatchewan was led by the Regina-based State Hospital and Medical League (SHML), which had been established on 24 April 1936. Convinced that the Liberal Government of Jimmy Gardner lacked the will to fulfil its 1934 provincial election promise to inaugurate a provincial medical care program, Alderman C. L. Dent of Prince Albert brought together the multitude of indi-

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vidual farm, labour, and governmental organizations interested in “socialized medicine or state control of health” into a “common front” to devise, implement, and promote the establishment of a provincial medical and hospital scheme.47 As part of an on-going initiative to direct the movement for a provincial medical services plan towards a scheme congruent with the interests of organized medicine, the Chairman of the SMA Health Insurance Committee, Dr. S. E. Moore, attended SHML meetings to “provide guidance” to this organization.48 Dr. Moore was in turn elected President of the SHML at its first annual convention on 15 October 1936.49 However, the League’s membership eventually rejected a FFS contributory health insurance plan devised by Dr. Moore, who was subsequently replaced as President by Dr. W. H. Setka, a Prince Albert-based general practitioner who supported salary remuneration.50 At the SHML’s fifth annual convention in October 1940, delegates endorsed the League’s “Eight Point Plan of State Medicine for Saskatchewan,” which envisaged a system of group practice clinics staffed by full-time salaried personnel.51 Despite the SCPS’ vocal criticism of the League’s proposals, the League continued to expand its membership and to acquire support for its medical scheme.52 At the League’s annual convention in October 1942, the executive declared that 296 organizations had affiliated with the League during 1942, an increase of 100 affiliations over the previous year. And by early 1943 each of the League’s proposed health care districts had an executive committee to administer the plan. It was in this context that the SCPS launched a comprehensive “education campaign,” consisting of newspaper and radio advertisements, to inform the public of the perceived “advantages of Health Insurance on the one hand, and the dangers of State Medicine on the other.”53 The SHML responded with its own radio campaign, consisting of a series of addresses delivered by the League’s executive and senior officials of its affiliated organizations such as the Saskatchewan Wheat Pool, United Farmers of Canada, Saskatchewan Section (UFCSS), and the Saskatchewan Teachers Federation.54 The province’s existing forms of salaried medical practice were cited in defence of the League’s proposals: The League advocates the clinic system of medical care with doctors, dentists, and specialists on straight salary. Is this undemocratic? We are told that by putting doctors on salaries all personal initiative will be destroyed that there will be no choice of doctor. Yet we all know of the excellent progress that has been made in this province in the control of tuberculosis by men who are on salary. Many of us have experiences with the excellent medical care provided by municipal doctors, by salaried medical health officers.55

These opposing public relations initiatives corresponded with the

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first of three provincial government-appointed inquiries into the health services and postwar reconstruction in Saskatchewan in 1943-44: 1. Select Special Committee on Social Security and Health Services (1943-44) 2. Saskatchewan Reconstruction Council (1943-44) 3. Health Services Survey Commission (1944) The bi-partisan Select Special Committee in its Final Report of 31 March 1944, observing that federal monies would be required and that Ottawa had opted for a contributory format, declared that its decision between state medicine and contributory health insurance had been “determined for it” and, thus, “it became no part of their task to state a preference for State Medicine or Health Insurance.”56 The Committee recommended that the Legislative Assembly “endorse the principle of health insurance for all the people of Saskatchewan,”57 and set up a commission to administer the anticipated federal scheme. The latest draft of the proposed federal contributory Health Insurance Act at the time, left the contentious area of physician remuneration, whether FFS, capitation or salary, to the provinces to decide. Yet the Final Report of the Committee did not discuss, let alone make a recommendation concerning physician remuneration. It is significant in the context of the alleged Saskatchewan CCF commitment to a salaried medical service that the Committee’s CCF members did not express opposition to FFS during the proceedings, let alone submit a minority report recommending salaried physicians. The Saskatchewan Reconstruction Council (SRC)58 acknowledged the “strong representations [that] were made with respect to state medicine,” but concluded “after due consideration” that a recommendation for the establishment of state medicine “as opposed to the [proposed Federal] Plan for health insurance would not be warranted.”59 The factors cited in reaching this conclusion were (1) the province could not finance a complete system of state medicine; (2) it appeared that federal assistance was contingent upon the acceptance of the Dominion proposals; (3) the “lack of administrative experience in this field…necessary for success”; and (4) the “very strong professional opposition to state medicine.”60 The SRC recommended that doctors be paid on a FFS basis with the exception of areas where this would result in a shortage of doctors.61 The Commissioner of the Health Services Survey Commission (HSSC), Dr. Henry E. Sigerist (1891-1957) of Johns Hopkins University, submitted his report to the Douglas government on 4 October 1944. As we shall see, by this juncture Douglas had announced his intent to develop a provincial medical service from existing services and implicitly rejected the notion that this entailed a choice between salaried “state medicine” and “health insurance.” Sigerist wrote his report from this perspective and unlike the two previous government-appointed

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inquiries, did not discuss the merits and choose between “state medicine” and “contributory health insurance.” For the cities, he recommended “a system of compulsory health insurance, the details of which would have to be worked out.”62 In rural Saskatchewan, the municipal doctor system should be extended. He made no recommendation in terms of financing, i.e., general revenues or direct taxation/premiums. As noted below, Sigerist endorsed salary remuneration, but he did not call for the medical profession to be placed on salary. The three inquiries conducted broad surveys of public opinion in Saskatchewan with respect to medical care policy. Notwithstanding the findings of the Select Special Committee, which observed a “preponderance of opinion favoured contributory Health Insurance as against State Medicine,” these inquiries suggest that there was significant support for a state salaried medical service.63 For example, an equal number of organizations conveyed their support for “state medicine” and “health insurance” in their submissions to the HSSC. Of the three inquiries, the HSSC received the most submissions.64 In addition to the SHML, salaried state medicine was strongly supported by the two agriculture organizations that appeared before the HSSC—the UFCSS and the Saskatchewan Federation of Agriculture (SFA), “representing the organized Producers and the Consumers’ Cooperatives”; the Regina, Saskatoon and Moose Jaw & District Labour Councils; the Prince Albert co-operative medical services clinic, the Saskatchewan Old Age Pensioner’s Association and several rural municipalities.65 The majority of these organizations indicated their support for the SHML “Eight Point Plan for State Medicine.” The endorsement of salaried state medicine by the UFCSS and the SFA challenges the validity of Lipset’s assertion that the “farmers supported “state” medicine but to them the term meant state payment of medical care … [and not a state salaried medical service].”66 The SFA, for example, noted in its brief to the HSSC that it supported the Canadian Federation of Agriculture’s state medicine principles “which would eliminate the fee-for-service system.”67 With respect to physician remuneration among the supporters of health insurance,68 the three medical insurance co-operatives in Regina, Saskatoon and Melfort, like the SHML, claimed that the FFS method was not conducive to preventive medicine and demanded that doctors work on a salary or capitation basis.69 In its brief to the HSSC, the SCPS took exception with these claims: “The College deplores such statements as ‘the Medical Profession is not concerned with preventive care,’ and that ‘Fee For Service Cannot Support Preventive Health Services.’”70 The three railway union locals recommended FFS payment—the only lay organization to do so in all three public inquiries.71 The remaining supporters of health insurance, including SARM, and the representations

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with no stated preference for either “health insurance” or “state medicine,” did not indicate a position on physician remuneration. This indifference may suggest that many were unconcerned as to how physicians were remunerated. SARM does not appear to have had an official physician remuneration policy, let alone to have supported the establishment of a state salaried medical service as suggested by Naylor. Indeed, an account of a SCPS-SARM meeting in 1944 in which the SARM Executive was reportedly “willing to stand for fair returns for services rendered,”72 suggests that it was agreeable to FFS payment. However, as we shall see, Douglas’ future senior health advisor would report in 1947 that there was strong support for salaried state medicine among the SARM Executive. While the majority of people who voted for the CCF were probably indifferent as to how physicians were paid in a provincial medical care scheme, many of the party’s principal and active constituencies of support, such as the organized farming movement, labour, and the teaching profession favoured the introduction of a salaried medical service. In addition, there was the SHML and its broad and active membership that was, as stated in its brief to the HSSC, “prepared to go to the limits side by side with any government having courage and conviction that these ideals [e.g., a salaried service] can be attained.”73 Thus, contrary to Lipset’s assertions, there appears to have been significant support and even formidable allies for the establishment of a state-salaried medical service in Saskatchewan in the mid-1940s. Yet this support did not lead to a CCF commitment to such a scheme as suggested by many scholars. SASKATCHEWAN CCF HEALTH CARE POLICY: SALARY OR FEE-FOR-SERVICE?

The Handbook to the Saskatchewan CCF Platform and Policy (1937) is the earliest document cited by scholars in support of their assertion that the Saskatchewan CCF originally envisaged a provincial medical services plan in which all physicians would work on a salaried basis. This document seems to have been written by Dr. Hugh MacLean (1871-1958), a Regina-based surgeon, and Vice-President of the Saskatchewan CCF until his departure to California in 1938 for health reasons.74 It would appear to be a verbatim excerpt from a text MacLean delivered as a radio address on 17 March 1937, in the capacity of Vice-President of the Saskatchewan CCF, and as a speech to the annual convention of the Women’s Farm Organization on 2 June 1937, in Saskatoon.75 Lipset presents an extensive quotation from the 1937 Handbook in Agrarian Socialism to substantiate his claim that the CCF envisaged a salaried medical service in which “the emphasis would be changed from curative to preventative measures” and doctors “paid to keep people well rather than

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to treat their ailments.”76 Stan Rands provides a similar interpretation of the 1937 Handbook.77 However, MacLean does not infer that the medical profession did not practice preventative medicine because they are remunerated on a FFS basis rather than salary, but because the majority of citizens could not afford, and only sought medical treatment when an illness or condition had passed beyond its preventable and curable stage: In our present system of practice, preventive medicine is largely neglected because the members of the [medical] profession are almost wholly engaged in the curative end of practice, so that preventable deaths are not being prevented and correctable conditions are not being corrected because the people are not in a financial condition to have their condition discovered.78 (This excerpt from MacLean’s text is quoted in Agrarian Socialism with the crucial exception of the clause “because the people are not in a financial condition to have their condition discovered.”)

Nowhere in Lipset’s excerpt from the 1937 CCF Health Plank or in MacLean’s communications is there a declaration that a CCF government would place doctors on salary. Subsequent policy papers and statements issued by the Saskatchewan CCF leading up to and during the 1944 provincial election campaign, unlike those of the National and Ontario CCF in 1943,79 did not declare that a CCF government would establish a salaried medical service; nor do the resolutions pertaining to health services policy passed at the party’s annual provincial conventions. Prior to the 1944 provincial election, the CCF health care policy was set forth in the CCF Program for Saskatchewan (November 1943; reprinted April 1944); a pamphlet “Let There Be No Blackout of Health” and a newspaper advertisement “The CCF Plans Health.” In these communications the party promised to set up a complete system of “socialized medicine with a special emphasis on preventative medicine so that every resident of Saskatchewan will receive adequate medical, surgical, dental, nursing, and hospital service without charge.”80 At this juncture, “socialized medicine” was used as a generic term for a medical services plan provided on a universal basis. For example, the introduction to the first edition (December 43) of the SCPS’ “Bulletin” states that the object of this new communication is: “to keep the medical profession in Saskatchewan in touch with the development and turn in events dealing with socialized medicine, be it in the form of ‘Health Insurance,’ or ‘State Medicine.’”81 None of the CCF policy papers, nor summaries of the CCF health policy in Saskatchewan newspapers, suggest that the CCF, or the Saskatchewan public, understood their pledge to implement “socialized medicine” as a commitment to salaried physicians. In fact, none of the above mentioned CCF policy statements indicate a position on health financing or physician remuneration. The health

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care policy resolutions passed at Saskatchewan CCF annual conventions are similarly vague, with the exception of the 1943 CCF convention “resolution on social services” which states that “provincial and federal government contributions to cover all costs should be made out of the Consolidated Revenue funds.”82 In terms of physician remuneration, however, the resolution merely states that: “all payments for professional services rendered should be made on the basis of a mutually acceptable contract for services.”83 This resolution lends support to the assertion of McLeod and McLeod that the Douglas-Fines Executive decided in 1943 that a provincial medical services plan should be financed with “general government revenues,” but “the question of whether doctors should work on salary or receive a fee for each service provided was left open.”84 Nevertheless, several aspects of CCF health care policy and its members’ health care activism, may have suggested to some observers that the party supported a state salaried medical service. First, those organisations which conveyed their support for scheme financed entirely from general government revenues to the three government-appointed enquiries were without exception in favour of a salaried service. Second, the party criticized “health insurance” along the same lines as the advocates of salaried state medicine, such as the SHML and UFCSS.85 Third, some party members, including one executive member, were active in the SHML. The Vice-President of the party, P. G. Makaroff, was on the SHML executive and an outspoken advocate of salary remuneration.86 And the Saskatoon CCF constituency informed the Sigerist Commission that it endorsed the SHML Eight Point Plan for State Medicine.87 However, the “CCF Program for Saskatchewan” stated categorically that the party did not support the SHML plan.88 Following the 1944 election victory, Dr. Hugh MacLean, Premier Douglas’ external health policy advisor during his tenure as Minister of Public Health (1944-49), delivered an address on health services to the Saskatchewan CCF convention on 13 July 1944. His speech was considered by the Canadian press and many observers to be the new government’s health care policy. Jacalyn Duffin contends that MacLean’s address was the blueprint for Sigerist’s Report and the subsequent development of health services in Saskatchewan.89 MacLean’s address suggested a personal preference for salaried medical schemes;90 however, he stated that either FFS or salary could be used in a provincial plan. Moreover, whatever the choice: “No scheme can or should be put into operation without asking for the cooperation of the medical profession.”91 MacLean’s call for co-operation appears to have guided Douglas’ negotiations for a medical services scheme for social assistance beneficiaries in August 1944—the CCF government’s first step towards the development of Saskatchewan Medicare.

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SOCIAL ASSISTANCE HEALTH SERVICES PLAN

According to Taylor’s account of the negotiations between Douglas and the SCPS on 23 August 1944, based on correspondence with Dr. C. J. Houston, “differences in their ideological approaches” emerged.92 But “despite their differences in philosophy … the basic understandings on the operation and the costs of the social assistance medical care program were agreed upon.”93 Doctors’ payments would be made on a prorated FFS basis from a pooled sum representing $9.50 per capita as part of the so-called Old Age Pensioners Agreement. On 1 January 1945 approximately 25,000 pensioners and other social assistance beneficiaries were eligible for free hospital and medical services. While FFS payment was insisted on by the SCPS, Houston’s account of the negotiations does not suggest that Douglas sought to secure alternative payment methods.94 According to Houston’s correspondence with Taylor, at the meetings of 23 August 1944, Douglas informed the SCPS that he wished to provide medical services to old age pensioners and other wards of the state and “asked for suggestions, about methods costs etc.”95 In Houston’s recollection “there was no pre-selected position defended by either side.”96 These negotiations and their outcome may have been an early indication that the Douglas government’s chief aim was the provision of state-funded medical services as rapidly as possible; and in this context, the method of payment for medical services was negotiable. Owing to SCPS opposition to capitation and salary remuneration, for the government to insist upon alternative payment methods, would have undoubtedly delayed the introduction of medical services under a state-controlled plan. An inflexible position on physician remuneration would have led to protracted negotiations with SCPS or the even more difficult option of attempting to directly force the medical profession into a salaried service. Neither of these scenarios was agreeable to the Douglas government. As McLeod and McLeod state: “to the distress of his socialist supporters, Douglas declined to force the doctors on to a salary system in the mid-1940’s because he wanted to get his health program for the poor off to a quick start.”97 This first agreement between the CCF government and the SCPS was the first official manifestation that the Douglas government was committed to a policy of co-operation with the medical profession; it is also supportive evidence for Naylor’s interpretation that the 1945 HSPC proposals for state salaried medical service were not implemented because Premier Douglas’ primary objective was to implement health services programs as quickly and amicably as possible. The Douglas government’s acceptance of FFS payment in the Social Assistance Health Service Plan was one of several policy decisions in

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the mid-1940s which facilitated the entrenchment of FFS remuneration in Saskatchewan Medicare. This was recognized by the SCPS as reflected in a memo by Dr. B. C. Leech (Chairman of the College’s Medical Committee responsible for administering medical service payments to participating physicians): The organized profession has undertaken through the O.A.P.[Old Age Pensioners] scheme to prove conclusively that a fee for service basis of payment for medical care can operate and be adequate for beneficiaries and fair and satisfactory to both government(or contracting party) and all members of the profession who take part.98 SIGERIST COMMISSION

The appointment of an expert on the Soviet health care system and a staunch advocate of salary remuneration, Dr. Henry E. Sigerist, to lead an inquiry into the health services in Saskatchewan in the autumn of 1944, may have raised suspicions among the SCPS, and expectations among the supporters of “state medicine,” that the new CCF government was planning to introduce a state salaried medical service. In an interview, published in the Regina Leader-Post, 7 September 1944, Sigerist enthusiastically explained the Soviet medical care system of health centres staffed by salaried doctors.99 However, on the first day of Sigerist’s tour of the province, Douglas dismissed suggestions that his government intended to place doctors on salary, the first of several such statements during the survey.100 In a similar statement at the SCPS annual General Meeting in September 1944, Douglas declared that his objective was to provide all citizens with medical care “on whatever basis the government could get possible co-operation with the medical profession.101 In terms of physician remuneration, Sigerist’s report of 4 October 1944 simply states that “there can be no doubt that in the future more and more medical personnel will be employed on a salaried basis.”102 He thus endorsed salary remuneration, but did not recommend placing private practitioners on salary or the termination of the FFS municipal doctor contracts. Nor did he advise that salaried municipal doctors be denied private practice privileges. Yet the Douglas government’s Health Service Planning Commission (HSPC) would recommend just such a policy. THE REJECTION OF THE 1945 HSPC SALARIED MEDICAL SERVICE PROPOSALS

As recommended by Sigerist, the HSPC was appointed in November 1944 to implement the government’s reform agenda.103 The Commission’s initial members had served on the Sigerist Commission: Dr. Min-

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del Cherniak Sheps (1913-1973),104 general practitioner; Thomas H. McLeod, economic advisor to the government, and C. C. Gibson, hospital administrator. Dr. C. F. W. Hammes, Deputy Minister of Health, was a member ex officio. Dr. M. Sheps, who had served as secretary to the Sigerist Commission, had been appointed as Douglas’ assistant shortly after the CCF victory in 1944 to ensure that the new government had personnel who were sympathetic to its health reform objectives. She chaired and was a member of both the Manitoba and National CCF research committees on health.105 Dr. M. Sheps and her husband Dr. Cecil G. Sheps, Director of Venereal Disease Control for the Canadian army in Alberta before he became acting HSPC Chairman in March 1946,106 were staunch socialists from Winnipeg’s North End with family members among the upper echelons of the Manitoba CCF.107 It was Dr. M. Sheps in particular, as HSPC secretary, who urged the Douglas government to establish a salaried service. On 2 March 1945 the HSPC unveiled its rural health care proposals to its Advisory Committee, comprising representatives of the SCPS, agriculture, trade unions, SARM, and lay organizations interested in health care reform, e.g. the SHML. The HSPC proposed the division of the province into health regions that would, as personnel, equipment and facilities became available, provide a comprehensive medical and hospital service.108 It was recommended that a complete service be established in one of the regions in the near future as an experiment. The “general practitioner service should be a salaried service,”109 built upon the existing municipal doctor system. Accordingly, the HSPC’s proposed municipal doctor contract prohibited private practice. Doctors would work in group practice settings in health centres and provided with pensions, paid holidays and leave for post-graduate study.110 To enable communities to hire doctors on salary, equalization grants would be provided to poorer and less populous municipalities. Flat grants were recommended to “induce the more prosperous rural municipalities to enter the scheme.”111 It was through these grant-in-aids that the HSPC hoped to develop the municipal doctor system into a province-wide, salaried medical service. These proposals, which were very similar to the SHML plan, were endorsed by all the members of the HSPC Advisory Committee112 except the SCPS delegates who “vigorously protested a vote being taken on the acceptability of the plan.”113 The SCPS subsequently obtained a meeting with Premier Douglas to discuss the HSPC proposals on 21 March 1945. At the outset of the meeting, Douglas was presented with a resolution stating the SCPS’ opposition to “an exclusively salaried service” and their support for “state-aided health insurance on a fee-for-service basis.”114 While in favour of subsidizing physicians in poor and sparsely settled areas, the doctors were opposed to grants which could be used

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“as a means of coercion to force a salaried system of medicine in rural areas.”115 Moreover, R. K. Johnston, the municipal doctors’ representative in the SCPS delegation, protested the HSPC’s proposed straight salary contract that would deny municipal doctors private practice privileges. Johnston cited his 1944 survey indicating that the municipal doctors favoured a practice consisting of “municipal contract” and “outside practice,”116 [private practice] which, as noted above, did not consist exclusively of FFS payment for major surgery as Taylor and Naylor suggest; the municipal doctor’s extensive private practice consisted of both general medical and surgical services to patients from within and outside the boundaries of the contracting municipality. Hence Johnston did not inform Douglas that the municipal doctors were in favour of straight salary remuneration with the exception of major surgery on a FFS basis as Taylor infers. C. Stuart Houston’s assessment that the HSPC proposals “at once alienated the salaried municipal doctors, for it would deny them any right to private practice or to attend any one from beyond a rigid area boundary,” is a more accurate interpretation.117 Johnston clearly was not a “discordant voice” in the SCPS delegation as Taylor claims. In response to the doctors’ objections, Douglas reiterated that the method by which medical service would be provided to all residents as rapidly as possible was not important. He stated categorically that his government was not committed to a salaried medical service. The government’s policy was to provide state-aided health insurance in the cities and municipal doctor scheme in the rural areas this would “still leave a very large place for private practice.”118 Moreover, he was willing to subsidize both FFS and salaried municipal doctor plans. Douglas “assured” the doctors that a “new plan could be worked out” that conformed with the SCPS “principles” on health insurance which included a tenet that salary contract be restricted to areas where FFS was impractical.119 To this end, the Premier proposed that the SCPS representatives form a subcommittee of the HSPC to “obtain the necessary revisions.”120 Thus the Premier ’s rejection of the HSPC recommendations for a salaried service and his so-called “capitulation” to the SCPS was immediate and not during a series of subsequent negotiations in 1945 as existing scholarship suggests. Indeed, there is no documentary evidence to suggest that after Douglas’ meeting with the SCPS on 21 March 1945, he and his Cabinet “weighed the situation and assessed the opposition of the College,”121 and then rejected the HSPC recommendations for a salaried service as Taylor maintains.122 The departures from the 1945 HSPC proposals naturally followed, without any apparent resistance by the Douglas government. First, on 14 April 1945 the HSPC and SCPS officials devised a draft agreement on the administration of a provincial medical services plan

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incorporating SCPS health insurance “principles” that, if followed, would preclude the establishment of a salaried service.123 This text formed the basis of Premier Douglas’ widely quoted letter of 19 September 1945.124 Second, the HSPC proposed straight salary municipal doctor contract was not introduced; a new salary model contract that permitted private practice was devised on 22 April 1945.125 Third, FFS plans were eligible for the government’s medical care grant scheme introduced on 1 July 1945.126 Fourth, in July 1946 a FFS medical care plan was inaugurated in the Swift Current Health Region. THE SWIFT CURRENT REGIONAL MEDICAL CARE PROGRAM PHYSICIAN REMUNERATION IN SASKATCHEWAN

The latter departure was the result of local decision making rather than a provincial government initiative. The prerogative to establish health regions and the particular organization of medical services, including remuneration, resided with local health boards.127 Yet this policy unintentionally facilitated this departure because the first area to petition the Douglas government to be declared a health region was the least conducive to the establishment of a salaried service. Unlike other areas of the province where FFS plans were the exception rather than the rule,128 all five municipal doctor plans in the Swift Current area in 1945 were FFS schemes.129 And the senior executives of the Swift Current Health Board and W. J. Burak, who mobilized support for the regional medical and hospital services plan, were from these same municipalities.130 Thus the Swift Current Health Care Board did not object when local physicians demanded FFS payment.131 This departure from the 1945 HSPC proposals for a salaried service was also facilitated by the policy to subsidize FFS municipal medical care plans. The Swift Current Medical Care Plan received a subsidy equal to the grants the individual municipalities in the health region were entitled to for financing municipal doctor schemes, approximately 10% of the plan’s operating budget.132 This medical care plan established a critical precedent with respect to physician remuneration. The government referred to the Swift Current plan as its “experimental health insurance scheme to determine the costs for a provincial-wide program.” When the provincial government tried, unsuccessfully, to encourage the establishment of regional medical services plans in the mid-1950s, the Swift Current FFS plan was proposed.133 However, in 1946 the predominance of FFS in Saskatchewan was far from certain. First, in April 1946 the Saskatoon Mutual Medical and Hospital Benefit Society, a medical insurance co-operative with 16,000 members, announced a million-dollar plan to build a clinic with a staff of 40 salaried doctors and satellite operations in North Battleford and 10 addi-

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tional rural centres.134 To pre-empt the co-operative’s plans, which a 1951 SCPS report later maintained “threatened to completely jeopardize the future of prepaid medical care in the province and the welfare of the profession in general,”135 Saskatoon doctors established Medical Services, Inc. (Saskatoon).136 In the interim, the co-operative cancelled its plans for a group-practice clinic owing to the proposed establishment of a similar facility as part of the medical school at the University of Saskatchewan.137 Second, there remained the predominantly salaried municipal doctor system and the government’s grant-in-aid scheme for its expansion. Although there was only a modest extension of the system to the relief of SCPS officials, the vast majority of municipalities continued to hire doctors on salary.138 In order to prevent the spread of these salaried medical care plans, MSI (Saskatoon) and Group Medical Services (Regina) expanded into rural Saskatchewan. Third, the Swift Current Medical Care Program did not preclude the establishment of a salaried service in other health regions. Other areas might reject FFS, especially after the costs of the Swift Current plan greatly exceeded its annual budget. At a SCPS meeting on 6 September 1947, it was reported that SARM believed that the cost-overruns of the Swift Current scheme proved that salary contracts offered better expenditure control. Moreover, SARM members were reluctant to accept FFS contracts for fear of being “dragged into a health region.”139 Based on a meeting with the SARM executive 23 October 1947, the new HSPC Chairman Dr. Frederick Dodge Mott (1904-1981)140 reported that: There is a very strong sentiment among members of the Executive for straight state medicine, with physicians on salary. However, they realize that this kind of development is not to be anticipated in the immediate future and they are reasonably open-minded about using the fee-for-service system as a basis for payments to physicians.141

SARM also agreed with the HSPC that the salaried municipal doctor schemes should be strengthened so that they would not be “eliminated and replaced by more expensive fee-for-service plans.”142 In the Swift Current Region itself, FFS payment was far from secure. At a meeting held on 10 December 1947 to discuss expenditure ceilings for regional, municipal, and provincial FFS plans, with Douglas, the HSPC, and the SARM medical care committee in attendance, the Chairman and Secretary-Treasurer of the Swift Current Health Region Board announced that: if the doctors would not agree to a reasonable limitation on the expenditure of funds, the Region was prepared to institute a system of medical care with doctors on salary and with clinics owned and operated by the Region.143

In this context, participating physicians in the Swift Current medical

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care programme agreed to a budget ceiling for 1948.144 Furthermore, the Swift Current plan was an “experiment.” The Douglas government could return to the principles of the 1945 HSPC proposals. However, it would appear that the provincial government had no intention of utilizing the municipal doctor system to establish a salaried service. At a HSPC Advisory Committee meeting in May 1947, Dr. Mott indicated that the establishment of regional medical care schemes would entail the discontinuation of municipal doctor plans; in order to retain doctors in the outlying areas of the health regions, it might be necessary to provide a special supplement to those doctors who otherwise would be unable to earn an adequate income under a FFS plan.145 Mott subsequently ignored a suggestion by T. H. Thain, a trade union representative, that all doctors be placed on salary. At a Trades and Labour Congress meeting, Thain stated that the Douglas government “didn’t have the guts to implement a real scheme of socialized medicine.”146 Thain subsequently resigned from the HSPC Advisory Committee because of the government’s acceptance of FFS.147 The supporters of salaried service, both within and outside the CCF, expressed their opposition to FFS remuneration in the Swift Current plan, and urged the provincial government and the lay health board to hire doctors on salary. Maintaining that the FFS method was “the antithesis of preventative medicine” and the Swift Current Medical Plan was “unsatisfactory” in that it was “impossible to budget satisfactorily in advance and that it has proven to be too costly,” the Saskatoon CCF constituency at its annual convention on 13 June 1947 resolved: That in the establishment of future Health Regions, the Government bring strong pressure to bear to ensure adoption of a salary basis of payment of medical practitioners so that that the principle of “paying the doctors well to keep the people well” may have an opportunity to be realized.148

This resolution was submitted to the Resolution’s committee at the Provincial CCF Convention in July 1947. The following resolution was passed: “We urge that wherever possible the Provincial Government and the Regional Health Board should encourage the hiring of doctors on a salary basis.”149 The Swift Current plan was also criticized by the SHML, which continued to pass resolutions at its annual conventions calling for doctors to be paid on a straight salaried basis.150 Although the provincial government clearly did not intend to force private practitioners into salaried medical service, it did recruit recent graduates from Canadian medical schools to work in health regions and medical centres in Saskatchewan on a salary basis.151 In addition, the HSPC sought to strengthen the salaried municipal doctor plans, and pressed the Board of the Swift Current Health Region to establish a group-practice clinic with full-time salaried specialists.152 These efforts,

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coupled with the municipalities’ preference for salary as opposed to FFS plans, may have prompted Dr. Setka, President of the SHML, to state at a SARM meeting on 24 February 1948 that he was “convinced that the Province was heading rapidly into a salaried medical service.”153 This was not to be. First, despite the initiatives to secure doctors on salary, the provincial government was nonetheless agreeable to the continued development of a province-wide health care system on a FFS basis, provided that there was a ceiling on expenditure. In a letter to Dr. G. Gordon Ferguson, SCPS Registrar, in 1949 clarifying the government’s policy on physician remuneration in the FFS plans operated by individual municipalities and health regions, Douglas referred to these schemes as the “forerunners of an over-all provincial program to be developed as soon as it is feasible.”154 He was agreeable to paying physicians “adequately and generously for their services,” but that such programs must “be financially sound” and not “overtax the paying ability of the people concerned.”155 The fact that the government was neither developing nor planning a salaried service was noted by HSPC Chairman Mott in a letter to Dr. Hugh MacLean in 1949: … the medical profession here simply don’t know when they are well off. Sometimes I feel like pulling out and leaving them to their fate with a population which wants to see real state medicine developed rather than the conservative form of health insurance which we are slowly developing.156

Second, the anticipated expansion of the salaried municipal doctors system via the government’s grant scheme did not occur. The system grew incrementally until 1947, its peak year with over 210,000 persons covered (about 25% of the population),157 when, in the words of a Department of Health official, the “better [rural] practices [had] been taken.”158 Thereafter, the scheme returned to its average coverage, since 1944, of approximately 200,000 persons, where it remained until the early 1950s.159 When the Douglas government announced its plans to introduce a province-wide medical services scheme in 1959, the municipal doctor system had been reduced to 136 contracts covering only 103,750 persons. The doctor-sponsored FFS plans, in contrast, had enrolled 280,819 persons. In this context, one may suggest that if the CCF had followed the 1945 HSPC recommendations and provided financial assistance exclusively for salary municipal medical care plans— the system would not have been extended into a province-wide salaried medical service. CONCLUSION

An examination of Saskatchewan CCF party health policy in the period

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1934-44 reveals that the party was never committed to, or an advocate of, the establishment of a state-salaried medical service as many historians suggest. After the CCF came to power in June 1944, Premier Douglas repeatedly denied that his government intended to place the medical profession on salary. Douglas’ health policy statements in 1944, coupled with his immediate consent to FFS payment in the Social Assistance Health Services Plan, suggest that his government had rejected a statesalaried medical service long before the HSPC presented such a proposal to its advisory committee in March 1945. Indeed, when the SCPS objected to the HSPC proposals on 21 March 1945, Douglas categorically denied that his government was committed to such a plan. The various departures from the 1945 HSPC proposals occurred without any apparent resistance from the Douglas government. Indeed, it is evident that there was no confrontation between the Douglas government and the SCPS concerning salary remuneration in 1945—apart from the presentation by the HSPC to its advisory committee proposals for a salaried service in rural Saskatchewan. Taylor clearly over-emphasized the importance and intensity of the friction concerning the 1945 HSPC proposals. These correctives to the historical record facilitate a further evaluation of the existing interpretations, and the development of a more comprehensive explanation, as to why the Douglas government did not implement the 1945 HSPC recommendations for a salaried medical service. The Douglas government would have likely implemented the HSPC physician remuneration recommendations if the medical profession had not been opposed. Based on this probability alone, SCPS opposition clearly was a factor in the rejection of the 1945 HSPC proposals as the established historical accounts suggest. Indeed, medical opposition to the HSPC proposals was greater than Taylor infers—the province’s municipal doctors were also opposed to a full-time salaried service that would eliminate their private practice privileges. The role of the doctor shortage and SCPS threats that the development of a salaried medical service would compel doctors to leave the province and deter emigration in the Douglas government’s decision making is less discernible. The establishment of a salaried service in Saskatchewan without the co-operation of the SCPS and with the province’s doctor shortage was viewed as a viable policy by the HSPC, its advisory committee and a large number of organizations representative of Saskatchewan society. They believed that generous remuneration, pensions, and modern, well-equipped facilities would attract a sufficient number of physicians for a salaried service. The SCPS also recognized that a salaried service was a viable policy option for the Douglas government; it recognized that public opinion and the existing municipal doctor system were conducive to the development of such a scheme, and campaigned against such an outcome. Thus the doctor

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shortage and the threat of loss of doctors (and physician opposition) was probably less of an impediment to the establishment of a salaried medical service in Saskatchewan than Taylor and Naylor suggest. And in this context, the 1945 HSPC proposals were likely not rejected by the CCF solely on the basis of SCPS opposition and the threat of loss of doctors as Taylor suggests. Other factors must have been involved. Although the establishment of a salaried medical service was considered to be feasible in Saskatchewan, because of SCPS opposition and the probable loss and deterred immigration of doctors, the provision of accessible medical services to all the people, as promised by the CCF, would take longer to realize. Perhaps this was unacceptable to Douglas; as he told the SCPS on 21 March 1945, his “concern was to provide medical care to everyone as rapidly as possible.”160 This stated objective would be attained far more quickly with the co-operation of the SCPS and the development of medical services on a FFS basis. Indeed, Douglas’ statements and actions during the period 1944-45 support Naylor’s interpretation that the HSPC recommendations for the establishment of a salaried service were not implemented because Premier Douglas’ “concern was to implement programs of health services as amicably and rapidly as possible.”161 However, there was an additional critical factor that led to this policy outcome: the CCF party in Saskatchewan (and more importantly, the Douglas government) was never, as several historians maintain, committed to the establishment of a state salaried medical service. Public support for the HSPC proposals and a state-salaried medical service was not lacking as Lipset contends. Indeed, Douglas rejected this option within an environment of considerable support for such a policy. There was a broadly based, well-organized and determined popular movement for the establishment of state-salaried medical service in the 1940s led by the State Hospital and Medical League. So strong was this movement that the SCPS launched a sophisticated public relations campaign to counter this threat. In addition to the SHML, a diverse number of agriculture organizations, trade unions, rural municipalities, medical service co-operatives and citizen organizations indicated their support for salaried state medicine to the Sigerist Commission. Several of these organizations forcefully maintained that FFS was not conducive to preventive medicine to the extent that the SCPS was compelled to counter these assertions. This segment of the movement for a salaried medical service clearly desired what Lipset considers “qualitative changes in medical care.”162 These organizations would have, in Lipset’s words, acted to “counterbalance” the SCPS if the CCF had implemented the 1945 HSPC recommendations.163 In this context, because the 1945 HSPC proposals were seen as a viable policy option without the co-operation of organized medicine, and

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many of the party’s principal constituencies of support, such as the organized farming movement and labour, favoured the introduction of a salaried medical service, one may suggest that if the CCF had been committed as a party, and more importantly as a government, to salary remuneration as some historians have claimed, the Douglas government would have implemented the 1945 HSPC proposals despite SCPS opposition. In the final analysis, then, it would appear that the Douglas government did not follow the 1945 HSPC proposals for a state-salaried medical service because: neither the party nor government was committed to salary remuneration; the policy of the Douglas government was to provide medical services to the people of Saskatchewan as rapidly as possible with the co-operation of organized medicine; and the medical profession, including the province’s municipal doctors, was fervently opposed to being placed on salary. ACKNOWLEDGMENTS

The research for this article was supported by a First Year Master’s Hannah Scholarship awarded by The Hannah Institute for the History of Medicine/Associated Medical Services Inc. The author wishes to acknowledge in particular the late Ray Sentes for his supervision. C. Stuart Houston provided comments on my MA thesis which were helpful in preparing this article. I am grateful to Greg Marchildon for his guidance and constructive criticism of an earlier version of this paper. I wish also to thank two anonymous referees for their comments. NOTES 1 Seymour Martin Lipset, Agrarian Socialism: The Co-operative Commonwealth in Saskatchewan (Berkeley: University of California Press, 1950), p. 288. 2 C. David Naylor, Private Practice, Public Payment: Canadian Medicine and the Politics of Health Insurance, 1911-1966 (Kingston and Montreal: McGill-Queens University Press, 1986), p. 136, 141; Donald Swartz, “The Politics of Reform: Public Health Insurance in Canada,” International Journal of Health Services, 23, 2 (1993): 225; Stan Rands, “The CCF in Saskatchewan” in Donald C. Kerr, ed., Western Canadian Politics: The Radical Tradition (Edmonton: NeWest Press, 1981), p. 61; Privilege and Policy: A History of Community Clinics in Saskatchewan (Saskatoon: Community Health Co-operative Federation, 1995), p. 98; and Aleck Ostry, “Prelude to Medicare: Institutional Change and Continuity in Saskatchewan, 1944-1962,” Prairie Forum, 30, 1 (Spring 1995): 1013. 3 Naylor, Private Practice, Public Payment, p. 140; Malcolm G. Taylor, Health Insurance and Canadian Public Policy: The Seven Decisions That Created the Canadian Health Insurance System (Montreal: McGill-Queens University Press, 1986), p. 248. 4 Taylor, Health Insurance and Canadian Public Policy, p. 417. 5 G. Gray, Federalism and Health Policy (Toronto: University of Toronto Press, 1991), p. 35; Katherine Fierlbeck, “Canadian Health Care Reform and the Politics of Decentralization,” in Christa Altenstetter and James Warner Bjorkman, eds., Health Policy Reform, National Variations and Globalization (London: Macmillan Press Ltd, 1997), p. 26.

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6 R. A. Devlin, S. Sarma, and W. Hogg, “Remunerating Primary Care Physicians: Emerging Directions and Policy Options for Canada,” Healthcare Quarterly, 9, 3 (2006): 34-42. 7 Taylor, Health Insurance and Canadian Public Policy, p. 248. 8 Taylor, Health Insurance and Canadian Public Policy, p. 246. 9 Naylor, Private Practice, Public Payment, p. 140. 10 Lipset, Agrarian Socialism, p. 297. 11 Naylor, Private Practice, Public Payment, p. 136. 12 Taylor, Health Insurance and Canadian Public Policy, p. 85. 13 Taylor, Health Insurance and Canadian Public Policy, p. 84-85. 14 In 1939, the Department of National Defence established a Medical Procurement and Assignment Board to assess the medical personnel needs of both the military and the civilian population. Medical Procurement and Assignment Board, Report of the National Health Survey conducted by the Medical Procurement and Assignment Board (Ottawa, E. Cloutier, 1945). 15 Saskatchewan Archives Board, Regina (hereafter SABR), Records of the Health Services Survey Commission (hereafter HSSC), R-251, File 34, “Survey of Medical Manpower and Facilities for M.D and A.B. M.D. #12,” (circa 1943). See page entitled, “Medical Man Power Survey, M. D. #12, Statistical Report,” (circa 1943). 16 On the municipal doctor system see Joan Feather and Vincent L. Mathews, “Early Medicare in Saskatchewan,” Saskatchewan History, 37 (1984): 47-52; C. Stuart Houston, Steps on the Road to Medicare: Why Saskatchewan Led the Way (Montreal and Kingston: McGill-Queen’s University Press, 2002), p. 28-37. Gordon S. Lawson, “Municipal Doctor System,” Encyclopaedia of Saskatchewan (Regina: Canadian Plains Research Centre, 2005), p. 634. 17 R. K. Johnston, “We Like Municipal Contract Practice!” Canadian Doctor (May 1943): 19; R. K. Johnston, Saskatchewan Medical Quarterly, 7, 1 (1943): 14-16. 18 Saskatchewan Archives Board, Saskatoon (hereafter SABS), Records of the Health Services Board (hereafter HSB), S-PH.4, File 2, “Health Services Board: Municipal Medical Services,” circa 1943, p. 1- 4, 10-13; and Health Services Board Submission to Select Committee of the Legislative Assembly of Saskatchewan re. Social Welfare etc., Regina, 28 March 1943, p. 4-5. 19 SABS, HSB, S-PH.4, File 2, “Health Services Board: Municipal Medical Services,” (circa 1943), p. 3, 10-11. 20 Naylor, Private Practice, Public Payment, p. 163. 21 SABR, HSSC, R-251, File 34, “Medical Man Power Survey, M. D. #12, Statistical Report,” Table 3 (circa 1943). 22 Johnston, “We Like Municipal Contract Practice!” p. 17-19; Saskatchewan Medical Quarterly, 7, 1 (1943): 14-16. 23 R. O. Davison, “Municipal Medical Services in Saskatchewan,” Saskatchewan Medical Quarterly, 5, 3 (August 1941): 13. 24 Dr. J. J. Collins, “A Proposal for Modification of the Municipal Doctor Contract: And Suggested New Model Contract,” Saskatchewan Medical Quarterly, 5, 1 (April 1942): 1516. 25 SABS, HSB, S-PH.4, File 5, C. S. MacLean to Dr. Davison, 19 February 1937. 26 No author, no title (hereafter n.a., n.t.), Saskatchewan Medical Quarterly, 8, 4 (December 1944): 18. 27 J. J. Collins, “State Medicine, Health Insurance and Hiring Municipal Doctors,” Saskatchewan Medical Quarterly, 5, 4 (December 1941): 21. 28 SABR, HSSC, R-251, File 2, “Rural Municipality of Tisdale, Brief on Medical Services, 15 September 1947,” p. 4. 29 Collins, “A Proposal for Modification of the Municipal Doctors Contract,” p. 15-26. 30 Collins, “State Medicine, Health Insurance and Hiring Municipal Doctors,“ p. 16. 31 Saskatchewan Medical Association/College of Physicians and Surgeons of Saskatchewan Archives (hereafter SMA/SCPS) File 6-14-6, “A Preliminary Report And

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35 36

37 38

39 40 41 42 43 44 45 46 47 48

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Contribution to the Problem of State Medicine in Saskatchewan,” p. 4; Collins, “State Medicine, Health Insurance and Hiring Municipal Doctors,” p. 18, and n.a., n.t., Saskatchewan Medical Quarterly, 8, 4 (December 1944): 17-18; Collins, “State Medicine, Health Insurance and Hiring Municipal Doctors,” p. 18. SMA/SCPS, College of Physicians and Surgeons of Saskatchewan, Annual Report (1932), p. 20-1. SMA/SCPS, “Minutes of the 28th Annual Meeting of the Saskatchewan Medical Association and the College of Physicians and Surgeons, September 24, 25, 26, 1935,” p. 8; “Minutes of Meeting of the Joint Special Legislative Committee,” 15 January 1936; Saskatchewan Medical Quarterly, 2, 4 (1938): 22; and Saskatchawan Medical Quarterly, 3, 1 (1939): 6-8. SMA/SCPS, “Special General Meeting, Saskatoon, Saskatchewan, 28 February 1933,” p. 25-6. SMA/SCPS, File “Medical Services Incorporated Regina,” Dr. G. K. Lindsay to Honourable R. J. M. Parker, Minister of Municipal Affairs, 28 February 1940; Davison, “Municipal Medical Services in Saskatchewan,” p. 12-13. N.a., n.t., Saskatchewan Medical Quarterly, 5, 1 (1941): 6. N.a., n.t., Saskatchewan Medical Quarterly, 7, 1 (December 1943): 14-16. For a detailed and nuanced discussion of the debate and tension within the medical profession in Saskatchewan concerning the municipal doctor system, health insurance and salaried state medicine see Gordon S. Lawson, “The Co-operative Commonwealth Federation, Health Reform and Physician Remuneration in the Province of Saskatchewan, 19151949,” MA thesis, University of Regina, 1988, p. 50–64. N.a., n.t., Saskatchewan Medical Quarterly, 6, 1 (April 1942): 52-54. N.a., n.t., Saskatchewan Medical Quarterly, 7, 1 (December 1943): 14-16. N.a., n.t., Saskatchewan Medical Quarterly, 8, 4 (December 1944): 17-18. SMA/SCPS, File 2-9-4, “Bulletin # 2,” p. 1. N.a., n.t., Saskatchewan Medical Quarterly, 9, 1 (May 1945): 28. Select Special Committee on Social Security and Health Services, Final Report, (Regina, 1944), p. 10. SMA/SCPS, Saskatchewan Medical Association, Annual Report (1931), p. 7-8. Naylor, Private Practice, Public Payment, p. 66. SABS, Pamphlet Collection, “Saskatchewan State Hospital and Medical League, Second Edition,” 30 September 1936. Saskatchewan Medical Association and the College of Physicians and Surgeons, Annual Report (1936), p. 12; and SMA/SCPS, “Minutes of Annual Meeting, Saskatchewan Medical Association and the College of Physicians and Surgeons: September 22, 23, 24, 1936,” p. 14. “State Medicine Urged for Saskatchewan,” Leader Post, 16 October 1936; “State Medicine League in First Convention Decides to Urge Plans upon Govt,” Western Producer, 22 October 1936. SABS, Pamphlet Collection “Saskatchewan State Hospital and Medical League, Fourth Annual Convention, Saskatoon, Sask., October 20, 1939,” p. 6. SABS, Phamphlet Collection, “Report of the Fifth Annual Convention of the State Hospital and Medical League, Saskatoon, October 8 and 9, 1940,” p. 9. SABR, Pamphlet Collection, “Report of the Seventh Annual Convention of the State Hospital And Medical League, Odd Fellow’s Hall, Saskatoon, October 13 & 14, 1942,” p. 1; and Joan Feather, “From Concept to Reality: Formation of the Swift Current Health Region,“ Prairie Forum, 16, 1 (Spring 1991): 65. N.a., n.t., Saskatchewan Medical Quarterly, 6, 2 (August 1942): 4; and Saskatchewan Medical Quarterly, 5, 4 (December 1941): 30-2. State Hospital and Medical League, The Case For State Medicine (Regina, 1944), University of Regina Library Special Collections. Dr. W. H. Setka, “Competitive Medicine and Its Results,” radio address delivered over CKBI and CJRM, 14 February 1943. Cited in State Hospital And Medical League, The Case For State Medicine, p. 22.

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56 Select Special Committee on Social Security and Health Services, Final Report (Regina, 1944), p. 10. 57 Select Special Committee on Social Security and Health Services, Final Report (Regina, 1944), p. 13. 58 The Saskatchewan Reconstruction Council was established by the provincial government on 20 October 1943 to formulate a post-war reconstruction and rehabilitation plan for Saskatchewan. 59 Saskatchewan Reconstruction Council, Report of the Saskatchewan Reconstruction Council, (Regina: King’s Printer, 1944), p. 172. 60 Saskatchewan Reconstruction Council, Report of the Saskatchewan Reconstruction Council, p. 172. 61 Saskatchewan Reconstruction Council, Report of the Saskatchewan Reconstruction Council, p. 173-74, 188-89. 62 Henry E. Sigerist, Saskatchewan Health Services Survey Commission: Report of the Commissioner, (Regina: King’s Printer, 1944), p. 6. 63 For an analysis of the submissions to these government-sponsored inquiries see Gordon S. Lawson, “The Co-operative Commonwealth Federation, Health Reform and Physician Remuneration in the Province of Saskatchewan, 1915-1949,” MA thesis, University of Regina, 1988, p. 50-64. 64 The Sigerist Commission received submissions from 24 rural and urban municipalities, SARM, 7 trade unions, Saskatchewan’s 4 medical services cooperatives, 2 “agriculture organizations,” 4 citizen’s organizations, the Saskatchewan Hospital Association, Saskatoon Constituency Association (CCF) and the Saskatchewan Old Age Pensioners’ Association; and the Hogarth Committee received testimony from 42 organizations; the SRC heard representations concerning health services from 26 organizations. 65 SABR, HSSC, R-251, File 11, D. Demarias (Secretary Treasurer Rural Municipality of Big Quill No. 308) to Mindel C. Sheps & accompanying “Resolution.”; File 5, “Brief on behalf of the Regina Trades and Labour Congress”; File 8, “Prince Albert Mutual Medical Benefit Association, Ltd: A Brief to be presented to the Saskatchewan Health Services Survey Commission at Saskatoon, Tuesday, September 19, 1944,” p. 2; File 6, United Farmers of Canada (Sask. Section) “Memorandum on “Social Health Services” to Saskatchewan Enquiry Commission, September 19th, 1944,” p. 2; File 6, “Submission to the Saskatchewan Health Survey Committee,” Saskatoon, September 10th/44 (Saskatchewan Federation of Agriculture),” p. 1; File 5, brief submitted by P. W. Haffner for the Regina Trades and Labour Congress,” p. 2-3; File 5, Saskatoon Trades and Labour Council, 19 September 1944; and File “Extra Copies,” “Report of Sittings Held at Saskatoon—September 20, 1944,” p. 1. 66 Lipset, Agrarian Socialism, p. 297. 67 SABR, HSSC, R-251, File 6, “Submission to the Saskatchewan Health Survey Committee, Saskatoon, September 19th/44 (Saskatchewan Federation of Agriculture),” p. 1. 68 Contributory health insurance was preferred by SARM, three of the four medical insurance co-operatives in Saskatchewan, several Canadian Brotherhood of Railway Employees union locals, the Canadian Daughter ’s League; the Provincial Council of Women, the Saskatchewan Hospital Association, and two rural municipalities. 69 SABR, HSSC, R-251, File 8, “Submission by the Regina Mutual and Medical Benefit Association,” p. 5; “Melfort and District Mutual and Medical Benefit Association Limited,” p. 10; “Supplemental Brief in Conjunction with the Melfort Medical Coop Brief on Health Services [Saskatoon Mutual and Medical Benefit Association],” p. 4. 70 SABR, HSSC, R-251, File 3, “Addendum of Dr. J. F. C. Anderson. Saskatoon, Sept 20, 1944,” p. 2. 71 SABR, HSSC, R-251, File 5, “Memorandum Respecting Health Insurance, Public Health Services, etc., submitted to the Health Service Survey Commission of the Province of Saskatchewan, 26 Septembers 1944, by the Local Unions of the Canadian

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75

76 77 78 79 80

81 82

83 84 85

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87 88 89 90 91 92

93 94 95 96

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Brother Hood of Railway Employees and other Transport Workers, Regina, Saskatchewan,” p. 1-2. N.a., n.t., Saskatchewan Medical Quarterly, 8, 4 (December 1944): 8. SABR, HSSC, R-251, File 8, “Brief presented at Saskatoon to Doctor Sigerist… State Hospital & Medical League,” p. 67. On Hugh MacLean see Jacalyn Duffin, “The Guru and the Godfather: Henry Sigerist, Hugh MacLean and the Politics of Health Care Reform in 1940s Canada,” Canadian Bulletin of Medical History, 9 (1992): 191-218. SABS, Hugh MacLean Papers, S-A69, File 2, “Radio Address by Dr. Hugh MacLean, Vice-President, C.C.F. SASK. Section, Wednesday, March 17, 1937,” p. 2, 4; “Health Services, Women’s Farm Organization. By Dr. Hugh MacLean, Wednesday, June 2, 1937,” p. 5, 10. Lipset, Agrarian Socialism, p. 288. Rands, Privilege and Policy, p. 297. SABS, MacLean Papers, S-A69, File 2, “Radio Address by Dr. Hugh MacLean,” p. 2-3; and Lipset, Agrarian Socialism, p. 289. Naylor, Private Practice, Public Payment, p. 123; and Rands, Privilege and Policy, p. 98-9. SABR, Political Pamphlets, Co-operative Commonwealth Federation, Saskatchewan Section (hereafter CCFSS), File 19, #10, “The CCF Program for Saskatchewan,” first printing, November 1943, reprinted, April 1944, p. 7-8; File 19, “ Let There Be No Blackout of Health, “ circa 1943-1944; and “The CCF Plans For Health,” Regina Leader, 12 June 1944. N.a., n.t., Saskatchewan Medical Quarterly, 7, 3 (December 1943): 5. SABS, Co-operative Commonwealth Federation, Saskatchewan Section Papers (hereafter CCFSS Papers), S-B7, File 1.2, Minute Book #3 (1942-1944), “Resolution on Health Services,“ p. 13-14 (#749-750). SABS, CCFSS, Papers, S-B7, File 1.2, “Resolution on Health Services,” p. 13-14 (#749750). Thomas H. McLeod and Ian McLeod, Tommy Douglas: The Road to Jerusalem (Edmonton: Hurtig Publishers, 1987), p. 148. The CCF, SHML and UFC, for example, claimed that health insurance only provided coverage to those who could afford the premiums and did not provide adequate facilities for preventive medicine. P. G. Makaroff, “The Municipal Doctor, Health Insurance, Co-operative Insurance and Other Alternatives,” radio address delivered over CJRM and CFQC, 21 February 1943. Cited in State Hospital and Medical League, The Case For State Medicine (1944). SABR, HSSC, R-251, File 10, “Fred Gordon (Secretary CCF Saskatoon Constituency) to Secretary Sigerist Commission, September 16, 1944.” SABR, Political Pamphlets, CCFSS, File 19, #41, “The CCF Program for Saskatchewan,“ p. 7. Duffin, “The Guru and the Godfather,” p. 203-7. SABS, MacLean Papers, S-A69, File 2, “An Address on Medical Health Services by Dr. Hugh MacLean At the C.C.F. Convention, Regina Saskatchewan July 12, 1944,” p. 4 SABS, MacLean Papers, S-A69, File 2, “An Address on Medical Health Services by Dr. Hugh MacLean…. July 12, 1944,“ p. 5. The nature of the “differences in ideological approach” is not discernable from Taylor ’s correspondence with Houston. SABS, C. J. Houston Papers, S-A569, C. J. Houston to Malcolm G. Taylor, 25 February 1975. Taylor, Health Insurance and Canadian Public Policy, p. 244. McLeod and McLeod, Tommy Douglas, p. 149. SABS, C. J. Houston Papers, S-A569, File 23, C. J. Houston to Malcolm G. Taylor, 25 February 1975. SABS, Houston Papers, S-A569, File 23, C. J. Houston to Malcolm G. Taylor, 25 February 1975.

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97 McLeod and McLeod, Tommy Douglas, p. 198. 98 SMA/SCPS, File “O.A.P Administration, 1944,” Dr. B. C. Leech, “O. A. P. etc. Scheme,“ n. d. 99 “Organized Medicine: Army plan should be applied to Civilians, “Leader Post, 7 September 1944. 100 “Doctors Will Not Be Civil Servants,” Regina Leader, 14 September 1944. 101 “Adequate Health Services for All the People Is C.C.F. Aim,” Western Producer, 28 September 1944. 102 Sigerist, Saskatchewan Health Services Survey Commission: Report of the Commissioner, p. 10. 103 On the establishment of the HSPC see Duane Mombourquette, “An Inalienable Right: The CCF and Rapid Health Care Reform, 1944-1948,” Saskatchewan History, 43, 3 (1991): 103; McLeod and McLeod, Tommy Douglas, p. 128, 149; and A. W. Johnson, Dream No Little Dreams: A Biography of the Douglas Government in Saskatchewan, 19441962 (University of Toronto Press, 2004), p. 77, 79-80. 104 Jane Menken et al., “Obituary: Mindel C. Sheps: 1913-1973,” Population Index, 39, 4 (October 1973): 507-13. 105 Allan Mason Chesney Medical Archives of the Johns Hopkins Medical Institutions, Henry Sigerist Papers, Box 25, Mindel C. Sheps to Henry E. Sigerist, 12 August 1944. 106 Duffin, “The Guru and the Godfather,” p. 195-96. 107 McLeod and McLeod, Tommy Douglas, p. 147. 108 SMA/SCPS, Health Services Planning Commission, Report on Regional Health Services: A Proposed Plan, “Part 2: Principles of Health Services Planning,” p. 6; “Part 3: Local Health Services,” p. 2; “Part 5: Implementation of Plans,” p. 5; and Part 4: Regional Organization and Services, p. 1. 109 SMA/SCPS, Report on Regional Health Services, “Part 3: Local Health Services,” p. 7. 110 SMA/SCPS, Report on Regional Health Services, “Part 3: Local Health Services,” p. 7-9. 111 SMA/SPCS, Report on Regional Health Services, “Part 5: Implementation of Plans,” p. 2. 112 SABR, Premier ’s Office, Health Services Planning Commission (Thomas C. McLeod Papers), R-191, File 5.1, “Minutes of Meeting of the Advisory Committee, March 2 & 3, 1945,” p. 2. 113 N.a., n.t., Saskatchewan Medical Quarterly, 9, 3 (December 1945): 25. 114 N.a., n.t., Saskatchewan Medical Quarterly, 9, 3 (December 1945): 15-16. 115 N.a., n.t., Saskatchewan Medical Quarterly, 9, 1 (May 1945): 20. 116 N.a., n.t., Saskatchewan Medical Quarterly, 9, 1 (May 1945): 21, 25. 117 C. Stuart Houston, “The early years of the Saskatchewan Medical Quarterly,“ Canadian Medical Association Journal, 118 (May 1978): 1127-28. 118 N.a., n.t., Saskatchewan Medical Quarterly, 9, 1 (May, 1945): 18. 119 N.a., n.t., Saskatchewan Medical Quarterly, 9, 3 (December, 1945): 28. 120 N.a., n.t., Saskatchewan Medical Quarterly, 9, 3 (December, 1945): 28. 121 Taylor, Health Insurance and Canadian Public Policy, p. 248. 122 T. H. McLeod does not recall any such decision going to cabinet. Interview with author, Ottawa, 7 August 1995. 123 Saskatchewan Medical Quarterly, 9, 3 (December 1945): 28. 124 Historians agree that this letter precluded the establishment of a salaried service. Taylor, Health Insurance and Canadian Public Policy, p. 250; and Naylor, Private Practice, Public Payment, p. 140-41. 125 SMA/SCPS, File 7-4-8, “Minutes of the Meeting of the Advisory Sub-Committee on Local Health Services Held April 22, 1945,” p. 1. 126 Order in Council 876/45. Regina, Tuesday, 12 June 1945. Saskatchewan Gazette, 30 June 1945. 127 Regulations Governing the Establishment of Health Regions Under the Health Services Act. Chapter 51 of the Statutes of Saskatchewan, 1944; SABR, T. C. Douglas Papers, R-33.1, File 3 133 (14-24) Memorandum for Douglas from Sheps, # “Notes

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130 131 132

133 134 135 136 137

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141 142

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144 145 146

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re Meeting with Health Insurance Committee of Sask. College of Physicians & Surgeons,” no date (circa December 1945), p. 3. Of the approximately 170 plans in 1944 all but 10 were on a salary basis. SABR, McLeod Papers, File 38, “Fee-For- Service Schemes.” RM Pittville, RM Webb, RM. Miry Creek, RM. Riverside and the town of Cabri. SABR, HSPC, R-191, File 38, “Fee-For-Service Schemes”; Feather, “From Concept to Reality,” p. 70-1; Lester Jorgenson, “Rural Municipality of Miry Creek No. 229 and Health Region 1,” in Bridging the Centuries (Abbey: Miry Creek Area History Book Committee, 2000), p. 53-54; SCPS/SMA, (“Dr. Houston’s Municipal Contract File”), Mindel C. Sheps to Dr. C. J. Houston, 7 May 1945; and Saskatchewan Medical Quarterly, 10, 2 (July 1946), p. 8. Feather, “From Concept to Reality,” p. 70-5. N.a., n.t., Saskatchewan Medical Quarterly, 10, 2 (July 1946): 9. SABR, Records of the Department of Health, Policy Research and Management Services Branch, R-536, File 14(a) “History of the Swift Current Health Regina Medical Care Plan: 1946-1966,” June 1969, p. 11. Joan Feather, “Impact of the Swift Current Health Region: Experiment or Model?” Prairie Forum, 16, 2 (Fall 1991): 227-29. “Medical Co-op Directors Authorized to Borrow Million for Development,” Saskatoon Star Phoenix, 30 April 1946. Taylor, Health Insurance and Canadian Public Policy, p. 260. MSI Inc. (Saskatoon) was modelled after the doctor-sponsored FFS plan established by Regina doctors in 1939. SABR, Records of the Health Services Planning Commission (hereafter HSPC), R-326 (Sask. Dept. of Health, HSPC, 1938-1952), File 121b, E. J. Loer to Dr. F. D. Mott, 12 October 1946; 7 November 1946. There were 12-13 FFS municipal schemes in 1947. SMA/SCPS, Health Services Planning Commission, Research and Statistics Division, 1948, “Survey of Municipal Doctors Plans Operating in 1947.” The municipal doctor system continued to expand until 1947, its peak year, when it provided coverage to 210, 000 persons (25% of the rural population). SMA/SCPS, Advisory Planning Committee on Medical Care, Study Document 2A, “Memorandum on Municipal Medical Care Plans in Saskatchewan,” circa 1960-1961, p. 4. Saskatchewan Medical Quarterly, 2, 4 (December 1947): 44. Dr. M. Sheps resigned from the HSPC in January 1946. She was temporarily replaced by Dr. C.G. Sheps, who became acting chairman of the HSPC (a position that had been held unofficially by Dr. M. Sheps) and Dr. O. K. Hjertaas who became secretary. The Drs. Sheps would leave the province during the summer of 1946. F. D. Mott, a former senior officer in the United States Public Health Service and a graduate of the McGill University medical, was subsequently recruited to chair the HSPC. During Mott’s tenure, relations between the government and the SCPS improved. SABR, HSPC, R-326, File 143, F. D. Mott, “Memorandum for File: HSPC 6-2-2: re. Meeting with Executive of S.A.R.M.,” 25 October 1947. SABR, HSPC, R-326, File 143, F. D. Mott, Memo for File: HSPC 6-2-2: re: meeting with Executive of Saskatchewan Association of Rural Municipalities, 15 January 1948; and F. D. Mott to T. C. Douglas, “Address at Convention of Saskatchewan Association of Rural Municipalities,” 25 February 1948. SABR, HSPC, R-326, file 130, F. D. Mott, “Memorandum for the File: re. meeting of December 10, 1947 with S.A.R.M. Regina Health Services Union etc. concerning 1947 Contract Schedule of Fees and Related Problems,” n.d. E. A. Tollefson, Bitter Medicine: The Saskatchewan Medicare Feud, (Saskatoon, Saskatchewan: Modern Press, 1963), p. 41. SMA/SCPS, file 7-4-8,”Advisory Committee to the Health Services Planning Commission, Minutes and Proceedings, May 9 and 10, 1947,” p. 33. “New Plans for Health Services,” Leader Post, 22 May 1947.

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147 SABR, Records of the State Hospital and Medical League, R-690.1, File 8, “My Memories of The State Hospital and Medical League by Joseph A. Thain,” p. 6. 148 SABS, CCFSS Papers, S-B7, File 11 55 (1), “Resolutions passed at the Saskatoon Constituency Convention on June 13, 1947,” # 5176-5177. 149 SABS, CCFSS Papers, S-B7, File 1 11, Minute Book, 1944-1948 (#4) “Minutes of Twelfth Annual Provincial CCF Convention July 29-31, 1947,” # 1053. 150 SABS, Pamphlet Collection, “Editorial: Well Ordered Medical Services,” Health Services Review, (October 1947): 4; and “Brief To The Government of The Province of Saskatchewan: Submitted by The State Hospital and Medical League 1946,” Health Services Review, 2, 1 (May, 1946): 6-7; “Brief To The Government … February 8, 1947,” Health Services Review, 3, 1 (April 1947): 6-7. 151 “Physicians Shy From Sask. Posts,” Saskatoon Star Phoenix, 21 February 1947. 152 SABR, HSPC, R-326, File 2e, “Memorandum for the File: re. Employment of Specialists by Health Region No. 1, 30 November 1948.” 153 SABS, Pamphlet Collection, “League Officials Address Sask. Assn. of Rural Municipalities,” Health Services Review, 3, 5 (April 1948): 19. 154 SABR, HSPC, R-326, File 1O5c (1of 2), T. C. Douglas to Dr. G. Ferguson, 26 February 1949. 155 SABR, HSPC, R-326, File 1O5c (1of 2), T. C. Douglas to Dr. G. Ferguson, 26 February 1949. 156 SABS, MacLean Papers, S-A69, File 29, Fred Mott to Hugh MacLean, 21 March 1949. 157 SMA/SCPS, Advisory Planning Committee on Medical Care, “Memorandum on Municipal Medical Care Plans in Saskatchewan,” circa 1960-1961, p. 2. 158 SMA/SCPS, File 7-4-8, “Advisory Committee to the Health Services Planning Commission, Minutes and Proceedings, May 9 and 10, 1947,” p. 33. 159 In 1950, 173 plans provided coverage to 200,000 persons, approximately 24% of the population. Milton I. Roemer, “Prepaid Medical Care and Changing Needs in Saskatchewan,” American Journal of Public Health, 46 (1956): 1083. 160 N.a., n.t., Saskatchewan Medical Quarterly, 9, 1 (May 1945): 17. 161 Naylor, Private Practice, Public Payment, p. 140. 162 Lipset, Agrarian Socialism, p. 297. 163 Lipset, Agrarian Socialism, p. 297.

9 The Hoadley Commission (1932-34) and Health Insurance in Alberta ROBERT LAMPARD

The health of the people of Canada is of vital importance…. To have the responsibility refused by the federal government, accepted by the province, and by it passed on to the municipality, the body with the least taxing power and least financial ability to assume it means the maximum of expectations are met with the minimum of accomplishment. — Albert Archer and Wilfred A. Wilson, 19381 INTRODUCTION

Medicare was a centennial gift to Canadians, but its formative steps go back at least another 40 years, to the first provincially conceived health insurance program in Alberta. It was to be a voluntary and comprehensive program, with the provincial government contributing to its funding. Alberta’s Hoadley Commission proposal of 1932 to 1934 became a national one after its principles were included in the Canadian Medical Association’s (CMA) Health Insurance Plan of 1934 to 1935, and the services to be insured (medical, hospital, dental, drugs, essential nursing) and citizens to be insured (all), were re-proposed by the Heagerty Advisory Committee to the federal government in 1943. Enamoured, the federal government increased the offer of funding to a universal or 100% level in 1945. The federal proposal dissolved in 1946 over taxation arguments, not over the health services or citizens to be covered. The federal government continued to take the universal funding approach in 1957 (for hospitals) and during 1967 to 1968 (for medical care). Improved access to healthcare was viewed as early as 1915 as a duty by the United Farmers of Alberta (UFA). After they were elected in 1921, the UFA government’s decisions demonstrated how important healthcare was to the government and to Albertans. The UFA approach was maintained by the Social Credit government that succeeded it in 1935.

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BACKGROUND

Historically, the settlement and growth patterns of Alberta and Saskatchewan to 1948 were very similar. Both were administered by the federal Ministry of the Interior as the North West Territories until they became provinces in 1905. The construction of the CPR main in 1885 and branch rail lines between 1885 and 1892 occurred almost simultaneously in the two provinces, bringing waves of new immigrants. After the turn of the century there were strong agricultural based interest groups formed in every province from Ontario to British Columbia. In Alberta, the movement was formalized in 1909 through the incorporation of the UFA. As the UFA philosophy and objectives became clearer and their followers more numerous, the UFA purview expanded well beyond agriculture. It encompassed many rural life issues, including health care. As it did, the UFA influence on the mainstream parties increased. Disenchanted at the rate of progress, the UFA created their own political party in 1919, and was successfully elected in Alberta for three consecutive terms from 1921 to 1935.2 Farmer-based political parties formed governments in Manitoba and Ontario for shorter periods of time than in Alberta. Nationally, the western farm movement saw its interests reflected in the Progressive Party in the House of Commons. Access to health care became a priority for the UFA during the Great War, as the province faced a high rate of disabled soldiers returning from Europe.3 The health care seeds were sown by farm women after they gained the right to vote in 1915 and formed the United Farm Women’s Auxiliary. They reorganized one year later as the autonomous United Farm Women of Alberta (UFWA). Irene Parlby, who later became one of the “Famous Five,” was elected as the first UFWA vice-president from 1915 to 1916 and served as its second president from 1916 to 1920.4 She was also the UFWA health convener. In 1916, Parlby and future UFA Premier Herbert Greenfield were appointed by the Liberal government to a committee to draft a Municipal Hospitals Act. The 1917 Act, revised in 1918, was designed to promote the establishment of hospitals in rural communities, partially funded through municipal taxes. The Municipal Hospitals Act was the rural counterpart to the federal Military Hospitals Commission under Sir James Lougheed, which rapidly acquired urban hospital beds to handle increased need after the chlorine gassing of Canadian troops at Ypres in 1915. The Spanish flu epidemic of 1918 and 1919 compounded the postwar bed shortage. Many private hospitals were closed because of insufficient funding. By 1918, Parlby was declaring publicly that medical care was a right, and the Alberta government had a duty to provide it to its citizens.5

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Through UFWA and Alberta Medical Association (AMA) encouragement, the postwar Liberal government in Alberta created Canada’s second Public Health department6 in 1918 and began hiring public health nurses. Then the government began a District Health Nurse program in 1919 to improve care in the remote areas not served by physicians. In 1920, travelling child welfare clinics were started to serve rural and northern Alberta communities.7 Elected in Alberta in 1921, the UFA had only one MLA with legislative experience, the Honourable George Hoadley. He had been a Conservative MLA since 1911, before switching to the UFA in the 1921 election. Hoadley was on the short list to become Premier. George Hoadley was a British immigrant who came to Manitoba in 1890 and Alberta in 1891.8 He became a farmer, horse breeder, politician, and the 1918 Leader of the Conservative opposition, before switching to Independent status in 1919. He won his 1921 UFA seat by acclamation. Hoadley became the longest-serving member in the Alberta Legislature, from 1909 to 1935. Although he was initially Alberta’s Minister of Agriculture from 1921 to 1934, Hoadley was also responsible for the Ministry of Health portfolio from 1923 to 1935. He was supported on women’s issues by the UFA Minister without Portfolio, Irene Parlby. The Hoadley appointment as Health Minister in 1923 began a period of ministerial and deputy ministerial stability in health care, that was unparalleled in Canada. There were only two Ministers of Health in Alberta from 1923 to 1957—Hoadley and Wallace Warren Cross, M.D.— and two deputy Ministers from 1912 to 1952—Dr. W. C. Laidlaw and Dr. Malcolm R. Bow. Hoadley continued as Alberta’s health minister under three consecutive Premiers—Herbert Greenfield, John Brownlee, and Richard Gavin Reid—and rose to become the Deputy Premier.9 Following the Hoadley appointment in October 1923, the pace of health care changes in Alberta accelerated. Hoadley’s objective was to improve the health of Albertans.10 To improve rural health care access, his strategy was to build more municipal hospitals. To improve health care programs, his strategy was to expand the public health, district nurse and travelling clinic programs. The latter began as a travelling dental clinic in 1921, with the addition of a physician and nurse in 1924, a surgeon in 1927, and eventually a psychiatrist. The travelling clinic operated during the summers from 1924 to 1943, and was primarily focused in northern Alberta under a government agreement with the University of Alberta Hospital. In 1924, Hoadley noted that the post-operative death rate in Alberta was the highest in Canada. It was even higher in rural Alberta. He amended the Alberta Hospital Act to require a second medical opinion before surgery. All tissues removed at surgery were also to be examined by a pathologist.11

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After being re-elected with an increased majority in 1926, the UFA government felt increasingly unrestricted by the mainline parties in the political decision-making process. Health Minister Hoadley set a limit of six general acute care hospital beds per 1,000 in Alberta in 1926.12 This lasted for almost 50 years. In part because of concerns over the high postoperative mortality rate, the UFA government unilaterally amended the Alberta Medical Profession Act and Regulations to require a review of the credentials of all physicians before they could advertise themselves as specialists. The University of Alberta Senate was appointed as the reviewing and approving body. Specialist diplomas were issued by the University after a credential assessment was completed by the Faculty of Medicine. It was the first specialist recognition and approval system in Canada, but it was government mandated. The 1926 amendments to the Alberta Medical Profession Act preceded the 1927 initiative of Dr. David Low and Regina’s “Mighty Triumvirate,” leading to the formation of the Royal College of Physicians and Surgeons of Canada in 1929. 13 The Alberta regulations remained in place until 1944. Following the sudden death of Deputy Minister Dr. W. C. Laidlaw who had served in this capacity from 1912 to 1926, Health Minister Hoadley enticed Regina’s Medical Officer of Health Dr. M. R. Bow to become Alberta’s Deputy Minister of Health from 1927 to 1952. Bow chose the Alberta position over a similar opportunity in Saskatchewan, created by the retirement of Deputy Minister Dr. M. M. Seymour in 1927. Bow brought with him a diploma in public health and considerable experience in addressing and solving public health problems.14 Minister Hoadley and Deputy Minister Bow faced a plethora of challenges: Canada’s first polio epidemic, an enduringly high post-operative death rate,15 TB and mental health issues, and uneven rural/urban access to healthcare, a problem that the drought in southeasterm Alberta in 1927 and the Depression in 1929 would exacerbate. On 2 November 1927, members of the Edmonton Academy of Medicine sent a letter to the Calgary Medical Society to signify their alarm over the government’s rumoured initiative to pass a state medicine plan.16 The two bodies recommended that the part-time Registrar, Dr. G. R. Johnson, become the full-time Registrar, to better prepare the AMA and the College of Physicians and Surgeons of Alberta (CPSA) to cope with upcoming government legislation. The CPSA responded by appointing Drs. A. E. Archer and W. A. Wilson as College presidents for most of the decade spanning 1928 to 1939.17 The AMA/CPSA began their own rapid education program on the topic of state medicine and what it meant. To most physicians it meant placing doctors on a salary. Dr. Malcolm MacEachern of the American College of Surgeons came to Edmonton to talk about the New Zealand health program. He criticized it as

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destructive for hospital-based physicians and surgeons. Dr. A. E. Archer did not entirely agree.18 The AMA/CPSA attitude toward salaried or contracted medicine was based on considerable experience. The first organized medical care, lasting from 1874 to 1892, was brought to the two prairie provinces by contracted NWMP surgeons. After 1886 physicians signed CPR contracts to provide medical care to CPR employees. One of these contracts led to Drs. J. D. Lafferty and H. G. Mackid forming the first group practice in Calgary in 1890. Other medical contracts were signed with coal mining and lumber companies. In 1907, the Calgary Medical Society, led by the Registrar Dr. Lafferty, did an about-face. Lafferty called for the abolition of all existing medical contracts and the tendering of them.19 Alberta physicians officially maintained that position except in mining and lumber towns. They did not support the municipal doctors’ plan that began in rural Saskatchewan during the Great War. Some medical politicians even viewed the travelling clinic as a form of contracted practice. In 1922, the newly merged AMA/CPSA amended their Code of Ethics, calling unethical, any practice which interfered with reasonable competition.20 Retirement home (lodge) contracts were viewed as unnecessary too,21 even though well-known future Lt. Gov. (Dr.) William Egbert (1925-30) signed one. THE WHITE/PATTINSON INQUIRY (1928-29) 22

Long interested in government involvement in improving access to health care, the UFA’s annual conventions in 1919, 1923, and January 1928, passed motions requesting the government initiate a state medicine program in Alberta.23 In February 1928, the UFA government accepted an all-party supported motion from Labour MLAs White and Pattinson, for a legislative Inquiry into State Medicine. February 1928 became even more notable, when Minister Hoadley audaciously passed the 1928 Sexual Sterilization Act, a British Empire precedent.24 To cap the government’s February 1928 legislative agenda, Health Minister Hoadley tabled the Professions Disclosure Act. Hoadley wasn’t satisfied that patient complaints forwarded to the CPSA only led to a report by the CPSA to the Department of Health.25 The 1928-29 White/Pattinson Legislative Inquiry was limited by its terms of reference: to examine only health insurance and to “look into legislation in any country, and suggest proposals regarding surgical or medical services their nature, extent, efficiency, cost and financing, and the feasibility of adapting them in Alberta.”26 The Inquiry found that most international health insurance plans in the 1920s included sick-

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ness, disability, and absentee coverage in their benefits. In Britain, the health insurance program covered 15 million employees and included medical and sickness benefits. Half of Britain’s physicians participated in it. The French program covered one-half of the population, including dependents, and provided more benefits (maternity care, drugs). In Germany, non-manual workers were covered. In the US, there were 11 Commissions that investigated health insurance. Seven recommended it. Four were indifferent. From a preventive medicine perspective, there were 330 medical officers operating public health programs. A five-year American study of health insurance was started in 1927. In Canada, the Inquiry noted Quebec had established a few county health units. Saskatchewan was pleased with its rural medical contracting system. The 1921 British Columbia Royal Commission had investigated health insurance and recommended a health and sickness program for employers/employees. The provincial government was to contribute one-fifth of the cost, but no action was taken by the British Columbia government at that time. In Alberta, the Inquiry found there were 17 municipal hospitals, a travelling clinic that provided rural dental, nursing, and medical services, and seven district health nurses, mainly in the frontier areas of Northern Alberta, where there were too few citizens to support a physician. It noted the maternal death rate was 6.4 per thousand, compared with New Zealand’s four and Holland’s two per 1,000. In the mining and lumber towns, there were between 20 and 30 contracted doctors who provided care for 25,000 people. CPR employee medical contracts existed throughout the province. Several Alberta municipalities had signed municipal doctor contracts. The province had signed 10 provincial medical contracts to keep physicians in the drought stricken southeastern Alberta, and retained several full-time physicians in northern Alberta. In Drumheller, a local medical and hospital insurance program had been started by mining companies for all the miners. The Inquiry report ended with an outline of one American corporation’s health benefit plan for 16,000 employees and a statement by an American politician encouraging state or salaried physicians. There was no record of any briefs being submitted to the Inquiry. Nor did its membership appear to extend beyond White and Pattinson. The Inquiry concluded a state medical insurance plan was feasible in Alberta. It recommended a 1921 British Columbia-type plan for urban Alberta for employees and employers, and a rural (doctor and hospital) insurance plan for the rest of the province. The authors noted such a plan could be costly and would need to be weighed against spending on preventive medical programs, where “great gains had been made in the recent past and shouldn’t be overlooked.”27 Hoadley took no action on the Inquiry report, which was tabled in

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February 1929. Instead he implemented two public health programs in High River/Okotoks (his own constituency) and Red Deer. They included Medical Officers of Health and were partially funded by the Rockefeller Foundation. The health department opened mental health and tuberculosis clinics in Calgary and Edmonton. The same month Hoadley announced a provincial doctors program for the Peace River country in Northern Alberta, paid for by the provincial government.28 Then he amended the Municipal Districts Act to allow Districts to pay physicians from tax revenues. A month after the White/Pattinson Inquiry was tabled, BC MLA Dr. H. A. Wrinch, Dr. A. E. Archer’s colleague in the Methodist/United Church Mission Hospital system, moved that a second BC Royal Commission be appointed to investigate health insurance and maternity benefits. Accepted, it deliberated from 1929 to 1932. The British Columbia Inquiry stimulated Dr. J. H. MacDermot of Vancouver to write two authoritative articles on health insurance in the CMAJ, in April and May of 1929. At their annual meeting in June 1929, the CMA Council commissioned a search of the health insurance literature. State medicine was again discussed at the third Federal/CMA Health Services Conference in Ottawa in November 1929. The CMA’s response was to appoint a Study Committee in 1931, with Albertan Dr. J. S. McEachern on it.29 Starting with the 1930 sitting of the Legislature, Labour MLAs White and Pattinson annually moved that the government design a plan to implement state medicine in Alberta. Each time Hoadley turned the motion aside. The government wasn’t ready, he said, and he wanted “a closer understanding between individual doctors and myself.”30 In 1931, founding UFA President Henry Wise Wood retired. The UFA society took a definite left turn in its policies aimed at attenuating the Depression crisis, even distancing itself from the UFA government.31 Little happened until January 1932. After the second editorial on state medicine by D. O. Wight, the owner of the Cardston News, there was an Oxford style debate on state medicine. Wight implored Hoadley to address it. Community interest in a voluntary prepaid medical insurance program was confirmed when over 150 families signed $25 per year prepaid medical contracts to start the program on 1 March 1932.32 It complemented the Cardston municipal hospital program begun in 1919. The concept of signing family medical contracts spread throughout Southern Alberta, to Lethbridge, Stettler, and Lamont, where it reached Dr. A. E. Archer of the Lamont Clinic. He remodelled it into the Di Bozsha program.33 THE HOADLEY COMMISSION PROGRESS REPORT (1933) 34

In February 1932, the second British Columbia Royal Commission report

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on health insurance was tabled. Hoadley liked the Commission’s recommendation for a two-ninths government contribution toward the cost of the health insurance programs. He surprised many by accepting the annual White/Pattinson motion that same month. On 4 March Hoadley appointed an all-party Commission to design a health insurance plan for Alberta. It was colloquially known as the Hoadley Commission after its chairman. There were eight members, including the Honourables George Hoadley and Irene Parlby, Chris Pattinson, and Conservative MLA Dr. W. Atkinson. The Commission was charged with making recommendations “as to the best method of making adequate medical and health services available to all the people of Alberta” and to report on “the financial arrangement which will be required on an actuarial basis to ensure the same.”35 The Commission began by researching all the available material from the British Columbia and Manitoba studies, the 1929 Inquiry, and any information that could be secured nationally and internationally. With former UFA Minister of Health and future Premier R. G. Reid in the chair, in November 1932 the CPSA, AARN, Alberta pharmacists and dentists, the Alberta Hospital Association, and Labour representatives presented briefs. A letter objecting to the concept of health insurance was received from the Christian Science Association. A civil service member of the government presented the British concept of health insurance to the Commission. At the December meeting, with Minister Hoadley in the chair, Drs. Archer and Wilson recommended a health insurance program on behalf of the CPSA that covered hospital and medical services. So did Drs. A. F. Anderson and W. T. Washburn in their brief on behalf of the Alberta Hospital Association. The Commission decided to expand the program to include hospital and medical services as well as drugs, dental, and public health services. Commission members agreed the information available was not sufficient and released the proposal as a progress report in March 1933. The Commission concluded that improving access to healthcare was possible through a contributory health insurance program and that any program should be adaptable to local needs and capable of provincial or national expansion.36 The cut-off date of January 1933 for the progress report was the same month the UFA joined the Cooperative Commonwealth Federation (CCF) party, and six months before the CCF released its Regina Manifesto in August 1933. The Manifesto contained the principle that healthcare was to be as accessible as education.37 One early member of the CCF was Reverend Tommy Douglas.38 He failed in his first attempt to become elected as a CCF member in the 1934 Saskatchewan election.

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Douglas would not return to the provincial scene until 1943, when he became the CCF party leader, and Premier the following year. The Hoadley Commission proposal was to be based on the municipal hospital and municipal district systems, with six to eight municipal districts comprising one hospital district. Public hospital districts were to be modified to match the boundaries of the health districts. Citizen participation had to be large enough for the program to be financially viable. A 50% favourable vote committed each hospital district to join the program. The Commission said insured coverage of long hospital stays needed to be capped. In larger cities, groups such as professions, trades, and companies would have to be formed to be insured. Land owners as well as individual wage earners would need to be contributors. Any contributions by the government were to be the same for the urban or rural programs. A central administration would be needed and a Commission appointed to oversee the program. The fee-for-service system would be maintained except in remote areas, where a contract or salary would be considered. Fees would be similar to those paid by the WCB. The Commission noted surgery and specialists’ fees were too high. The report found that three part-time municipal doctor programs existed in the province. A fourth was discontinued because of the Depression. Specialist coverage was not to be included in the original program or at least until the program was province wide. The estimated total cost of the provincial health insurance program was $10.6 million per year. In 1934, the provincial hospital grant was $400,000 per year. It would increase to $2.2 million if the whole province was covered by the program. The cost to an average employee or wage earner would be about $32. For a family it would be about $43 per year, on the average. Both Plans A and B contained a provision that the provincial government would contribute two-ninths, or 22% of the cost of the program. Plan A divided the province into hospital/health districts. The government could control which district(s) could undertake a vote. The individual (including dependents) was to pay seven-ninths of the cost. The Plan B option was similar to one of the 1932 British Columbia Royal Commission’s five options. It covered employees only, and did not provide maternity benefits or cover dependents. The employer was to pay two-ninths of the cost, and the employee five-ninths. Plan B costs were estimated at $6.54 per wage earner per year. In the summer of 1933, Hoadley sought to increase the number of municipal districts hiring municipal doctors, by offering them money for a district health nurse, so long as they agreed to retain a municipal physician at the end of a three- or four-year period. The CPSA approached all physicians with a questionnaire, asking if they supported a health insur-

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ance plan. Physicians responded by favouring a plan on a twenty-to-one basis.39 THE HOADLEY COMMISSION’S FINAL REPORT (1934) 40

The final report, released after the February 1934 legislative sitting, was basically the same as the progress report. The report concluded that no single plan could be applied throughout the province. The Commission encouraged municipal districts to consider contracts and salaries (parttime or full-time) with individual physicians, or failing that district nurses, but did not make them mandatory. The Commission declined to accept the British panel or capitation system where physicians were approved to provide care to insured citizens, as the province was too rural in nature. No user fees were recommended. If hospital districts ran a deficit, non-government charges were to be increased, so that any plan was actuarially sound. The recommendations of the Commission were incorporated, unaltered, into The Alberta Health Insurance Act. The Act was supported by all parties, passed in February 1935, and assented to on 23 April 1935. Dr. Angus McGugan was to canvas municipal districts for a candidate hospital district. For Plan A, it was to be Camrose. No further action was taken, pending the outcome of the election in August 1935. In anticipation of the election, and being mindful of the rising popularity of teacher and future premier William Aberhart, Hoadley suggested that the government hire William Aberhart as an economic consultant with a salary of $6,000 per year. The caucus did not act on the suggestion in Hoadley’s absence.41 In the 1935 election, every UFA member was defeated, following the Brownlee scandal of 1934 and the resignation of the Premier. The electorate overwhelmingly turned to the Social Credit party, which was more conservative and involved less government intervention. The new Social Credit government immediately prepared a budget. It was a difficult one as much of its revenue was pre-committed to cover interest and relief payments. Fiscally frozen, the government had few options but to further restrict its expenditures. It was left to individual Alberta politicians and physicians to carry forward the 1932 health insurance agreement. For the physicians, it was Dr. A. E. Archer. DR. A. E. ARCHER, THE AMA/CPSA AND THE CMA

Archer was a 1902 University of Toronto medical school gold medallist, who arrived in the Star/Lamont area in 1903 as a United Church Mission Hospital physician to treat nearby Ukrainian settlements.42 He was a church builder (1906), and hospital builder (1912) of the largest hospital

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outside Calgary/Edmonton which had 90 beds in 1948. The United Church Mission Hospital of which Archer was medical superintendent from 1912-1948 was fully accredited from 1921 by the American College of Surgeons. Archer was the second president of the Alberta Hospital Association from 1920 to 1921 and oversaw the merging of the two hospital organizations during his AMA/CPSA presidency in 1943. In 1921 and 1922, as AMA President, he presided over the merger of the AMA and CPSA, resulting in all Alberta physicians becoming members of the AMA. After 1932, Archer became actively involved in the health insurance debates, having started the Di Bozsha program in his own health district in 1933.43 The Di Bozsha, or May the Lord Give You Health program, began after families signed Cardston-like medical contracts with the Lamont Clinic in 1933. The municipality of Wostok, in 1934, signed a medical contract covering all its citizens. The clinic was deluged with patients for the next two years.44 Three adjacent municipalities signed a larger contract with seven doctors in an adjacent clinic, likely Vegreville.45 Dr. Horace Wrinch of Hazelton, British Columbia, another United Church Mission Hospital physician, had begun a local prepaid health insurance program in 1909.46 By 1926, Dr. Wrinch had secured the support of the British Columbia Hospital Association, but not the government, for a health insurance program.47 MLA Wrinch’s 1929 motion for a second British Columbia Royal Commission to assess the merits of a health insurance program, was accepted. He told the Commission, “he had long ago concluded that state health insurance was the only solution to equitable healthcare.”48 Archer was of a similar mind, particularly after confirming the difference prepaid health insurance made to the health status of his community. Archer favoured government involvement in health insurance, as had the British Medical Association in 1930, and Dr. Harvey Smith, the CMA President from 1930 to 1931, who outlined his views at the joint BMA/CMA annual meeting in Winnipeg in 1930.49 In 1929, health insurance—or state medicine as it was often called— was not widely understood nor universally embraced by the medical profession. Over the 40 years it was debated (1927-1967), even the mention of it polarized opinions and divided physicians. To many, it meant doctors on salary, or the thin edge of the wedge that led to salaried medicine. To others more familiar with the European approaches, or those who had practical experience with it, there was support for the concept. At the same time there was fear over its application, particularly when it came to government participation. The first Alberta government intervention came in response to the drought in the Palliser Triangle in 1926. With up to an 80% drop in personal income and access to medical care, the government signed bonuses

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and offered subsidies for doctors to stay in the area. The AMA/CPSA began to take notice of the UFA government’s state medicine initiatives as early as 1927. At the third federal government/CMA conference in November 1929, the AMA representative Dr. J. S. McEachern flagged health insurance as the most important topic discussed.50 He noted the lack of preparedness on the part of organized medicine, to react in unison, provincially, or nationally. As the Depression progressed, access to health care plummeted, in direct relation to diminished incomes. The worst areas hit in Canada were the prairies. Near simultaneous government interest in state medicine in Alberta and BC captured the CMA’s attention. It began by collecting data and studying it from 1929 to 1932. The CMA was precipitated to act when the Alberta government unexpectedly announced the appointment of the Hoadley Commission in March 1932, to design a state health insurance plan.51 The UFA government’s decision forced the CPSA to develop a set of negotiating principles and include them in their brief. The CPSA turned to the British medical insurance approach, articulated by CMA president Dr. Harvey Smith, which supported government involvement in the funding of an insurance program. The CPSA discussed the principles underlying their 1932 brief with the CMA executive. Dr. J. S. McEachern was the unobtrusive link with the CMA.52 The CPSA brief proposed a hospital and medical insurance program. At a meeting held in November 1932, the CMA’s Committee on Economics was charged with developing “A Plan for Health Insurance in Canada.”53 The CPSA principles became the basis for the CMA Committee’s Plan, tabled two years later, which noted that no country that had introduced a national insurance program had ever discontinued it. In 1933, the CMA took a second approach to the diminished access problem in 1933. It petitioned Prime Minister Bennett to allow relief funds paid to the provinces to be used to pay physicians when they provided medical care for those on relief. Bennett refused the request, saying that healthcare was a provincial responsibility.54 When the western provincial premiers made the same request of Bennett later that year, his reply remained unaltered. Tabled for one year by the CMA, the 1934 plan was reviewed by the provincial associations. The CMA plan followed the British and Alberta approaches to health insurance, and included government participation. The CMA resolve was tested in February 1935, when the American Medical Association refused to support health insurance under any guise. American physicians left the responsibility for health insurance to the patient.55 Any anticipated joint discussions on the role of government in health insurance never materialized at the first and only joint Canadian/American annual medical meeting in Atlantic City, New Jersey,

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in June 1935.56 Seventeen CMA principles were accepted in 1935 and revised over the next eight years, following the tabling of the Ontario government’s agreement to pay physicians providing care for those on relief in 1935, and the demise of the proposed employer/employee limited program in British Columbia in 1937. The CMA needed to be united to represent all physicians, The provincial and national organizations had always been separate, with less than 30% of Canadian doctors belonging to the CMA in the mid-1930s. The AMA/CPSA led the movement to federate the two organizations. Following the pattern of two other provincial medical associations (Manitoba and British Columbia), the AMA/CPSA executive agreed in principle to join the CMA.57 Not satisfied with the progress, in September 1935 Dr. J. S. McEachern, the CMA President, formally moved that the AMA/CPSA join the CMA.58 The payment of conjoint dues began in December 1936. All other provinces followed the Alberta lead in 1938, uniting or federating the CMA. To record their progress, the AMA began the Alberta Medical Bulletin in January 1935. Dr. Archer, seeing the federation movement and unification a fait accompli by 1938, and most of the Hoadley Commission principles enshrined in the CMA’s health insurance plan, decided to take a dual approach to place the Hoadley Commission health insurance concept in front of the CMA and federal Liberal government. In 1939, Archer was elected to the CMA executive. By then the Alberta contingent was the second largest in the CMA. Archer’s position, which supported the CMA principles on health insurance, resonated with the executive. In 1941 Archer was elected Vice-President and in 1942-43 he became the third CMA President from Alberta. His primary objective was to obtain CMA consensus and support for a national health insurance plan, which he did in January 1943.59 Dr. Archer’s second approach to nationalize the health insurance concept was less successful; he lost as a Liberal candidate in the federal election of 1940.60 THE EDMONTON GROUP HOSPITAL PLAN (1934)

The Edmonton Group Hospitalization Plan was another spin-off from the Hoadley Commission’s plan.61 Consistent with their 1932 brief recommending a joint hospital/medical insurance plan, Drs. A. F. Anderson and W. T. Washburn began a four hospital voluntary insurance program for employers and employees in Edmonton in 1934. As per the Hoadley Commission recommendations, if the government decided to contribute two-ninths of the cost, it could be extended to all Edmontonians. This was the first Canadian Blue Cross type plan followed the Texas model of

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1929. Hospitals needed a cash flow on which they could rely. In 1948, the Manning government extended the plan, through government contributions, to all Albertans as the Hoadley Commission had recommended in 1932. The Alberta program followed the failure of the 1946 federal health insurance proposal and the discovery of oil in 1947. Participation remained voluntary but operated on a group basis due to administrative costs. HOADLEY AFTER 1935

The most unexpected outcome of the UFA government’s demise in 1935 was the post-political decision of Honourable George Hoadley to pursue his, by now passionate, interest in health insurance. He approached his friend Dr. Clarence Hincks of the National Committee on Mental Hygiene (NCMH) for a job. Hoadley wanted to survey existing health services in Canada, a study the CMA had wanted since 1932. Hoadley and Hincks obtained the agreement of the NCMH Board chairman, Sir Edward Beatty of the CPR, to fund Hoadley for $5000 per year for three years.62 The study, with the later contribution of Dr. Grant Fleming, became the most comprehensive survey of public health programs to that time.63 Provincial communicable, death and other disease rates were accumulated in the study, using data up to 1936. After analyzing the data, the authors concluded that some mortality rates increased if the individual could not afford to access healthcare.64 Hoadley and Fleming estimated that 25% of the Canadian population were indigent or needed a subsidy to pay their health insurance premiums.65 The authors recognized the need for an actuarial assessment of any plan, if the health insurance program was not 100% tax-back.66 Contracts with municipal doctors were recommended for outlying rural areas where there was no doctor.67 The document was tabled in 1939 with the NCMH Board and published by Metropolitan Life. Hoadley continued his crusade by joining the Dominion Health study group based in Toronto. The Hoadley/Fleming Study of the Distribution of Health Services was subsequently referenced in CCF publications.68 THE ROWELL-SIROIS ROYAL COMMISSION (1937-40) 69

At the first health ministers conference in May 1935, Hoadley called for a Royal Commission to assess the effects of the Depression on access to healthcare.70 Prime Minister Bennett had started to address these issues with his 1935 Employment Insurance and Social Benefits Act. It was declared ultra vires by the British Privy Council. The new King government inherited the problem. It appointed the Rowell-Sirois Commission (1937-1940), to determine which level of government was responsible for the social

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programs (pensions, unemployment, WCB, and health) not covered by the BNA Act. To help discharge its mandate, the Commission appointed University of Toronto social scientist A. Grauer to study public health in Canada.71 In their January 1938 brief, the CMA seemed unaware of the Hoadley study, when it asked for a national assessment of health care in Canada. At the same time the CMA declined to support a national insurance plan.72 In April 1938, Drs. A. E. Archer and W. A. Wilson presented the CPSA brief to the Commission. It specifically endorsed the health insurance concept proposed by the Hoadley Commission.73 Following their brief, which listed the healthcare responsibilities they thought the federal government should discharge, Archer said he was pessimistic about what had been accomplished toward the development of a national program.74 THE SOCIAL CREDIT GOVERNMENT (1935-43)

The new Social Credit government inherited and supported the Hoadley designed health insurance proposal. It was delayed by the struggle with the provincial deficit and the Social Credit economic philosophy, when the government passed 11 Acts which were declared ultra vires. Dr. M. R. Bow continued as the Deputy Minister of Health, and returned the government to a less expensive public health orientated agenda. Healthcare insurance was set aside—temporarily. The government passed the second free TB Act in Canada in 1936, the first Polio Rehabilitation Act in 1938, and the first free Cancer Act in 1941. Bow became President of the Canadian Public Health Association in 1936, a recognition of his stature in the field of public health. While the effect of the Depression was diminishing in Alberta, it continued in Saskatchewan. There was no Saskatchewan funding available for extras, let alone an expensive health insurance program.75 In 1938, Social Credit Health Minister Dr. W. W. Cross indicated for the first time that a health insurance program could be implemented by extending the WCB program.76 He took no further action until 1942. That year, in anticipation of the passage of a Federal Enabling Act, the Alberta government re-passed the UFA’s 1935 Health Insurance Act in 1942 with virtually no changes. The Alberta Act and the federal Haegerty Advisory Committee proposals meshed perfectly in their coverage of services and citizens, and were similar in their proposed provincial financing expectations. THE FEDERAL GOVERNMENT (1939-46) 77

The Rowell-Sirois Commission reaffirmed healthcare as a provincial responsibility, but the federal government could still make specified

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healthcare grants to the provinces.78 After World War I, future Prime Minister King believed Canadians wanted a more humane post-war society and led the Liberal party to incorporate a health insurance plan into its party platform. King expected World War II to be no different. In late 1939, the first federal interest in health insurance appeared, following the appointment of British Columbia’s Dr. Ian Mackenzie as the Minister of Health and Pensions. To orchestrate the CMA’s input to a feasibility study on health insurance, a wartime Committee of Seven, which included Dr. Archer, was appointed in June 1941. Dr. Mackenzie and deputy minister Dr. J. J. Heagerty quickly concluded the major parties were interested in a health insurance plan. The federal Heagerty Advisory Committee was formally appointed in January 1942 to research health insurance. The Heagerty report was tabled in March 1943 and recommended the same coverage of services as the Hoadley Commission had in 1932, namely doctors, hospitals, drugs, dentists, and essential nursing services.79 It assumed that public health services would continue to be paid by provincial governments. The Heagerty Commission suggested financial support by the two levels of government be about two-thirds of the estimated $230 million cost, with the provinces paying somewhere between 10 and 35% of the total.80 To continue to lead the CMA position, Archer was appointed as chair of the Executive Committee in June 1943. The voluminous Heagerty report was turned over to the House of Commons Social Security Committee, who endorsed it with minor changes after its review between 1943 and 1944. The Cabinet’s finance committee subsequently recommended full funding for the program sometime before the Dominion/ Provincial Reconstruction Conference in 1945.81 Archer stepped down from his CMA executive position to run as a Liberal candidate in the federal election for a second time in 1945. It was rumoured that King offered him the Minister of Health position.82 As in 1940, Dr. Archer was defeated by the Ukrainian Social Credit candidate, Anthony Hlynka. The CMA then appointed Archer as their Consultant on Economics. He crisscrossed the country, supporting the federal proposal, which was the Hoadley Committee’s proposal of 1932, with 100% government funding. THE PLACE OF HOADLEY AND THE HOADLEY COMMISSION IN CANADIAN HEALTH INSURANCE HISTORY

Hoadley and the Hoadley Commission are inseparable. The appointment of the Commission was only one step among many taken by Hoadley to address the UFA’s goal of improving healthcare through preventative and interventional means. By 1928, even before the Depression, the UFA government was

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becoming concerned over the access to healthcare. With the dramatic 50% decrease in access to medical care caused by the Depression, and the rapid public acceptance of a prepaid medical insurance program in Cardston, alongside a pre-existing municipal hospital program, Hoadley decided to appoint the Hoadley Commission in 1932 to design a provincial health insurance plan. The heretofore relatively unknown Hoadley Commission has been viewed as an incidental or isolated initiative, by the soon to be demised and forgotten UFA government. But unlike most health care Commissions, it was led by two cabinet ministers and included the health leaders from all political parties, to ensure all party support for its recommendations. As a result there were no changes from the last draft in December 1932 until the Act received royal assent in April 1935. By 1934, Hoadley had become Alberta’s Deputy Premier. He was so passionate about solving the health access problem that he exuberantly declared in July 1935, “Humanity is on the march. Out of the great upheaval of recent years, I am confident that a greater civilization than we have known will be evolved.… It is vital to the future well being of our people.”83 Hoadley deserves recognition for many decisions he made both before and after the 1932-34 Commission. Hoadley was responsible (1) for reinterpreting state medicine as a state health insurance program; (2) for narrowing the concept from an employer/employee benefit program to a pure healthcare one, without absentee or sickness benefits; (3) for supporting the British Columbia Commission recommendation for a two-ninths government contribution, but for a different reason—to pay for those who could not afford to pay; (4) for designing a plan to cover all Albertans; (5) for not forcing the Saskatchewan municipal doctor program into the design of the Commission’s program; (6) for recognizing the requirement for an actuarial reserve in the absence of 100% tax-backed funding; (7) for calling for a federal healthcare Royal Commission in 1935 that was eventually bundled into the Rowell-Sirois Royal Commission; and (8) for his post-political research and conclusion that reduced access to healthcare increased morbidity and mortality. The Hoadley Commission itself deserves recognition: (1) for reaching an accord with the provincial medical college to insured physician and hospital services; (2) for extending coverage to include the less expensive drugs and dental services; (3) for determining how to take voluntary participation and make it mandatory and eventually province wide, through municipal votes that guaranteed a cash flow for the program; (4) for developing a rural plan and outlining how it could be urbanized; (5) for including a control mechanism to affect the rate of implementation and thus the cost to the Treasury; (6) for identifying a separate less expensive urban Plan B, if the first Plan A was not acceptable; (7) for

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designing an administrative process that incorporated most of the hallmarks of today’s Medicare (government operated, negotiated fees, a Commission to oversee it); (8) for being idealistic or intentionally farsighted in its proposal, and not short term or Depression limited; and (9) for leaving successive Alberta Governments with a contributory, and not a universally funded approach to health insurance, one that would be supported by the Social Credit government a decade later. The outcome of the Hoadley Commission’s proposal and agreement were quickly recognizable. In 1934-35, the CMA designed and approved a plan for health insurance for negotiating with any government. The CPSA not only agreed with the Hoadley Commission proposal but never retracted, altered, or qualified its position. The Commission crystallized the efforts of four Edmonton hospitals to start a Blue Cross type hospital insurance, which could be integrated into the Commission’s proposal. The succeeding Social Credit government supported the proposal in principle and later in fact, by re-passing the 1935 Act verbatim in 1942. Although the Hoadley Commission proposal was not implemented, its principles of service and citizen coverage were reaffirmed by the Heagerty Advisory Committee and the Federal government in 1943, when they came to the same conclusions regarding coverage. The remaining issues of universal versus contributory government funding, and the federal/provincial apportionment of funding would take from 1943 to 1968 to resolve. The major difference between the 1932 Hoadley Commission proposal and the 1967 Pearson government plan was the federally required doubling of the Alberta contribution to 50% and the universal government funding requirement of the plan. When drugs and dentists were deleted from the Pearson plan in 1968, the coverage became the same as Drs. Archer and Wilson had recommended in 1932 on behalf of the CPSA—and doctors. NOTES 1 Albert E. Archer and Wilfred A. Wilson, “Final Memorandum” submitted by the Council of the College of Physicians and Surgeons of Alberta to the Rowell Royal Commission, dated 3 March 1938, Calgary, Alberta. 2 Paul V. Collins, “The Public Health Policies of the United Farmers of Alberta Government,” introduction, MSc. thesis, University of Western Ontario, 1969. For more on the pre-1920 UFA/UFWA roots and formation, see Bradford Rennie, The Rise of Agrarian Democracy, The United Farmers and United Farm Women of Alberta 19091921 (Toronto: University of Toronto Press, 2000), p. 110-223; Carl Betke, “Farm Politics in an Urban Age: The Decline of the United Farmers of Alberta After 1921,” in Essays in Western History (Edmonton: University of Alberta Press, 1976), p. 175-92; William Ralph, Henry Wise Wood of Alberta, (Toronto: University of Toronto Press, 1950), p. 9293; and William J. Morton, The Progressive Party in Canada (Toronto: University of Toronto Press, 1950). “To paraphrase UFA President Wood, the new farmers’ movement must shine through education, to create this spirit of (economic)

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5 6 7

8 9

10 11 12

13

14 15

16

17 18 19

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cooperation among the agrarian class. Water cannot rise above its source, neither can social progress rise higher than the level of the citizenship of the people,” in Western Independent, 18 February 1920, p. 12, and 25 February 1920, p. 13. Hoadley pleaded for co-operation with the AMA, in his 1931 convention address to the AMA. An introduction to the Progressive Movement can be found in Foster J. Griezic, “A History of Farmers Movements in Canada: The Origins and Development of Agrarian Protest 1872-1924,” in Louis A. Wood, A History of Farmers’ Movements in Canada (Toronto: University of Toronto Press, 1975), p. 6-34. Collins, “The Public Health Policies,” p. 4-8. Alexis Soltice, “Dried Applies, Victorian Ideals, Organization Works: The Private Persona of Mary Irene Parlby,” PhD thesis, University of Calgary, 2005. For Parlby’s imperial ties, see Catherine A. Cavanaugh, “Irene Marryat Parlby” in C. A. Cavanaugh and R. R. Warne, eds., Telling Tales: Essays in Western Women’s History (Vancouver, 2000), p. 100-22. Collins, “The Public Health Policies,” p. 4-8. Jane E. Jenkins, “Baptism of Fire: New Brunswick’s Public Health Movement and the 1918 Influenza Epidemic,” CBMH, 24 (2007): 317-42. Collins, “The Public Health Policies,” p. 4-16. Also see Sharon Richardson, “Alberta’s Travelling Clinic 1924-42,” CBMH, 19, 1 (2002): 245-63; Richardson’s history of the District Nurse Program, “Frontier Health Care: Alberta’s District and Municipal Nursing Services 1919 to 1976,” Alberta History, 46 (Winter 1998): 9. F. B. Watt, “Hoadley of Alberta,” MacLean’s Magazine, 15 July 1929, p. 13, 60-1. Robert Lampard, “The Hons. George Hoadley, Irene Parlby, W. W. Cross and the UFA Government Healthcare Program 1921-1955,” in Alberta’s Medical History, Young and Lusty and Full of Life (Red Deer: R. Lampard, 2008). Heber Jamieson, Early Medicine (Edmonton: Alberta Medical Association, 1947), p. 75. Alberta government amendments to the Regulations to the Alberta Hospital Act, 1924. R. Kenneth Thomson, “The Development of Hospitals Since World War II,” in D. R. Wilson and W. B. Parsons, eds., Medicine in Alberta: Historical Reflections (Edmonton: Alberta Medical Foundation, 1993): 1-21; and H. C. Jamieson, Early Medicine in Alberta, p. 56. For further discussion of Alberta’s hospitals see William Carney, “The Hospitals’ Story: The History of the Alberta Hospital Association.” Unpublished manuscript, Edmonton: Alberta Hospital Association, 1987. D. Sclater Lewis, The Royal College of Physicians and Surgeons of Canada 1920-1960, (Montreal: Royal Victoria Hospital, 1969), p. 16-17, 25, opp. 40. The Mighty Triumvirate were Drs. David Low, D. S. Johnstone, and S. E. Moore. The fourth member was Dr. A. MacGillivray Young, the MP for Saskatoon, who piloted the Act through the House of Commons. Robert Lampard, “Dr. Malcolm R. Bow,” in Alberta’s Medical History (Red Deer: R. Lampard, 2008): 297-310. Heber C. Jamieson, Early Medicine, p. 56. Hoadley’s point was valid. Drs. A. E. Archer and M. A. R. Young published their first 245 cases with a death rate of 1.22% in “The Mortality in Appendicitis,” CMAJ, 16 (1926): 1491-94, 1926 and 1.28% in the second 703 case series, CMAJ, 36 (1937): 507-10. The literature reported rate was 5-7% at the beginning of the study (1921); 2.13% in Alberta in 1927 and 1.66% in Alberta when the second series was published in 1935. W. Fulton Gillespie, Secretary of the Edmonton Academy of Medicine, wrote a letter to Dr. A. I. McCalla, President of the Calgary Medical Society, 30 October 1927. Attached were the proposed motions from the Edmonton Academy of Medicine, in the Minutes of the Calgary Medical Society, 3 January 1928. Heber Jamieson, Early Medicine, p. 201. A. I. McCalla, “Minutes of the Calgary Medical Society,” 3 January 1928. Gerald McDougall and Fiona C. Harris, Medical Clinics and Physicians in Southern Alberta, (Calgary: University of Calgary, 1991), p. 8-20. The authors discuss the longstanding and thorny issue of group and contract practices in Calgary. The debate

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started at the Calgary Medical meetings on 12 and 19 February 1907. It was led by the original 1885 CPR medical contractor, Dr. J. D. Lafferty. Physicians in Calgary, except for the contract recipient, Dr. H. G. Mackid , voted to open up the CPR contract to competition. Mackid was Lafferty’s 1890 partner and the holder of the CPR medical contract. The CPR Vice-President responded by saying he wouldn’t allow it and would bring contracted doctors to Calgary if that was necessary. Western Canadian Medical Journal 1 (1907): 125-26, 263-64; and Dr. J. D. Lafferty in Alberta’s Medical History, p. 59-71. The topic boiled to the surface again in 1922-24. A caution was sent to the AMA/CPSA members discouraging the signing of contracts. It was included in the Alberta College Code of Ethics. A review of contracted practice in BC to 1929 was undertaken by the BCMA. Dr. J. H. MacDermot, in his report as the chairman of the Committee on Economics, suggested it be part of a Dominion-wide survey. CMA annual meeting Report to Council, p. 200-6, 18 June 1929. The new (1923) Minister of Health George Hoadley formalized (by regulation) the travelling medical, surgical, and dental services (1924) to northern Alberta, and later to southern Alberta, as outlined in Sharon Richardson’s, “Alberta Provincial Travelling Clinics 1924-42,” CBMH, 19, 1 (2002): 245-63. For additional references on contracted practice see C. David Naylor, Public Payment, Private Practice (Montreal: McGill-Queens), p. 50-5; and Malcolm Taylor, The Administration of Health Insurance in Canada, (Oxford University Press, 1956). Naylor, Public Payment, Private Practice, (Montreal: McGill-Queens, 1986), p. 51. “Minutes of the College of Physicians and Surgeons of Alberta,” 6 September 1923, Vol. 1, p. 308, 310. Fred White and Chris Pattinson, “Report of an Inquiry into State Medicine,” Alberta Government, 1929. Collins, “The Public Health Policies,” p. 122-23. Robert Lampard, “The Sexual Sterilization Act of Alberta,” in Alberta’s Medical History, p. 571-91. “Minutes of the CPSA,” 16 February 1928, Vol. 1, p. 379, 442. White and Pattinson, “Report of an Inquiry,” p. 7. White and Pattinson, “Report of an Inquiry,” Abstract, p. 42. Robert Lampard, “Dr. Mary Percy Jackson,” in Alberta’s Medical History, p. 354-65. J. H. MacDermot and Harvey Smith, CMA Minutes of the Executive Council, Winnipeg, 1931, p. 314. George Hoadley, “Many Problems Face Medical Men of Today,” Calgary Herald, September (n.d.), 1931. Franklin Foster, John Brownlee: A Biography (Lloydminster: Foster Learning, 1996), p. 181-82. Robert Lampard, “The Cardston Medical Contracts,” in Alberta’s Medical History, p. 631-36. The article was published as, “The Cardston Medical Contracts and Canadian Medicare” in Alberta History 54, (Autumn 2006), p. 5-10. Morley A. R. Young, “Di Bozsha. May the Lord Give You Health,” New Trail (Edmonton: University of Alberta, 1948), p. 9-15. George Hoadley et al., “Progress Report of the Commission appointed to (a) consider and make recommendations to the next Session of the Legislature as to the best method of making adequate medical and health services available to all the people of Alberta; (b) report as to the financial arrangements which will be required on an actuarial basis to ensure the same,” Alberta Government, 1933. The recommended principles and coverage were outlined in Drs. A. E. Archer and W. A. Wilson, submission on behalf of the CPSA to the Hoadley Commission, presented 8 November and 11, 12 December 1932. Reaffirmation of support for the 1932-33 agreement was contained in the “Memoranda to the Rowell-Sirois Royal Commission,” by the CPSA, presented April 1938. Ottawa, Parliamentary Library. “The BC Royal Commission on State Health Insurance and Maternity Benefits,” Final Report outlined Plans A to E. All Plans were for Employees and/or their Dependents

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38

39

40

41 42 43 44

45 46 47 48 49

50 51 52

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only. The recommended and equally shared (provincial and federal) government contributions to each plan were to total 2/9s of the cost. Hoadley et al., “Progress Report,” p. 1, 2. Hoadley et al., “Progress Report,” p. 11. Morden Lazarus, Socialized Health Services, (Ontario: Woodsworth Memorial Foundation, January 1976), p, 57-59. For details on the CCF formation, see W. L. Morton, The Progressive Party in Canada, p. 279-85. The similar ideological beliefs of Henry Wise Wood (Alberta) and Frank Eliason (Saskatchewan) are apparent in the George Hoffman review of “Frank Eliason A Forgotten Founder of the CCF,” Saskatchewan History, 58 (Spring 2006): 18-31. My grandfather Rev. R. S. Leslie was the Progressive Party Speaker in the Saskatchewan Legislature (1929-34) under Premier J. T. M. Anderson. He ran second and Rev. T. C. Douglas ran third in the Weyburn constituency in the provincial election of 1934. They remained lifelong friends. My mother took elocution lessons from Mr. Douglas in 1932-33. Together they won the Grade 12 oratorical competition, with the speech “Japan: friend or foe.” My cousin Eleanor McKinnon was the secretary to Mr. Douglas for 40 years. George E. Learmonth, “Medical Services in Alberta,” CMAJ, 30 (1934): 202-3. The survey was made in 1933. A similar survey was conducted in Ontario in 1934 with a 20:1 support for a plan that covered low income persons. Interest in a plan was also raised by doctors in BC, Saskatchewan, and Manitoba from 1932-35, as outlined in Naylor, Public Payment, Private Practice, p. 66-67. George Hoadley, “Final Report of the Legislative Commission.” Tabled March 1934, Alberta Government. The Hoadley Commission members accepted the state (Alberta) was responsible for a contribution of 2/9 of the cost. The Commission added important qualifications: the plan would cover everyone without regard to income. It would provide full coverage of benefits and would not rely on a guaranteed federal grant. George R. Oake, “Fury and Fidelity: The Onset of the Great Depression,” in Alberta in the 20th Century, Vol. 6 (UWC, 1997): 323. Robert Lampard, “Dr. A. E. Archer,” in Alberta’s Medical History, p. 256-76. Young, “Di Bozcha,” p. 15-19. Murray Ross, Personal Communication, 9 March 1998. Mr. Ross was the long term CEO of the AHA and the son of C. W. W. Ross, the administrator of the Lamont Clinic. He said the clinic provided about $35,000 in services for about $7,000 in payments. CPSA minutes, 18 July 1940, Vol. 2, p. 221. Bob Burrows, Healthcare in the Wilderness. A History of the United Church Mission Hospitals (Vancouver: Harbour Publishing, 2004), p. 32. Robert Lampard, “Dr. A. E. Archer,” in Alberta’s Medical History, p. 256-76. Horace C. Wrinch, “Royal Commission on State Health Insurance and Maternity Benefits,” BC Government, 1932, p. 23. J. H. Horociwz, “Highlights of the Evolution of Health Insurance of Canada,” Department of National Health and Welfare, CMAJ, 47 (September 1955): 166-67. Horociwz gave as his source Dr. Harvey Smith, “Presidential Address to the third joint British and Canadian Medical Association meeting” held in Winnipeg, June 1930, and published in the CMAJ, as the milestone meeting for the medical profession in the field of health insurance.” Dr. Smith’s obituary in the CMAJ, 43: 86-87 supported Archer ’s view. Proceedings from the “Third Conference on the Medical Services in Canada,” House of Commons, November 1929, Kings Printer, 1930. Robert Lampard, “Dr. J. S. McEachern,” in Alberta’s Medical History, p. 193-96. Harvey Smith and Grant Fleming, discussion of “A Plan for Health Insurance in Canada,” in the CMAJ Supplement, (September 1935): 27-30. For McEachern’s views see, “The President’s Address to the Canadian Medical Association,” CMAJ, 31 (1934): 119-23, and “The Annual Meeting,” CMAJ, 33 (1935): 204-6.

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53 W. Harvey Smith and A. Grant Fleming, “A Plan for Health Insurance in Canada,” CMAJ Supplement, (September 1934), p. 25-62. 54 G. A. B. Addy et al., Position paper and reply by the Prime Minister following a meeting on 6 October 1932 with the CMA delegation re: Medical Care of the Unemployed, CMAJ, 29 (1933): 554-56. 55 Daniel S. Hirschfield, The Lost Reform: The Campaign for Compulsory Health Insurance in the United States (Boston: Harvard University Press, 1974), p. 46-65. The American Medical Association’s Ten Principles (1934) were listed on p. 177. 56 Robert Lampard, “Dr. J. S. McEachern,” in Alberta’s Medical History, p. 193-96. Also discussed in the “Third CMA meeting in Alberta, 1934,” Alberta Doctors Digest, 30 (March/April 2005): 13-7. 57 J. K. Mulloy and D. S. Macnab, motion drafted with Dr. J. S. McEachern by the AMA, “to merge in principle with the CMA.” Minutes of the joint meeting of the AMA/CPSA, 4 October 1934, Vol. 2, p. 49-53. 58 John S. McEachern, “Motion to accept unanimously approved.” AMB, 1 (October 1935): p. 9. For Dr. McEachern’s plan see the AMB, (April 1935): 7-13. 59 Albert E. Archer, “The Progress of the Association,” CMAJ, 47 (1942): 116-17; “The Position of the Canadian Medical Association on Health Insurance,” CMAJ, 47 (1942): 261-62; “Special Meeting of General Council,” CMAJ, 48 (1943): 93 and 48 (1943): 25160. In his valedictory address, “The Challenge to Organized Medicine,” Dr. Archer outlined the trials and tribulations the CMA faced in his year as President (1942/43), as reported in the CMAJ, 49 (1943): 77-82. Dr. T. C. Routley outlined the “Principles of Health Insurance,” in the CMAJ, 47 (1942): 367-71 and the AMB, 8 (April 1943): 1319. Dr. H. E. MacDermot wrote, “A Short History of Health Insurance in Canada” in the CMAJ, 50 (1944): 447-54; and a longer history in his History of the Canadian Medical Association, Volume II (Toronto, CMA, 1958), p. 59-84. For a more detailed discussion of the deliberations see Malcolm G. Taylor in, “Whose Responsibility? Public Health in Canada 1919-1945,” in Martin S. Staum and Donald E. Larson, eds., Doctors, Patients, and Society (Waterloo: Wilfrid Laurier University Press, 1982), p. 220. 60 Oleh W. Gerus and Denis Hlynka, The Honourable Member for Vegreville: The Memoirs and Diary of Anthony Hlynka, MP (Calgary: University of Calgary Press, 2005), p. 2546. 61 Andrew F. Anderson, “History of the Royal Alexandra Hospital,” c1960. Copy deposited in the RAH Archives and Anderson Family Archives. Also see J. Ross Vant and Tony Cashman, More Than a Hospital (Edmonton: University of Alberta Hospital, 1986), p. 124-25; and the Anderson and Washburn AHA “Brief to the Hoadley Commission,” presented 11, 12 December 1932. Copy deposited in the Alberta Legislative Library. 62 Robert Lampard, “The Hons. George Hoadley, Irene Parlby, W. W. Cross and the UFA Government Healthcare Program 1921-1935,” in Alberta’s Medical History, p. 55870. 63 George Hoadley and Grant Fleming, The Study of the Distribution of Medical Care and Public Health Services in Canada (Toronto: The National Committee for Mental Hygiene, Canada, 1939). 64 Hoadley and Fleming, The Study, p. 61-96. 65 Hoadley and Fleming, The Study, p. 70-2, 93. 66 Hoadley and Fleming, The Study, p. 162-75. H. H. Wolfenden was retained by the CMA and then the federal government. His report to the CMA was highlighted in the CMAJ, 42 (1940): 470-5. 67 Hoadley and Fleming, The Study, p. 129-34. 68 Morden Lazarus, Socialized Health Services, a Plan for Canada (Toronto: Wordsworth Memorial Foundation, 1976), p. 13, 28, 54, 57. 69 Newton W. Rowell and J. O. Sirois, Report of the Royal Commission on Dominion-Provincial Relations, (Ottawa, Kings Printer, 1941), p. 168-71. For further discussion of this important report see Malcolm C. Taylor, Health Insurance and Canadian Public Policy

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70

71

72

73

74 75

76 77

78 79

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(Montreal: McGill-Queens, 1978), p. 10-11; and C. David Naylor, Public Payment, Private Practice, p. 92-93, 97-98, 109. George Hoadley, CMAJ Supplement, (September 1935): p. 35. The resolution calling for a Royal Commission was unanimously passed at the first meeting of the Ministers of Health in Canada on 25 and 26 April 1935. The chairman, Dr. Donald M. Sutherland, the federal Minister of Pensions and Health, proposed a survey of medical services in Canada. Prime Minister Bennett agreed to the survey but was defeated in the federal election of 1935. Hoadley would conduct the survey personally. CMAJ, 38 (1938): 290-92. Albert E. Grauer, “Public Health: a study prepared for the Royal Commission on Dominion-Provincial Relations,” manuscript, 1939. The report covered the same topics as the Hoadley-Fleming Study of Medical Services (1936-39) using primarily 1935 and 1936 statistics. The study encouraged federal leadership, supported the grant-in-aid concept as used to treat the post-World War I VD problem, encouraged Aboriginal TB care to be transferred to the provinces, and defined gaps and overlaps in the public health system. The first draft was completed in August 1938 and the final draft in the spring of 1939. The analysis of mental hygiene data was based on NCMH(C) General Director Dr. C. M. Hinck’s research (p. 69-70). It implied there was an open relationship between the NCMH(C) and the Royal Commission. Grauer concluded that a public health program wasn’t necessarily cost saving but improved the health, welfare and efficiency of the population (p. 72). Dr. Grauer, PhD was the Director of Social Services at the University of Toronto. He also wrote Appendix 6, a 98-page report on “Public Assistance and Social Insurance,” for the Commission. A summary of the key public health statistics to 1941 (infant mortality, maternal mortality, communicable disease deaths, etc), was provided in Malcolm G. Taylor, Health Insurance and Canadian Public Policy, p. 6-7. George S. Young and T. C. Routley, “A submission by the Canadian Medical Association to the Royal Commission in Dominion-Provincial Relations,” (Canada, 1937). All the provincial submissions to the Rowell-Sirois Royal Commissions on Medical and Social Services were reprinted in the Hoadley/Fleming study, p. 153-61. Archer and Wilson, “Final Memorandum submitted by the Council of the College of Physicians and Surgeons of Alberta to the Rowell Royal Commission,” dated 3 March 1935, Calgary. Albert E. Archer, “Minutes of the CPSA 28, April 1938, Vol. 2, p. 160. J. M. Ulrich, “State Medicine Held Inopportune,” AMB, (April 1936): 10. Confirmed by Dr. Lillian A. Chase who added, “A delusion held by many voters is that state medicine means free medicine” in the CMAJ, 35 (1936): 684. Former Saskatchewan Premier J. T. M. Anderson said that same year it “would have to be on a compulsory basis and absolutely free from political influence” in the Canadian Doctor, 2 (December 1936): 30. Wallace W. Cross, “Says Health Insurance is Under Study,” Alberta Medical Bulletin, 3 (July 1938): 13. Taylor, “The 1945 Health Insurance Proposals,” in Health Insurance and Canadian Public Policy: The Seven Decisions that Created the Health Insurance System (Montreal: McGillQueens, 1978): 1-68. Newton W. Rowell and J. O. Sirois, Report of the Royal Commission on Dominion-Provincial Relations (Ottawa, 1940), p. 168-71. For an in-depth discussion of the Haegerty Advisory Committee deliberations, see Taylor, Health Insurance and Public Policy, p. 19-28; and C. David Naylor, Private Practice, Public Payment, p. 97-111. Taylor, “The 1945 Health Insurance Proposals,” p. 21. Taylor, “The 1945 Health Insurance Proposals,” p. 18-22, 36-68. Kent Harrold, Personal communication with Dr. Robert Lampard, 29 September 2005. Mr. Harrold, the chairman of the Lamont Healthcare Center Board since 1975, indicated Dr. Archer was not wildly enthusiastic about politics. The offer could not

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be corroborated by Mr. Harrold’s aunt. Dr. Archer certainly knew Mackenzie King. As a youngster Kent Harrold sang with Dr. Archer in the Lamont United Church choir. He spoke of how highly regarded Archer was in Lamont and remembered him “as gracious and skillful, with an unassailable social responsibility.” 83 George Hoadley, “Public Health,” Alberta Medical Bulletin, (July 1935) 1: 4-5.

10 From Bennettcare to Medicare: The Morphing of Medical Care Insurance in British Columbia GR E GO RY P. M ARCHILDO N A ND NICO LE C . O ’ BY RN E

INTRODUCTION: COMPETING MODELS OF MEDICARE

As demonstrated by the 1962 Saskatchewan doctors’ strike, the introduction of public health insurance in Canada has not been smooth. It was far from inevitable that Canadians would adopt a compulsory, universal model of public health insurance more closely associated with Western European and Australasian countries rather than a voluntary, categorical model of a mixed private-public system associated with the United States, most Asian countries, all of Latin America, and (currently) most of Central and Eastern Europe. Among the many factors leading to this development, two are particularly significant. First, the federal-provincial history of hospitalization in which a compulsory, universal model that was pioneered by the government of Saskatchewan formed the template for the programs adopted by other governments. The Saskatchewan model’s influence was due largely to the problems that had been identified in the hospitalization programs in British Columbia and Alberta. Implementation and administration difficulties had plagued the British Columbia program since its inception, and the Alberta plan failed to provide universal coverage. Second, the government of British Columbia decided to support an indigenous “model” of medical care insurance known as Bennettcare rather than adopt the Alberta model called Manningcare.1 This decision ultimately weakened, perhaps fatally, the coalition of organized medicine, insurance companies, business and provincial governments opposing universal Medicare. With this split, the federal government could more easily support the Saskatchewan model over the Alberta model even if it paid lip service to some elements of the BC model. We explore the history of BC medical care insurance in order to determine why Premier W. A. C. Bennett’s Social Credit government—despite its ostensible ideological affinity with the Social Credit government of

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Alberta—chose to introduce its own program rather than adopt Albertastyle Manningcare. We also examine how the more unique aspects of Bennettcare were gradually dropped in favour of what would eventually become the Canadian model of Medicare. William Andrew Cecil (W. A. C.) Bennett, the Premier of British Columbia from 1952 until 1972, was largely responsible for this outcome. Although he espoused the rhetoric of free enterprise, Bennett was a political pragmatist who believed in using state intervention in the province’s economy when it suited his own political interests. He willingly compromised Social Credit political ideology in order to appeal to the electorate and keep his political opponents in check. His decisions with respect to hospital insurance and medical care insurance illustrate Bennett’s lack of ideological consistency. He guided the evolution of his government’s healthcare policies with an eye to appeasing powerful interests such as big business and the medical profession. At the same time, however, he was aware that the majority of the public favoured the development of publicly funded healthcare programs.2 In order to balance these interests, Bennett often defined and explained his policies in ways which were fundamentally misleading. Bennett’s reshaping of Bennettcare into Medicare illustrates his approach to both politics and public policy. Indeed, his approach to Medicare in the 1960s was foreshadowed by his opportunistic handling of the hospital insurance debate in the early 1950s when he dropped his affiliation with the Conservative Party in favour of Social Credit. BENNETT AND THE BRITISH COLUMBIA HOSPITAL INSURANCE SERVICE (BCHIS)

Born in 1900 and raised in small-town New Brunswick, W. A. C. Bennett moved to western Canada as a young man to make his fortune in the hardware business. After some success in Edmonton, Bennett purchased a hardware store in Kelowna and was elected president of the local Board of Trade. In 1941, he entered provincial politics when he was elected as a Conservative Member of the Legislative Assembly (MLA) for South Okanagan. Soon after the election, he became part of the LiberalConservative coalition that had been cobbled together to keep the new Co-operative Commonwealth Federation (CCF) Party from forming government. When he was not invited to join Cabinet after his re-election in 1945, he vacated his provincial seat in order to run as a candidate in a federal by-election in 1948. Defeated in this by-election, Bennett resurrected his political career by regaining the Coalition nomination for South Okanagan and winning his seat in the next provincial election a year later. From this time onwards, Bennett developed a reputation as the Coalition’s loose can-

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non. When the British Columbia Hospital Insurance Service (BCHIS) became a political flashpoint, Bennett joined opposition members in criticizing his own government.3 After an unsuccessful bid to replace the leader of the Progressive Conservative faction within the Coalition government, Bennett used the government’s mismanagement of the BCHIS as his excuse to cross the floor to sit as an independent MLA. In the months leading up to Bennett’s decision to cross the floor, the BCHIS increasingly became the focal point for public discontent with the Coalition government. By 1951, the major problem with the BCHIS was its inadequate funding base. The leadership within the Coalition government insisted that the BCHIS should be financed by individual contributions on the same basis as private insurance schemes. They were not prepared to use the general revenue funds of the province for fear that this would lead to higher income taxes. This program structure created a number of problems that plagued the BCHIS from its inception. The amount required to run the BCHIS forced the Coalition government to impose extremely high premiums, which had to be increased periodically in order to meet the growing costs of the program. A highly visible form of taxation, the compulsory premiums were extremely unpopular. However, rather than fixing the revenue problem by raising income or other general taxes, the Coalition government introduced a bill that provided for another hike in premiums along with a co-payment fee of $3.50 per day to a maximum of 10 days for everyone who was hospitalized. The introduction of the bill ignited a firestorm of protest throughout the province. The government hoped that the changes would cover the hospital plan’s spiralling deficit and hamper what the government felt was public overuse and abuse of the BCHIS.4 On 10 March 1951, Bennett publicly protested in the Legislative Assembly, claiming that the changes broke “faith with the people of the province.”5 Three other Coalition government backbenchers immediately joined Bennett in voting against the bill.6 The legislative debate fanned the flames of discontent as the public, unions, professional associations, chambers of commerce, and virtually all of the media criticized the Coalition government’s proposed changes to the BCHIS.7 During the final reading of the bill, Bennett stood up in the Assembly and delivered a speech in which he denounced both the BCHIS bill and the Coalition government in an hour-long tirade in which he declared his intention to quit the government and sit on the opposition side of the Legislature as an independent MLA.8 Bennett reiterated the opposition’s argument that the government’s large general revenue surplus made the premium increase an unnecessary burden on the working people of the province. He did not, however, go so far as to support the CCF’s contention that co-payments were wrong in principle.9 In December 1951, Bennett abandoned his independent status and

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joined the Social Credit League. In so doing, he helped transform a previously marginal movement in British Columbia into a political party ready to fight the next provincial election.10 In the process, he shaped a governing party that was, at least in terms of its much looser connection to evangelical Protestantism, ideologically and organizationally different than its Alberta counterpart which remained in office for over 35 years.11 At the same time, Bennett’s version of Social Credit shared some affinity with its Alberta neighbour, including an emphasis on the primacy of the individual over the collective, particularly in terms of the priority placed on individual freedom versus collective security through government-run social programs.12 In the lead-up to the June 1952 provincial election, Bennett put forward a new position on the BCHIS in order to distinguish Social Credit’s position from that of the CCF. He promised that “[t]he first act of a Social Credit government would be to take the word ‘compulsory’ out of hospital insurance.”13 Pointing to the government of Alberta’s plan in which publicly subsidized private insurance could be purchased through any number of insurance carriers, Bennett pledged that if a Social Credit government were elected in British Columbia, they would give “residents a choice of hospital insurance.”14 The controversy over BCHIS gave Bennett and the Social Credit a means by which they could distinguish themselves from the Coalition government of Liberals and Conservatives. The controversy over BCHIS fractured the fragile Coalition, and the Liberals and Conservatives went into the general elections as separate parties.15 Disaffected by both the Liberals and the Conservatives, the electors turned to the CCF and Social Credit, the new protest parties which would dominate British Columbia politics for the next half century. Shortly before the election, the coalition parties had tried to stem the tide of the protest vote by introducing a new voting system. The single transferable voting system allowed the voters to register as many choices as there were candidates in order of voting preference on their ballot. The Liberals and Conservatives had confidently predicted that their supporters would select the other party as their second preference. However, many of their supporters selected Social Credit as their second choice. This enabled the Social Credit to form a minority government even though the CCF had received the plurality of the popular vote. Having campaigned without a leader during the election campaign, the Social Credit Party held a leadership contest shortly after their unexpected victory. Bennett entered the race and won handily given his high profile surrounding the most important issue in the campaign—the reform of the BCHIS.16 Shortly after the election, Bennett reiterated the Social Credit government’s opposition to the compulsory nature of the hospital insur-

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ance program but not to the program itself.17 At the same time, however, he began to massage the definition of compulsory. First, Bennett stated that he was opposed to forcing people to pay BCHIS premiums and that he preferred that they join the hospital plan on a voluntary basis.18 However, in order to make the compulsory nature of the program more palatable, he lowered premiums by $3 per year for both families and individuals and substituted a new $1-a-day co-payment plan with no maximum days in place of the old $3.50-a-day charge to a 10-day maximum. Bennett adopted the $1-a-day plan directly from the Alberta Hospital Plan. Even the use of the “$1-a-day phrase,” which was identified with the Alberta plan, may have been an effort by Bennett to confuse the public. However, unlike the Alberta plan, there were no legal means by which one could opt out of the BCHIS. In order to promote the program, Bennett declared a moratorium on all the arrears that had accrued between 1949 and 1951 so long as individuals paid their premium for 1951.19 Bennett also declared that any deficit would be covered by the province’s general revenue fund.20 Bennett’s pragmatic changes to the BCHIS met with criticism from both sides of the political spectrum. The left attacked Bennett for introducing the co-payment of $1 a day with no maximum, and the right criticized him for failing to move to a “voluntary” plan. The left opposed the co-payment because it could be more financially onerous for people who were hospitalized for lengthy periods than the old Coalition government plan. In reality, however, the attack from the left on the unlimited $1-a-day provision proved to be less of a political stumbling block for Bennett than the criticism from the right concerning the compulsory nature of the BCHIS premiums. Bennett had never opposed the principle behind co-payment, and he had never promised to get rid of it. He had, however, promised to follow Alberta’s lead in making the BCHIS a voluntary scheme—a promise that he failed to keep. When his government extended compulsory payroll deductions, Bennett defended the basic rationale behind the decision. In Bennett’s view, it was not equitable to “enforce deductions in some plants and not others, or to require some people in a single plant to pay and not others.” He argued that eliminating compulsory payroll deductions for BCHIS premiums could only lead to “chaos and anarchy” and that his government did “not believe in chaos and anarchy.” When pressed by a reporter about the perception that his election promise had been understood to mean that a Social Credit government would eliminate compulsory premiums altogether, Bennett replied that if the people had presumed this, they had presumed incorrectly. He added that the “matter of voluntary versus compulsory hospital insurance is a matter of emphasis—of degree.” He specified further that he had meant to say that his government “didn’t believe in putting people ‘in jail’

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because they were against paying.” He also claimed that his policy of non-prosecution amounted to a voluntary approach based “on the fact that no sensible person who can pay premiums can afford to stay out of the heavily-subsidized hospital scheme.”21 Bennett’s circuitous, almost baffling, explanation of his party’s broken electoral promise quickly unravelled. Upon intensive questioning by mill workers, Bennett admitted that the BCHIS “was quite compulsory, but it is going to get less compulsory, and that in the meantime, the [compulsory] payroll deduction plan is going to be continued and expanded.” Then, in an effort to take the focus off himself, Bennett argued that the newspapers were keeping “the people’s mind confused” on the issue. In his view, compulsory payroll deductions would bring more residents into the plan because such deductions were easier than other forms of payment. Bennett explained that this “easy method of making payment” would, in turn, allow the government to minimize “the measure of compulsion.”22 Conveniently forgetting his earlier statements in favour of the voluntary Alberta model, Bennett claimed he had always been clear on what he meant by “voluntary” and that his alleged change in position had been fabricated by the newspapers. He added that “[o]ur position is clear. At no time have we said no person is required to pay hospital insurance premiums. We have only said that we will not prosecute delinquents.”23 Not surprisingly, Bennett’s argument that voluntary meant only freedom from state prosecution and not freedom to opt out of the plan was mocked in the newspaper headlines which stated the obvious—public hospital insurance in British Columbia was compulsory and would remain compulsory.24 In one sense, Bennett had been mistaken in his assessment of the BCHIS plan. The BCHIS had never been intended as a single-payer plan operating in isolation from the private sector. The government had neither compelled private insurers to withdraw from the field in favour of the public plan nor had it forced employer- sponsored group plans to give up their own hospital insurance schemes to the benefit of the public scheme. The BCHIS simply offered lower premiums than those charged by existing plans (at least it did prior to the premium hike in 1951) for a broader benefit package. As a consequence, a number of existing insurers simply stopped providing hospital insurance and concentrated instead on offering medical (physician) care insurance and coverage for hospital items not included in the public plan. Blue Cross and a number of the company plans withdrew from the hospital insurance business, but two industrial plans with comparable premium and benefit structures—Canadian Pacific Railway and British Columbia Telephone—continued to provide hospital insurance for their employees. These plans also folded, however, when Bennett eliminated individual premiums in April 1954.25

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Bennett’s decision to eliminate compulsory premium payments reflected his opportunistic approach to politics. Individual compulsory premiums functioned as a visible poll tax; as such, they had been the most unpopular component of BCHIS. In order to replace the funds generated from individual premiums and bolster his government’s popularity in an election year, Bennett decided to increase the provincial sales tax (then called the Social Services Tax) from 3% to 5%. This increase essentially solved the program’s revenue problem because the sales tax was collected from residents as well as corporations and visitors to the province.26 The change from a highly visible poll tax to a general revenue model based primarily on funds raised from sales tax made the BCHIS more politically sustainable. Individuals still contributed to the fund but it was tied to consumer spending instead of being deducted from payroll cheques or collected separately by the payment of premiums. In addition to the improved political optics, there were good policy reasons for eliminating premiums. From the beginning of the program, membership in the BCHIS had been tied to registration through the payment of premiums. Before Bennett expanded the scope of contributory premium payments, the BCHIS was struggling to increase enrolment in the plan. The reasons for this were the large number of transient workers in the province and the lack of municipal organization throughout much of the province. Even with the expansion in compulsory employment plans, only 92% of British Columbians had been registered in the BCHIS plan by 1953. By eliminating premiums, Bennett removed registration as a condition of membership in the BCHIS. The only condition placed on membership in the BCHIS plan was 12 months consecutive residence in the province. This alleviated many of the costly administrative problems that had been caused by the registration system. Bennett’s decision to eliminate premiums meant that the BCHIS easily met the federal government’s universality requirement as well as its other conditions for federal-provincial cost-sharing under the 1957 Hospital Insurance and Diagnostic Service Act. To be eligible for federal money under national hospitalization, only one change was required: a reduction in the residency period from twelve to three months.27 This easy transition stood in sharp contrast to the large-scale restructuring that Alberta underwent in order to meet the federal program’s conditionality.28 THE GENESIS OF BENNETTCARE, 1964-67

During the epoch of hospitalization, Bennett easily survived attacks from the left and the right in part because he had largely fixed an administratively flawed program. He would be in a very different position when public coverage was extended to medical care insurance in the

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1960s. From the beginning, Bennett would be held to account for shaping the province’s policy on public medical care insurance. In 1961, Prime Minister John Diefenbaker asked Justice Emmett Hall to chair the Royal Commission on Health Services (the Hall Commission) in order to provide the federal government with some recommendations with respect to the future of medical care insurance.29 By the time the commission began its work, all 10 provinces had implemented hospitalization programs and public opinion was strongly in favour of the public provision of physician insurance. At the same time, however, organized medicine, the insurance industry, and a good portion of the business establishment had become even more opposed to government involvement in health care than they had been in the 1950s. Considering himself to be simultaneously a free-enterpriser and a populist, Bennett tried to maintain the support of the medical profession and business interests while also shaping his government’s policies to reflect the voters’ interests. As a witness to the polarization of opinion during the doctors’ 23-day strike in Saskatchewan, in which the doctors refused to adhere to the new provincial universal medical care insurance scheme, Bennett was keenly award of the challenges involved in trying to maintain this balance.30 During the provincial election the following year, Social Credit attacked the Saskatchewan plan which the CCF—now reconstituted as the New Democratic Party (NDP)—opposition in British Columbia regularly championed. Eric Martin, Bennett’s Minister of Health, was unequivocal in his hostility to Saskatchewan Medicare, calling its implementation “the most shameful, frightful, and fearsome display of anti-democratic behaviour that we have ever witnessed in this country.”31 The Bennett government promised that it would provide the benefits of public Medicare without the compulsion and higher taxes implicit in the opposition’s proposed model.32 Throughout September 1963, Bennett’s Social Credit government contrasted their “voluntary” approach with the “compulsory” plan that had been implemented in Saskatchewan and promised by the NDP opposition in British Columbia.33 The essential problem confronting Bennett was the polarization of viewpoints that informed both sides of the Medicare debate. Bennett had to convince an extremely sceptical business and professional community that his version of Medicare would preserve a significant role for private enterprise and protect the physicians’ professional autonomy. He also had to take into account the public’s demand for a plan that would provide access to those who most needed medical care. In response to the provincial NDP’s promise of “no premium, no fee” Medicare, Bennett simply argued that the opposition’s plan was unsustainable, and he let the British Columbia Medical Association (BCMA) disparage the NDP’s cost estimate of $50 million as being too low by approximately $30

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million.34 Dubbing the NDP the “New Depression Party,” Bennett defeated the NDP easily in the fall 1963 election. This victory was due, at least in part, to Bennett’s promise of a “painless” version of universal Medicare—a low cost plan that would be available to everyone at minimal government expense.35 After his re-election, Bennett was faced with the task of how to fulfill his Medicare promises. To avoid a major confrontation with the BCMA and circumvent the social and political upheaval that had been caused by the introduction of Medicare in Saskatchewan, he began behind-thescenes negotiations with the central executive of this powerful organization. Bennett then reached out to the business community and the insurance industry; the latter group in particular had regularly championed the Alberta model of publicly subsidized private medical care insurance. The press had dubbed this model of Medicare “Manningcare” after Premier Ernest Manning, and it had been dismissed as “tin cup Medicare” by the NDP. The President of the Canadian Health Insurance Association lauded the introduction of the new multi-payer plan on 25 June 1963. He praised it as being the result of “months of meetings, negotiations and search for an acceptable common ground between representatives of the [Alberta] government, the medical profession, the prepaid plans, and the health insurance industry.” He added: For the first time, voluntary medical care insurance was put within the reach of the entire population of a province. Anyone who wanted or needed protection against the costs of doctors’ services could obtain it. A standard plan with a broad schedule of benefits and a statutorily set maximum premium was offered by each of the more than 45 insurance companies who agreed to participate in the plan.36

As had been the case during the introduction of hospital insurance in the 1950s, the Alberta government had become the proponent of a “voluntary” healthcare plan—a plan in which consumers were encouraged to purchase private medical care insurance by the government’s subsidization of premiums and provision of free coverage to those individuals who were too sick to be eligible for private insurance or too poor to pay any rate of premium.37 Organized medicine supported Manningcare because it preserved a direct financial link between physicians and their patients even while ensuring that most bills would ultimately be paid in full. The insurance industry and business community in general supported Manningcare because instead of the imposition of a single-payer, government monopoly over medical care insurance, the plan depended upon commercial and physician-based carriers to provide medical care insurance—a multi-payer insurance system. Hailed by organized medicine and the business community, Manningcare became the standard by which Bennett was measured in his own province. In an attempt to

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influence Bennett, prominent physicians and insurance company executives regularly sent copies of their speeches and addresses promoting Manningcare to Bennett and his health minister.38 Immediately following the June 1964 release of the Hall Commission report, the Bennett government began to position itself between the supporters of Manningcare model on one side and the advocates of a single-payer model, including the Hall Commission, on the other side. In the first federal-provincial meeting following the Hall Commission report, unlike the Manning government, the Bennett government affirmed its commitment to “the principle of a national health program and its willingness to take part in such a program” as long as it was developed in fiscally feasible stages.39 At the same time, Minister of Health Martin promised that his government would not “start a Medicare scheme in the manner in which the NDP Government of Saskatchewan did—without the least regard for democratic principles.”40 Over the next year, the foundation would be laid for British Columbia’s alternative model. From the beginning, Bennett had decided that his government’s new Medicare scheme would be designed in conjunction with organized medicine. He wanted to co-opt the BCMA as a full partner in the new scheme. The difficulty for Bennett was that until 1964, the BCMA had been more vehemently opposed to public medical care insurance than virtually any other provincial chapter of organized medicine in the country.41 At the same time, however, Peter Banks, the president of the BCMA, recognized that “the tide towards Medicare was running so strongly across the country” that it was better to work out an alternative rather than simply defend the status quo. By 1964, the BCMA had decided to take what Banks termed “a more positive and constructive” stance with respect to the provincial government. Rather than simply oppose any form of publicly sponsored medical care insurance program, the BCMA’s goal was to actively participate in constructing a program that would favourably reflect the interests of its membership.42 In return for their support, Bennett assured the BCMA that his model of Medicare would be fundamentally different than the Saskatchewan plan. Most significantly, it would allow British Columbia residents a choice among a group of approved insurance carriers.43 However, unlike Manningcare, Bennett wanted to ensure that almost the entire population would be covered by medical care insurance on similar terms and conditions. These aspects of Bennettcare allowed Bennett to claim that his Medicare scheme incorporated the best aspects of both the Saskatchewan and Alberta models: universal coverage and freedom of choice. Over a period of several months, the Bennett government, the BCMA, and selected private non-for-profit insurance companies negotiated the terms of Bennettcare. The interests of organized medicine,

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represented by the BCMA, were two-fold. First, the physicians wanted to protect their incomes and their individual practices from what they perceived as state incursions into their relationship with patients. Second, they wanted to ensure the viability of their physician-sponsored, nonprofit medical care insurance scheme known as Medical Services Association (MSA). Like similar doctor-sponsored insurance plans in the rest of the country, MSA had been created to provide an alternative to commercial (for-profit) medical care insurance. By providing better rates and wider coverage, MSA had also been intended to act as a pre-emptive strike against the creation of public Medicare.44 During discussions with the BCMA and the insurance carriers, Bennett insisted on two non-negotiable conditions. The first was that he would only permit non-profit insurance plans to sell medical care insurance under the new provincial plan. The second was that all insurance carriers would have to provide first-dollar coverage—a policy that precluded deductibles and co-payments.45 Initially, Bennett wanted all the insurance carriers to be non-governmental in nature. He had been prepared to use the general revenue fund of the province to subsidize insurance carriers as long as they insured high-risk individuals, including the elderly or people with preexisting medical conditions. MSA and the other insurance carriers rejected this idea, claiming that the inclusion of such individuals at government expense could “threaten the independence” of the physiciansponsored plan. In the end, Bennett agreed to separate the “bad risks” and to cover them under a separate government-run plan known as the British Columbia Medical Plan (BCMP).46 In his first proposal, Bennett included limited coverage for chiropractors and naturopaths. The BCMA executive, who thought of these groups as little better than quacks, resisted this inclusion. Bennett, however, insisted on their participation because their services were already a well-established part of the British Columbia Government Employees Medical Service Plan, and feared the controversy that would be generated if the new plan had less coverage. When confronted by a recalcitrant Bennett, the BCMA suggested that such services should only be permitted on the referral of a physician. However, as the discussion unfolded and the conflict-of-interest became increasingly apparent, the BCMA grudgingly dropped its objection, making what it considered to be a major concession.47 Bennett fought obstinately for a wide range of services under the plan. However, when it came to the issue of physicians’ rights and remuneration, Bennett had to be more yielding to get the BCMA’s agreement. In particular, the BCMA insisted that physicians should retain the right to extra bill patients and to opt out of the plan. Bennett agreed. Bennett also consented to paying physicians on the basis of their existing fee

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schedule. The fees were set at a minimum of 90% of the existing schedule and included an automatic escalator clause, which was based on a combined index of the Vancouver cost of living and provincial wage growth and would be triggered at the beginning of each calendar year. An initial cap for increases was set at 3.83%, but the BCMA insisted on a clause that allowed for a renegotiation of the escalator clause in the event of unforeseen circumstances.48 The final agreement containing all of these conditions was signed on 8 June 1965. The agreement was significant because it allowed Bennett to proceed with the development of his vision of Medicare with the political support of the BCMA, a stark contrast to the struggle in Saskatchewan.49 Bennettcare was implemented through a series of the regulations that were passed under the Medical Grant Act on 7 June 1965.50 These regulations stipulated that all approved insurance carriers would have to: (1) be non-profit organizations; and (2) provide medical care benefits equal or superior to those provided under the British Columbia Government Employees Medical Services plan. While it was up to the organizations to set their own premiums, the government’s premiums ($60 for individuals, $120 for a family of two, and $150 for a family of three) under the BCMP were set lower than premiums in the other plans. For example, the rates for subscribers to MSA were comparatively higher ($72.50 for individual and a range of $135.80 to $222 for families).51 In addition, all plans were to receive a 50% subsidy from the government for every non-income-earning subscriber and a 25% subsidy for every subscriber with a taxable income of $1,000 or less. While the regulations stipulated that all carriers should accept new applicants without “restriction on qualifications respecting age, state of health or financial status,” the private carriers nonetheless expected the BCMP to be responsible for the majority of high risk subscriptions.52 In June 1965, the BCMP was established as a non-profit organization under the British Columbia Societies Act. The Act provided that the Provincial Secretary, a government minister, would be responsible for determining whether a given non-profit insurance company met the criteria under the Medical Grant Act regulations in order to become a certified BCMP carrier.53 The governance of BCMP consisted of a six person board of directors composed of equal members of government and BCMA representatives. The BCMA was well-represented on the board by its president, Peter Banks. Alan W. Brown, an insurance executive long associated with the physician-sponsored MSA plan, was appointed as the general manager of the BCMP. The government proclaimed the participation of the BCMA with great pride because it exemplified its commitment to the inclusion of physicians in health care policy initiatives.54 In addition to the BCMP, the government licensed several private

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non-profit carriers: Medical Services Association (MSA), Fraser Valley Medical Services Society, C. U. & C. (Credit Union and Co-operative) Health Services Society, Provincial Teachers’ Medical Services, C. P. Employees’ Medical Association, and the Automotive Retailers’ Association.55 Shortly after the creation of the BCMP, the MSA and C. U. & C. voiced their concern over the fact that the BCMP’s lower premiums would cause them to lose many of their individual subscribers.56 This proved to be the case because the regulations under the Medical Grant Act made individual policies no longer profitable for these two carriers. The group plans, however, continued to be financially viable for the companies. The terms on which the various private, non-profit carriers could provide insurance were largely homogenized under the provincial legislation. However, the plan’s organizational structure allowed the government and the BCMA to argue that Bennettcare differed significantly from the Saskatchewan model. Peter Banks boasted about the voluntary nature of the plan and the participation of the private sector. He added that Bennettcare allowed British Columbians to escape “from the smooth duplicity of a [Tommy] Douglas or the bitter dogmatic rantings of a Bevan [the original minister responsible for Britain’s National Health Service].” In contrast, Banks described W. A. C. Bennett as “a proven pragmatist, as shrewd and able a political brain as this country has ever produced,” upon whom “the terrible lessons of Saskatchewan were not lost.” In his view, Bennettcare was a “tribute” to all the physicians “who bore the indignities and the humiliations of the struggle in Saskatchewan. They did not suffer in vain.”57 The BCMA’s initial support for Bennettcare was based primarily on the fact that organized medicine had successfully managed to engineer a Medicare plan that reflected their interests. Bennettcare allowed the private carriers such as MSA to continue doing business in British Columbia. However, the relatively close relationship between the Bennett government and organized medicine became strained as the province sought to meet the conditions for national Medicare required by the Pearson federal government.58 In one prescient newspaper column, it was even suggested that non-compulsory Bennettcare was simply the first step towards the inevitable evolution of compulsory national Medicare. It was also pointed out that Bennett must have understood this, but that he had chosen to adopt a gradual approach in order to pre-empt a Saskatchewan-style confrontation with organized medicine.59 In other words, Bennett had baited organized medicine into one form of Medicare, knowing all along he would have to eventually switch to a different kind of Medicare. While there is no direct evidence supporting this view, Bennett, always the populist and pragmatist, may have realized this from an early date. It is equally plausible, however, that he

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entered into the federal negotiations believing that he would be able to convince the Pearson government to allow his version of Medicare. THE MORPHING OF BENNETTCARE INTO MEDICARE

W. A. C. Bennett had a tumultuous relationship with the federal government during his tenure as premier. As a provincial Social Credit leader, he lacked the partisan affiliations to whichever party was in power in Ottawa. In addition to not having natural political allies in Ottawa, Bennett actively distanced himself from the traditional federal parties by strongly supporting the Social Credit alternative in every federal election. A further irritant was that Bennett’s political outlook could be highly parochial, and he had a tendency to evaluate all national issues solely by their potential impact on British Columbia. He was particularly hostile to Prime Minister Lester B. Pearson and his advisors, who were actively engaged in modernizing and extending the Canadian welfare state. While Bennett was more than willing to use the mechanisms of government to develop the provincial economy, he was only interested in promoting social programs that were in high popular demand by the voters. Often exploiting a strong sense of historical regional grievances in his relations with Ottawa, Bennett made a point to treat the federal government, especially Pearson, with disdain. For example, when Pearson scheduled a First Ministers’ Conference for 31 May 1965 in order to propose a national Medicare program, Bennett refused to attend on the basis that he had a business trip scheduled for Japan. This forced Pearson to move the meeting to 19-20 July. When informed of the change in dates, Bennett then informed Pearson that he would have to leave the conference early due to other business. Even the British Columbia press regarded this gesture as a snub.60 At the July meeting, Bennett quickly allied himself with the three other provincial premiers, Ontario’s John Robarts, Manitoba’s Duff Roblin and Alberta’s Ernest Manning, who shared his concerns with the underlying principles of the federal Medicare proposal. Prior to the conference, the federal government had indicated that a national plan would have to be universal in its coverage, transferable anywhere within Canada, and publicly administered. On the issue of universality, Bennett, Manning and Roblin argued in favour of a voluntary plan—one that would not force every resident to subscribe. In Manning’s view, what he termed “the principles of universal compulsory application” were “unsound in a free society” because every “individual should have the right to decide the manner in which he receives medical care.” Bennett added that so long as insurance was made available to all, it should be sufficient to meet the federal government’s requirement for universality even if it was voluntary in nature.

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Distinguishing the compulsory nature of his own province’s hospital insurance program, Bennett argued that people viewed medical services differently than hospital services and that “many people” might not wish to participate in a medical care insurance plan “for religious reasons.”61 However, after a particularly long and vitriolic denunciation of the federal proposal by Ernest Manning, Bennett swiftly broke ranks with his provincial allies. Despite the fact that he disagreed with aspects of the federal approach, Bennett stated that he was not only willing to “accept the plan proposed by the Federal Government,” but that his province was prepared to join as early as 1 April 1966.62 It is not clear from the historical record what fuelled Bennett’s sudden change of position at the conference. He may have believed that Bennettcare could be modified to meet the federal government’s concerns without changing any of its key design features that had proven attractive to physicians and others opposed to the Saskatchewan model endorsed by the Hall Commission and the Pearson government. Or he may have been willing to sacrifice these design features in order to access federal cost-sharing dollars without delay. Whatever his actual motive, Bennett made it clear that he was willing to make the necessary changes such that Bennettcare would be compliant with federal Medicare as quickly as possible. At the same time, Pearson and his aides must have understood the problems associated with the federal government’s universality requirement. In particular, it was becoming obvious that some provinces, such as British Columbia, might insist on a voluntary design, a stipulation that would not meet the federal objective of insuring all provincial residents. On the second day of the Federal-Provincial Conference, Pearson spoke directly to the issue in a prepared statement: There is often confusion as to the relation between universality and compulsion. Our purpose is that everyone should qualify for benefits. This involves compulsion in the sense that, if a premium is chosen by a province as part of the method of financing, the premium would be compulsory in the sense that taxes are compulsory. Obviously there is no compulsion on people to use the services, nor any compulsion on the individual doctor to join the plan if the demand for his services is such that he can practice successfully outside it.63

On its face, Bennettcare did not meet the Prime Minister’s definition of universal because the decision to purchase insurance was left to individuals. In addition to the universality hurdle, Bennettcare did not meet the public administration principle as laid out by Pearson. The principle seemed simple enough—if the medical care insurance plan was administered either directly by the provincial government, or an agency of the provincial government, then it would meet the public administration

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requirement. However, in the case of Bennettcare there was no agency acting on behalf of the government. The BCMP did not oversee the private non-profit insurance carriers. Under the Medical Grant Act regulations, the private carriers had to follow certain practices in order to be licensed by the provincial government; however, there was no umbrella public organization managing the entire scheme that was directly accountable to the provincial legislature. The federal Medical Care Act, passed in December 1966, clarified the principle of public administration by providing that the public body had to be directly responsible for assessing and approving accounts as well as determining the amounts paid under the plan by all subscribers.64 The final challenge for program compliance was that Bennettcare permitted physicians to extra bill. The federal government stated from the outset of the negotiations that it was not in favour of statutorily imposed user fees, deterrent charges, or co-payments. Nonetheless, Ottawa was still willing to live with such fees as long as they were low enough not to impede access. However, the federal government adamantly opposed user fees that could be imposed at the discretion of individual physicians, and Bennettcare explicitly permitted this kind of extra billing by physicians so long as they obtained an express agreement from their patients. To sum up, there were three problems with Bennettcare from the federal government’s perspective: (1) the plan lacked universality; (2) it was not publicly administered; and (3) it allowed discretionary extrabilling. These obstacles would have to be removed in order for Bennettcare to obtain cost-share funding from the federal government. By the end of 1965, it was estimated that approximately 89.2% of British Columbia residents were covered by medical care insurance. This was well above the 80.6% coverage reached under Manningcare, but it was well below the 100% coverage under Saskatchewan Medicare.65 Exhibiting a high degree of flexibility, Allan MacEachen, as the new federal Minister of Health and Welfare, set a minimum threshold of 90% as the level of coverage necessary to meet the definition of universality.66 In British Columbia, 1.5 million people were covered under the non-profit plans and a further 140,000 people had subscribed to the BCMP. In the spring of 1966, Bennett used additional tax revenue in order to increase the subsidy in hopes of achieving 90% subscription. For those without taxable earnings, the Bennettcare premium subsidy rose from 50% to 90%. For people who had a taxable income of $1,000 or less, the subsidy jumped from 25% to 50%.67 The result would put the plan well over the 90% mark in terms of subscription, and Bennettcare was deemed universal by the federal government. In this way, Bennett ensured that his plan met the per cent target set by the federal government. However, it was not so easy for Bennett to satisfy the public adminis-

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tration requirement given his desire to maintain the multi-payer nature of Bennettcare. During the Federal-Provincial Technical Conference on Medicare, during which the provisions of the federal Medical Care Act were fleshed out and clarified, federal officials made it clear that some sort of single public authority had to be responsible for medical care insurance in the province.68 To meet this requirement, Bennett was forced to establish the Medical Services Commission (MSC), a public body which was answerable to the provincial legislature. Unlike the BCMP, it was made up of only three directors, two of whom, including the chair, were provincial officials. The third was Peter Banks of the BCMA. Despite Banks’ continued involvement, the BCMA could no longer be considered an equal partner in Bennettcare. In the MSC, the BCMA held only one position of the Board of Directors, and the organization was directly accountable to the government through the legislature. The MSC was created pursuant to the Medical Services Act, which was passed by the provincial legislature in 1967. In reality, however, the MSC did not begin to operate until extensive regulations were made under its own legislative authority in May 1968. As pointed out in the government’s news release, the regulations were drawn up to ensure the province was qualified “to receive payments of contributions by Canada towards the cost of medical services under the Medical Care Act of Canada.”69 In order to avoid the obstacles inherent in amending legislation and to increase his government’s ability to act at its own discretion, Bennett preferred obtaining legal authority through regulation rather than statute. The regulations introduced the same premium structure; however, unlike the government’s earlier agreement with the BCMA, there was no mention of the right of physicians to extra bill. Instead, the regulations under the new Medical Services Act simply empowered the MSC to “determine the manner of and approve the form for submission of claims for insured services for insured services” and to “determine the information required to permit assessment and payment of claims for insured services.” While some doctors raised concerns about the fact that the new regulatory provisions eliminated their ability to extra bill, the regulations nonetheless came into force.70 This was the final change required to meet the federal government’s conditions for cost-sharing under federal Medicare. In order to comply with the federal government’s universality and public administration conditions, Bennett had introduced significant legislative and regulatory changes to Bennettcare. With respect to extrabilling, Bennett had quietly eliminated the physicians’ right to engage in the practice in order to address the federal government’s concern that extra-billing constituted a serious barrier to publicly accessible Medicare. With these changes, Bennettcare had effectively morphed into Medicare.

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CONCLUSION AND EPILOGUE

Bennettcare in its original design was incompatible with the national model of Medicare desired by the Pearson government. Initially controlled by private (albeit not-for-profit) insurance carriers, it did not meet the condition of public administration. On the issue of universality, a compromise was reached—even though the decision to purchase was left to individuals, the provincial government so subsidized the purchase of insurance through its public carriers that well over 90% of the population enrolled. However, this success also led the private insurance carriers to get out of the business as they could not compete with the public carrier. Bennett also removed a provision that had expressly permitted physicians to extra-bill patients, an important part of the BCMA’s original bargain to support Bennettcare. Over the coming years, the Bennett government’s relationship with the BCMA would deteriorate as the physicians increasingly resented the gradual manner in which Bennett had brought them into a universal, single-payer Medicare system. Bennett himself withdrew from direct discussions with the BCMA, leaving his health ministers to grapple with their concerns while at the same time making all final decisions. Over time, Bennett began to resent the ever-growing remuneration demands of doctors—and the share of government revenues flowing to Medicare. As a result, the Bennett government became so tough in its negotiations with physicians, that at least some in the BCMA initially welcomed Bennett’s defeat and the election of a new NDP administration under Dave Barrett in 1972.71 Organized medicine had become fed up with what it perceived as the Bennett government’s stinginess and the unsympathetic behaviour of the Minister of Health and his department. As explained by one scholar of the era, the BCMA’s relationship with the subsequent NDP government “lacked the animosity” that eventually came to characterize its relations with Bennett’s Social Credit government.72 It was not until 1992 that the final nail was driven into the coffin of Bennettcare, when another newly elected NDP government prohibited the sale of private medical care insurance.73 ACKNOWLEDGMENTS

We benefited greatly from the comments and suggestions of Patricia Roy as well as two referees. We are solely responsible for any remaining errors or omissions. NOTES 1 The term Bennettcare was coined by some newspapers in British Columbia immediately after the introduction of the British Columbia Medical Plan. See for

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example “Bennettcare under fire by Labour,” in the Victoria Daily Times, 10 June 1965, p. 21. Jean Barman, The West beyond the West: A History of British Columbia (Toronto: University of Toronto Press, rev. ed., 1996), p. 280. See also David J. Mitchell, W. A. C. Bennett and the Rise of British Columbia, 2d ed. (Vancouver: Douglas & McIntyre, 1995). At its inception, the BCHIS was popular because of the problems associated with financially unsound not-for-profit hospital insurance plans in the province. Vancouver News-Herald, 20 February 1948, p. 10. The controversy over the BCHIS dominated the spring session of 1950 and Bennett himself blasted the “haphazard approach” of the BCHIS’s administration. See Mitchell, Bennett, p. 96. Victoria Daily Colonist, 20 March 1951, p. 8; and 21 March 1951, p. 1. Bennett as quoted in Mitchell, Bennett, p. 101. Bennett and the three other dissidents were joined weeks later by Conservative coalition government member Tilly Rolston: Victoria Daily Colonist, 30 March 1951, p. 1; and Vancouver Daily Province, 30 March 1951, p. 6. Victoria Times, 2 March 1951, p. 4. Vancouver Sun, 10 March 1951, p. 1-3; 13 March 1951, p. 1-2; 14 March 1951, p. 1; and 15 March 1951, p. 4. Victoria Daily Colonist, 10 March 1951, p. 1, 14; 14 March 1951, p. 1; and 15 March 1951, p. 1. Vancouver News-Herald, 10 March 1951, p. 1-3. Vancouver Sun, 12 March 1951, p. 1, 13; 13 March 1951, p.1, 4; 17 March 1951, p. 1; 19 March 1951, p. 4; 21 March 1951, p. 25, 46; 29 March 1951, p. 4; and 31 March 1951, p. 1. Vancouver News-Herald, 12 March 1951, p. 4; 13 March 1951, p. 3; 16 March 1951, p. 3; 19 March 1951, p. 4; 28 March 1951, p. 1; 29 March 1951, p. 1; and 20 April 1951, p. 4. Victoria Times, 12 March 1951, p. 4; and 13 March 1951, p. 1. Victoria Daily Colonist; and 13 March 1957, p. 15-6, 16 March 1951, p. 3; 20 March 1951, p. 1; 29 March 1951, p. 1; and 15 April 1951, p. 1; Vancouver Daily Province, 29 March 1951, p. 1; and 31 March 1951, p. 21. Vancouver Sun, 16 March 1951, p. 1-2; and Victoria Daily Colonist, 16 March 1951, p. 1. Victoria Times, 16 March 1951, p. 5. Victoria Daily Colonist, 15 March 1951, p 1; and Vancouver Sun, 28 March 1951, p. 1. Victoria Daily Times, 8 December 1951, p. 4. Gordon Hak, “Populism and the 1952 Social Credit Breakthrough in British Columbia,” Canadian Historical Review 85 (2004): 277-96. In “Reckoning with the Machine: The British Columbia Social Credit Movement as Social Criticism,” BC Studies, 124 (1999-2000): 9-39, Leonard B. Kuffert emphasizes the indigenous nature of Social Credit as a movement and a political party relative to Social Credit in Alberta and Quebec. On Social Credit’s equating of freedom and democracy with private property, see Maurice Pinard, The Rise of a Third Party: A Study in Crisis Politics (Montreal and Kingston: McGill-Queen’s University Press, 1975), p. 11-12. Bennett as quoted in the Vancouver Sun, 25 March 1952, p. 2. Bennett as quoted in the Vancouver Sun, 25 March 1952, p. 2. Barman, West, p. 275. Mitchell, Bennett, p. 163; and Vancouver Province, 16 July 1952, p. 1. Vancouver Province, 16 July 1952, p. 1; and Vancouver News-Herald, 16 July 1952, p. 1. Bennett said he was “opposed to bringing people before the courts” for failure to pay their premiums. He thought that once “changes” were “made in the regulations” more people would be prepared to join the BCHIS “on a voluntary basis than did under the compulsory scheme.” Bennett as quoted in the Vancouver Sun, 16 July 1952, p. 2. Vancouver Sun, 9 September 1952, p. 1; and Vancouver Province, 9 September 1952, p. 1. When asked how the government would distinguish between those who could not pay their arrears due to low incomes and those who simply chose not to pay their arrears, Eric Martin, the Social Credit government’s new health minister, stated that this “would be worked out.” Martin added that the main point was that the

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government did not “want to force any person to pay” who was not “in a financial position to do so.” Martin as quoted in the Vancouver Province, 9 September 1952, p. 1. Vancouver Province, 8 August 1952, p. 1; and Victoria Daily Colonist, 9 August 1952, p. 1. Bennett as quoted in the Vancouver Province, 7 November 1952, p. 1. Bennett as quoted in the Vancouver Sun, 7 November 1952, p. 1. Victoria Daily Times, 7 November 1952, p. 1. See Vancouver Sun, 7 November 1952, p. 1: “Hospital Act ‘Compulsory’ (but no more than forced by law, says Bennett)”; Victoria Daily Times, 7 November 1952, p. 1: “Bennett Rules B.C.H.I.S. Still Compulsory”; and Victoria Daily Colonist, 8 November 1952, p. 11: “Insurance Compulsory until Act is Changed.” British Columbia Archives (BCA), Department of Health (Deputy Minister) Fonds, GR 678, box 8, file 17, Reference Material on the British Columbia Hospital Insurance Service, 1 January 1949 to 1 July 1958, December 1958 (hereafter referred to as Reference Material on BCHIS, 1949-58). In contrast, the so-called “dollar-a-day” co-payments—also known as deterrent fees— remained in effect until at least 1958. Reference Material on BCHIS, 1949-58, p. 8. Reference Material on BCHIS, 1949-59, p. 4; BCA, Draft Agreement respecting Contributions under the Hospital Insurance and Diagnostic Service Act between the Government of Canada and the Government of British Columbia, 4 December 1957; and Department of Health (Deputy Minister) Fonds, GR 678, box 14, file 20, FederalProvincial Hospital Insurance Program report, 1 June 1958. Malcolm G. Taylor, Health Insurance and Canadian Public Policy: The Seven Decisions That Created the Canadian Healthcare System (Montreal: McGill-Queen’s University Press, 1977), p. 375. See Dennis Gruending, Emmett Hall: Establishment Radical (Markham, Ont.: Fitzhenry and Whiteside, 2005). Robin F. Badgley and Samuel Wolfe, Doctors’ Strike: Medical Care and Conflict in Saskatchewan (Toronto: Macmillan Canada, 1967); and Gregory P. Marchildon and Kevin O’Fee, Health Care in Saskatchewan: An Analytical Profile (Regina: Canadian Plains Research Center, 2007), p. 19. BCA, Department of Health and Welfare (Deputy Minister) Fonds, GR 117, box 2, file 7, Hon. Eric Martin as quoted in transcript of CBC speech, 13 September 1963. BCA, Department of Health and Welfard (Deputy Minister) Fonds, GR 117, box 2, file 7, Hon. Eric Martin as quoted in transcript of CBC speech, 13 September 1963. BCA, Department of Health and Welfare (Deputy Minister) Fonds, GR 117, box 7, file 5, Various news clippings on Medicare, 1963. BCA, Department of Health and Welfare (Deputy Minister) Fonds, GR 117, box 7, file 5, Various news clippings on Medicare, 1963. This is speculation but David Mitchell suggests a few reasons for the “surprising” Social Credit victory and for the relatively poor showing of the opposition NDP. See Mitchell, Bennett, p. 319-21. BCA, Department of Health Fonds, GR 120, box 8, file 3, Copy of speech by George R. Berry (President of the Canadian Health Insurance Association) at the annual meeting of the Health Insurance Association of America, Montreal, 13 May 1964. Cam Traynor, “Manning against Medicare,” Alberta History 43(1995): 7-19. Simon Fraser University Archives (SFUA), W. A. C. Bennett Fonds, F-55-39-0-22, Letter enclosing speech from G. N. Watson (Vice-President and Director of Group Insurance, Crown Life Insurance Co., Toronto) to Bennett, 27 November 1964. In his cover letter, Watson told Bennett that his speech contained “certain comments on the Alberta Plan which will serve to confirm the information which our group gave to you verbally at the time of our meeting. You will see that the paper gives the up-to-date information in regard to the number of people covered in Alberta together with the specific amounts of subsidy provided under the Alberta Plan, the maximum

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premiums required by the plan and sundry other information which will be interesting to you in this connection.” BCA, Department of Health Fonds, GR 120, box 8, file 3, Second draft of remarks prepared by D. M. Cox (Deputy Minister of Hospital Insurance) for the Hon. Eric Martin (Minister of Health Service and Hospital Insurance), 9 July 1964. The remarks were prepared for the first federal-provincial meeting (20-21 July 1964) held after the release of the Hall Commission report. Cox remarks for Martin, 9 July 1964. BCA, Department of Health (Deputy Minister) Fonds, GR 678, box 8, file 2, BCMA Statement (of principles) on Medical Services Insurance. In the same file is an abridged version of a speech given by then BCMA president, Dr. E. C. McCoy, in which he voices his strong opposition to government-sponsored medical care insurance in 1960. Reprinted in the Cowichan Leader, 25 August 1960. McCoy was one of the three BCMA directors in the original BCMP of 1965. SFUA, W. A. C. Bennett Fonds, Provincial Secretary—British Columbia Medical Plan, F-55-39-0-22, Peter Banks (President of the BCMA), Halifax address on the B.C. Medical Plan, early draft, 10 June 1965 (hereafter Peter Banks’ draft), p. 1. It should be noted, however, that the Saskatchewan plan also permitted the continuation of two physician-sponsored plans although they operated mainly as cheque-clearing agencies for what was, in effect, public insurance administered by the provincial Medical Care Insurance Commission. See Gregory P. Marchildon, “Private Insurance for Medicare: Policy History and Trajectory in the Four Western Provinces,” in Colleen M. Flood, Kent Roach and Lorne Sossin, eds., Access to Care: Access to Justice: The Legal Debate over Private Health Insurance in Canada (Toronto: University of Toronto Press, 2005), p. 429-53. C. David Naylor, Private Practice, Public Payment—Canadian Medicine and the Politics of Health Insurance 1911-1966 (Montreal: McGill-Queen’s University Press, 1986), p. 144. SFUA, Bennett Fonds, F-55-39-0-22, Peter Banks’ draft. SFUA, Bennett Fonds, F-55-39-0-22, Peter Banks’ draft. Dr. Banks rationalized the concession in this way: “If these people really have something to offer in our society they will in all probability survive and their standards will improve, or we might learn from them, their more successful empirical techniques. If they offer nothing then they will not survive and we thought it beneath our dignity to imperil otherwise good legislation in an effort to thwart their inclusion at this time.” SFU, Bennett Fonds, F-55-39-0-22, Peter Banks’ draft, p. 4-5. SFUA, Bennett Fonds, F-55-39-0-22, Peter Banks’ draft. BCA, Department of Health (Deputy Minister) Fonds, GR 678, box 12, file 2, Agreement between the British Columbia Medical Plan (BCMP) and the British Columbia Medical Association (BCMA), 8 June 1965. SFUA, Bennett Fonds, F-55-39-0-22, Press release on Medical Grant Act, 7 June 1965; and Regulations under the Medical Grant Act. Vancouver Sun, 12 June 1965, p. 2. SFUA, Bennett Fonds, Provincial Secretary, BCMP, F-55-39-0-22, Regulation 6.03(d) under the Medical Grant Act. Vancouver Sun, 9 June 1965, p. 1-2; and SFUA, Bennett Fonds, Provincial Secretary: BCMP, F-55-39-0-22, British Columbia government press release with supporting documents, 8 June 1965. However, it should be noted that the chair of the BCMP was a government representative. SFUA, Bennett Fonds, Provincial Secretary: BCMP, F-55-39-0-22, Printed material on launch of BCMP, statement of Wesley D. Black, Provincial Secretary. These were the licensed carriers listed by 1968. BCA, Medical Services Plan, GR 678, box 37, file 11, Article on Medical Services Commission in the British Columbia News, September - October 1968, p. 1.

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56 “Medicare expected to thin MSI ranks,” Vancouver Sun, 12 June 1965, p. 1; and “Health plan rates too low,” Vancouver Sun, 16 June 1965, p. 12. 57 SFUA, Bennett Fonds, F-55-39-0-22, Peter Banks’ draft, p. 1. 58 Robert Strachan, the provincial NDP leader, argued that the “real purpose of the new plan” was to “delay and defeat genuine Medicare.” He thought that it was a “betrayal of the people” and was the “type of plan condemned by the Hall Royal Commission on Health Services,” Victoria Daily Colonist, 10 June 1965, p. 1; and Victoria Daily Times, 10 June 1965, p. 1, 25. 59 Editorial, “B.C. Medicare: Step two …” The Province, 11 June 1965, p. 1. 60 “Snub, heavens no, says WAC,” Victoria Daily Times, 10 June 1965, p. 1. 61 SFUA, Bennett Fonds, Federal-Provincial Conferences, F-55-48-0-6, volume I, Transcript summary of proceedings of the Federal-Provincial Conference, 19-20 July 1965. 62 SFUA, Bennett Fonds, Federal-Provincial Conferences, F-55-48-0-6, volume I, Transcript summary of proceedings of the Federal-Provincial Conference, 19-20 July 1965. 63 SFUA, Bennett Fonds, Federal-Provincial Conferences, F-55-48-0-6, Statement by the Prime Minister of Canada to the Federal-Provincial Conference, 20 July 1965. 64 BCA, Department of Health (Deputy Minister) Fonds, GR 678, box 21, file 16, Transcript of the Federal Provincial Technical Conference on Medical Care, Ottawa, 14 February 1967. 65 BCA, Department of Health (Deputy Minister) Fonds, GR 678, box 21, file 17, Printed material on voluntary insurance. 66 MacEachen distinguished between a universal plan and a compulsory plan and concluded that only the former was essential. Victoria Daily Colonist, 31 March 1966, p. 8. 67 The subsidies increased on 1 April 1966 through an amendment to the Medical Grant Act. SFUA, Bennett Fonds, Provincial Secretary: BCMP, BCMP brochure, 15 August 1966. 68 BCA, Department of Health (Deputy Minister) Fonds, GR 678, box 21, file 16, Transcript of the Federal Provincial Technical Conference on Medical Care, Ottawa, 14 February 1967, p. 17-18. 69 SFUA, Bennett Fonds, Provincial Secretary: BCMP, Provincial Secretary press release, 22 May 1968. 70 SFUA, Bennett Fonds, Provincial Secretary: BCMP, Letter and attachments, Dr. E. C. McCoy (now Executive Director of the BCMA) to Bennett, 23 July 1968. 71 D. Farough, “Professional Autonomy and Resistance: Medical Politics in British Columbia, 1964-1993,” PhD thesis, University of British Columbia, 1996, chap. 5. 72 Farough, “Professional Autonomy,” p. 139. 73 Marchildon, “Private Insurance for Medicare,” p. 429-53.

11 Newfoundland’s Cottage Hospital System: 1920-1970 GOR D O N S . L AWSO N A ND A NDREW F. NOS EWORTHY

INTRODUCTION

In the 1930s, pre-Confederation Newfoundland1 began a unique experiment in health services delivery that represents one of North America’s earliest efforts at publicly funded health care. In 1936, the first of 23 so-called “cottage hospitals” were established in Newfoundland to provide publicly funded hospital and medical services to the rural population.2 By 1956, one year before the introduction of the federal government’s Hospital Insurance and Diagnostic Services Act (1957) that provided cost shared funding to provinces with their own hospital insurance plans, 47% of the population received medical and hospital services coverage through these hospitals.3 The so-called Newfoundland Cottage Hospital System (NCHS)4 also differed in profound ways from the evolution of health services delivery in other parts of the continent, and its development and evolution stands as an important example of policy development and strategic service delivery in what was one of the most turbulent times in Newfoundland’s social and political development. In most parts of 1930s North America, health services were principally provided by private medical practitioners on a fee-for-service (FFS) basis, and by private notfor-profit or charity-based hospitals.5 In Newfoundland, the difficulties of providing health services to a large number of small, dispersed and isolated communities which could not support doctors on FFS and to a population ravaged by disease and malnutrition, required innovation. The NCHS involved the establishment of small, state-owned hospitals and state-employed, salaried medical personnel. The system relied heavily on community support and engagement. Despite the distinctiveness of the NCHS, this system and its related prepayment plan have received limited scholarly attention. This article explores the origins, development, and evolution of the NCHS. In par-

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ticular, we seek to outline the origins of this system and the policy environment in which it developed. We also compare the Newfoundland system with the cottage hospitals and Highlands and Islands Medical Service (HIMS) of Scotland which the existing historiography maintains were the principal models for the NCHS.6 We further seek to examine the origins and influence of a separate public hospital and medical services scheme developed in Twillingate on the development of the NCHS. The importance of the Newfoundland experience as a foundation for the eventual development of Canada’s national hospital insurance program is then explained. Finally, we examine the issue of salaried employment within the NCHS leading up to Newfoundland’s participation in Canada’s national Medicare plan. ORIGINS AND POLICY ENVIRONMENT

To appreciate the circumstances that brought about the creation of the NCHS, it is critical to understand the state of both the health services and the health status of the population in 1930s Newfoundland. State intervention in health care was extremely limited. Outside of St. John’s, the only hospitals in operation on the Island prior to 1935 were administered by the International Grenfell Association (IGA) (St. Anthony), two paper companies (Grand Falls and Corner Brook), the Buchans Mining Company Limited (Buchans), and two local communities (Twillingate and Grand Bank).7 The latter two institutions were established in the 1920s and subsidized by a government grant. In more isolated communities, limited services were provided by “handy women” trained by district health nurses and by the Newfoundland and Outport Nursing and Industrial Association (NONIA)8 which operated four nursing stations in settlements not usually served by a doctor.9 The IGA also operated nursing stations on the Northern Peninsula, as well as four small hospitals along the coast of Labrador (Battle Harbour, Indian Harbour, North West River) and northern Quebec (Harrington Harbour).10 In many ways, the effective development of health care services in Newfoundland was impeded by the distribution of the population among a large number of remote settlements (known locally as outports) dispersed along the Island’s vast coastline. In 1936, Newfoundland’s 300,000 citizens were located in 1,300 settlements, 526 of which had less than 50 residents; virtually all but a handful had fewer than 200 inhabitants.11 Apart from the practical difficulties this presented in terms of service provision, there was a serious problem attracting and retaining doctors in these remote regions. Indeed, the number of registered doctors in Newfoundland had steadily decreased from 119 in 1911, to approximately 83 practitioners in 1933 (apart from those affiliated with the Grenfell Hospital at St. Antony).12 Outside of St. John’s and the

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hospital towns of Twillingate, Grand Falls, Corner Brook, Buchans and Grand Bank, the remaining 52 doctors were based in less than 5% of the Dominion’s settlements, and most of these doctors were concentrated in areas of the more densely populated Avalon peninsula and northeastern coast. Throughout the vast territories of the Island’s south and west coasts there were only 17 doctors.13 Owing to this small and dispersed population, poverty, and the vagaries of the fishing economy, most areas could not support a doctor on a FFS basis. Beginning in the late 1800s, an indigenous prepayment arrangement was developed between doctors and their patients for physician services. Under this so-called “book” (“blanket” or “contract”) system, each family or single adult paid the doctor an annual fee in return for unlimited medical services.14 As a further incentive to encourage doctors to set up practice in Newfoundland, the government appointed physicians to part-time public health positions and, with the co-operation of the Department of Justice, to magisterial posts in various parts of the Island on conditions that permitted them to engage in private practice in addition to fulfilling their official duties.15 Aggravating the challenge of health service delivery during this period, the health status of Newfoundlanders was also extremely poor. The population was ravaged by malnutrition and disease, especially tuberculosis which was rife on the Island.16 Newfoundland’s infant mortality rate, at 92.7 per 1000 infants, was the highest in the Western world.17 By the late 1920s, it became clear that government action was required to address the health status of Newfoundlanders and the state of the health services. Indeed, there were concerns that the further deterioration of health and welfare services could lead to political unrest, particularly in view of state initiatives to reduce Newfoundland’s debt through the retrenchment of services. This period also saw increasing political unease that eventually culminated into a major riot against the government in 1932.18 THE MOSDELL COMMISSION AND THE SCOTTISH HIGHLANDS AND ISLANDS MEDICAL SERVICE

It was within this context that on 5 February 1929, the Governor of Newfoundland established a “Royal Commission on Health and Public Charities” with a mandate to “investigate, enquire into and report to the Governor on all matters connected with the administration of public moneys provided for the relief and assistance of the poor.”19 Chaired by the physician-politician Dr. H. M. Mosdell (1883-1944),20 Minister without portfolio in the second administration of Sir Richard A. Squires and chairman of the Board of Health, this Commission was principally man-

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dated to review public expenditures on health and public charities, and to assess methods of reducing costs to government. However, the findings of the Mosdell Commission would lay the foundation for the eventual development of a cottage hospital system in Newfoundland. Under Mosdell’s direction, the Commission also undertook a focused assessment of health services, including a review and inspection of local health facilities and a survey of alternative forms of service delivery in other jurisdictions. The latter task was facilitated by a grant from New York’s Rockefeller Foundation to undertake a study tour in the United States and Canada.21 The Commission noted in its report that owing to the assistance of the Rockefeller Foundation, it had “secured to the Commission, knowledge of modern policies and modern legislation with respect to public health and welfare and of efficient and progressive administration in connections with such matters … that has been immense assistance in the making of decisions regarding similar interests in this country.”22 However, it was in Scotland, where the authorities had faced similar challenges in providing health services, that the Commission found applicable models for Newfoundland: the Highlands and Islands Medical Service (HIMS) and Scotland’s cottage hospitals. The Mosdell Commission’s knowledge of the HIMS and Scotland’s cottage hospitals was drawn from the Report of the Dewar Committee (1912)23 which had laid the foundation for the HIMS; a report by the Scottish Board of Health (1927) that detailed the scheme’s subsequent development; and the rules and regulations whereby medical services were provided. These documents were provided by British authorities in response to a cable from the Governor of Newfoundland for information as to “the Medical and Nursing Services conducted in the Highlands and Islands of Scotland by virtue, in large part, of subsidies granted by the Imperial Government.”24 Clearly, Mosdell’s deliberations were profoundly influenced by these documents: The Commission have given most careful attention to the papers so courteously obtained and supplied by His Excellency and are so impressed with the general similarity of conditions in the Highlands and Islands of Scotland to those that obtain in Newfoundland, that they feel it very well worth while to embody in their own report extensive extracts from the reports and papers in question. Similarly they hold that the Government of Newfoundland would be well advised to base its own undertakings in considerable part upon the principles adopted by the authorities in the Old Country, in coping with problems of very similar nature and largely similar extent.25

Established in 1913, Scotland’s HIMS provided a general practitioner service to 285,000 people scattered over 14,000 square miles of the Highlands and Islands, and more precisely, the special administrative area designated as the “Crofting Counties” in the Crofters Holding (Scotland) Act of 1886.26 The service was designed as a means of overcoming the dif-

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ficulties of implementing Britain’s National Health Insurance Act of 1911(NHI) in rural and remote areas of Scotland: a challenge that was in no small part a result of there being an insufficient number of general practitioners.27 Participating doctors received a grant from the HIMS Committee (and after 1929 the Department of Health for Scotland) to subsidize practice expenses, such as transportation, accommodation, and medicines that were customarily provided free to patients. The doctors were under contract to “visit systematically those requiring medical attention, including Poor Law and insured persons, and also to undertake such Public Health duties as may be required” in return for an annual grant.28 For patients not covered under the Poor Law or NHI, doctors were entitled to charge a nominal fee for their services.29 Many of these doctors had access to the area’s so-called cottage hospitals. Cottage hospitals were an important form of health care delivery in rural Britain.30 They differed from the larger voluntary and poor law hospitals in the medical centres of London and Edinburgh, provincial cities and larger towns in that they were much smaller in size; staffed exclusively by general practitioners, as opposed to consultants; and admitted private patients who were required to pay fees (even the poorest patients were required to pay a fee) as opposed to the charitable poor.31 These institutions included ex-dispensaries with in-patient facilities in parts of the south of England, hospitals established in smaller towns and so-called classic “village” hospitals such as the one established at St. Andrews in 1865;32 the latter facilities comprised less than 12 beds, were staffed by general practitioners and tended to be housed in a cottage or similar facility.33 According to Burdet’s 1902 study of the hospitals in Britain, more than 40 cottage hospitals were established in Scotland between 1836 and 1897 with a combined capacity of 600 beds.34 The 1912 Dewar Committee reported that there were 19 cottage hospitals in the Highlands and Islands ranging from 2 to 22 beds with an average of 11 beds.35 While at least one of these facilities had been established and maintained in its entirety through a single private endowment,36 the construction and operation of the vast majority of cottage hospitals in Scotland were financed through a combination of subscriptions and private philanthropy. For example, the construction of the Bignold Hospital at Wick was “gifted” by Sir Arnold Bignold and sustained by local subscriptions and donations.37 By 1935, there were over 600 cottage hospitals throughout the British Isles;38 including institutions of 6-30 beds in the most rural parts of Scotland which comprised 8% of Scotland’s beds.39 In 1929, the year the Mosdell Commission was launched, over 160 doctors employed in 150 practices served with the HIMS, and the recruitment and retention of doctors was no longer an issue. The Mosdell Commission did not describe the terms and conditions of medical

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provision in the HIMS, but simply noted that the Scottish authorities had found it necessary to provide “considerable subsidies to doctors to render medical facilities available to outlying and isolated sections” and that its recommendations for providing medical services in Newfoundland were of a similar nature.40 The Commission subsequently recommended the introduction of salaried Medical Officers of Health (MOHs) in Newfoundland to provide public health services and domiciliary medical services to the poor “at strategic points” in the Dominion.41 In Scotland, the HIMS also facilitated the expansion of the District Nursing Associations which, similar to NONIA in Newfoundland, raised money to support and train a salaried domiciliary nursing service.42 In 1929, 73 District Nursing Associations were being subsidized in Scotland, employing approximately 175 nurses; by 1936 this number had grown to 200. The expansion and incorporation of the nursing service into the structure of general practice proved to be crucial to the success of HIMS and enabled the Crofting Counties to be adequately served with a fewer number of doctors.43 As we shall see, the integration of medical and nursing services was one aspect of the HIMS that appears to have been emulated in the NCHS. The Mosdell Commission’s report quoted the Dewar Committee’s recommendation that “nursing be regarded as an integral part of the medical service” and observed that the particular conditions that the proposed reorganization of the nursing services in Scotland were to address were similar to those studied by the Commission in Newfoundland.44 The Mosdell Commission similarly quoted and discussed in considerable detail the Dewar Committee’s recommendations and plans for the building of more so-called cottage hospitals in Scotland that have occasionally been mistaken for the Commission’s own recommendations pertaining to Newfoundland.45 Specifically, the Dewar Committee noted: (a) That the existing general hospital provision is quite inadequate, even if available in every case to the full extent of its capacity. (b) That there is urgent need of further provision: that such provision should be mainly in the form of cottage hospitals, and for the following special purposes: 1) To bring near to the doctor a distant case requiring frequent visits. 2) To provide for the removal of patients from conditions that render medical treatment largely futile. 3) To reduce the cost and danger of travel entailed in removal from outlying parts to the existing hospitals. 4) To provide a home for the district nurse and a local dispensary for the doctor. (c) That in any scheme proposed for the improvement of hospital services the expediency of subsidizing hospitals on definite conditions should be favourably considered.

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We accordingly recommend that cottage hospitals should be erected at various convenient centres, and of such size as to accommodate from two to four patients, with a nurse and necessary assistance, and provide a local dispensary for the doctor….46

Indeed, while these recommendations pertain to Scotland, the Mosdell Commission maintained that they were “for the most, part, applicable to our own problem.”47 However, Mosdell and his colleagues did not proceed to recommend the construction of similar hospitals for Newfoundland as the established historical accounts suggest. Citing a similar decision by the Dewar Committee,48 the Commission in its Interim Report simply rejected the notion that the centralization of hospital services could constitute a solution to the inadequate provision of care in the outports. Mosdell declared that as a first measure, existing health facilities should be reorganized to improve their efficiency; the Commission could then proceed to study the problem of the hospitalization of minor and emergency cases in the outports, with a particular view of determining to what extent the larger, ‘corporate’ hospitals at Grand Falls, Buchans, Deer Lake and Corner Brook could be utilized to treat public patients. Only then would the Commission be “in a position to recommend to what extent it will be necessary in Newfoundland to make provision for cottage hospitals of a type with a scope similar to those provided in Scotland.”49 Despite the important precedent that the HIMS offered Mosdell, it is important to note that the observations on the Scottish cottage hospitals set out in his Interim Report and the subsequent work that followed in Newfoundland drew simply from a snapshot of the Scottish system that was frozen in time. The Dewar Committee’s recommendation to continue to rely on cottage hospitals and to expand their number was rejected by the HIMS Board shortly after its establishment in 1913; the Board determined that centralization was required in order to develop a modern specialist service. Improvement grants were provided on an ad hoc basis only to those existing hospitals that were large enough to support a consultant service.50 Very limited funding was made available for the Dewar Committee’s recommendation to provide financial assistance to existing cottage hospitals, although beginning in 1916 funding was provided to some institutions to prevent their closure.51 War-time conditions initially precluded hospital extension, but during the 1920s, general practitioner and nursing services were prioritized at the expense of other elements of the HIMS, although grants were provided for an expansion of the Lewis Hospital in1926.52 When the HIMS turned its attention to the hospital services in 1929, it was decided that all new funding should be devoted to extending the specialist services.53 This decision was made despite reports that many Scottish Islands needed small cottage hospitals to obviate the need for patients to undertake

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dangerous sea journeys when they required hospitalization.54 Thus the additional cottage hospitals envisaged by the Dewar Committee and referred to in the Mosdell Commission’s Interim Report were never built. The HIMS was eventually absorbed by the British National Health Service (NHS) established in 1948. It should also be noted that both the term and concept of “cottage” hospitals was not unique to Newfoundland and the British Isles, as much of the historiography of the NCHS suggests. In the Dominion of Canada, for example, beginning in 1898, the Victorian Order of Nurses (VON) established 44 so-called “cottage” hospitals in remote and isolated areas throughout Canada.55 Similar facilities were established in rural Canada by the Canadian Red Cross and churches.56 Comparable institutions were established in the United States.57 The Mosdell Report did not mention the existing cottage hospitals in the United States, Canada, Labrador and the short-lived cottage hospital established at Pilley’s Island, Newfoundland in 1911 under the auspices of the Grenfell Association.58 Nor did the Commission reference Grenfell’s proposal for a similar facility in the Bay of Islands in the context of the 1909 election pledge of Sir Edward Morris, to establish a cottage hospital system.59 However, the Commission did note the Reid brothers’ abortive plans of 1912 to build a series of cottage hospitals in the outports of Newfoundland for the treatment of tuberculosis patients.60 Thus the idea of establishing some form of small, community-based or cottage hospital system in Newfoundland appears to have pre-dated the Mosdell Commission. The Mosdell Commission tabled its Interim Report in 1930 amidst a severe and growing debt and economic crisis. The Squires government subsequently introduced legislation to reorganize the administration of health and welfare services on the Island. In 1931, the Newfoundland legislature passed An Act Respecting Public Health and Welfare, Section 8, which created a Department of Public Health (and a separate Department of Welfare); both departments were supervised by a Bureau of Health and Welfare. However, lack of funds prohibited the reorganization of the health services in accordance with the Act and no new health programming was introduced as the government sought to reduce public expenditure in order to meet the conditions set by the banks for further loans to finance Newfoundland’s debt. Increases in custom duties, including essential food items, and reductions to war veterans’ pensions prompted the resignation of Dr. Mosdell from the Squires Cabinet and the Bureau of Health and Welfare on 23 March 1932.61 In this context, the Mosdell Commission did not complete its review of provincial health programs and submit a final report. The further consideration of the development of a cottage hospital system for Newfoundland was put on indefinite hold. The challenges facing rural health care in Newfoundland, however,

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could not be avoided. The idea of establishing cottage hospitals in the outports was raised again in 1933 by the Royal Commission on Newfoundland which was appointed on 17 February 1933 under pressure from Canada and Great Britain to consider Newfoundland’s economic and financial crisis.62 Chaired by first Baron Amulree, a Scottish Labour Peer, the Amulree Commission in its report identified the following weaknesses in the health services that they declared any new government should seek to remedy: 1) An overlapping of services in St John’s 2) The absence of a preventive Public Health Service 3) The lack of adequate medical facilities in the Outports 4) The decline in the number of nursing centres in the Outports.63

In terms of the latter two deficiencies, the Amulree Commission noted that “in view of the distances which patients have to travel there is room in many parts of the coast for the establishment of small hospitals of the ‘Cottage Hospital’ type.”64 Amulree’s principal conclusion was that Newfoundland’s government should be “suspended until such time as the Island may become self-supporting again” and that the Legislature and Executive Council be replaced by an unelected “Commission of Government” appointed by the United Kingdom.65 These proposed actions were among the main features of the Amulree Commission’s recommended “joint plan of reconstruction” which, as we shall see, would eventually include the establishment of cottage hospitals. FROM CONCEPT TO ESTABLISHMENT: THE COMMISSION OF GOVERNMENT YEARS

With the establishment of the appointed Commission of Government66 on 16 February 1934, a new opportunity arose to consider the benefits and costs of the development of a cottage hospital system within a larger program of economic and social reform.67 As Peter Neary notes, “for the Commission to be credible, it was acknowledged in London, something would have to be done … Not surprisingly, improvement in health care loomed large in the thinking of the Commission of Government.”68 On 16 February 1934, Mr. (later Sir) John C. Puddester (1881-1947)69 was appointed Commissioner with responsibility for the Department of Public Health and Welfare; Dr. Mosdell was appointed Secretary. Based on the general recommendations of the Amulree Commission and new funding from Whitehall, work immediately began on the development of a new hospital scheme. Early in its work, the Commission of Government rejected the notion of centralizing the provision of health services throughout the Island. It determined that the cost of expanding existing facilities to treat the entire population would be far

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greater than constructing a series of cottage hospitals in the outports as recommended by the Amulree Report. In a memo to Commissioner Puddester, Mosdell declared that the development of a decentralized scheme of small hospitals would cost less than 15% of the expenditure necessary to expand the larger “general hospitals” of St. John’s and other larger centres and to ensure that these hospitals adequately met the needs of the people. Mosdell further noted that, even if such an extension occurred, the problem of transporting patients remained.70 In December 1934, the Commission of Government announced its plans to establish a cottage hospital system in Newfoundland with a mandate to “serve practical and progressive purposes; more specifically such hospitals: a) will provide a suitable and well-equipped home for a district nurse; b) will increase available hospital facilities by almost 100 beds; c) will bring such advantages to the neighbourhoods of the people served; and d)will ensure prompt and adequate treatment of conditions classed as minor, and which at present would have no chance of admission to a hospital at St. John’s.”71

The Island was subsequently divided into 18 cottage hospital districts. Central communities in each region were selected for the construction of hospitals. The first cottage hospital was established in Old Perlican in 1936. By the time Newfoundland joined Confederation in 1949, 15 cottage hospitals had been constructed on the Island. Notably, the new cottage hospital system did not cover Labrador or the coast of northern Newfoundland for which the Commission of Government and successive Newfoundland governments relied on the IGA for service provision, until its health care activities were taken over by the province in 1978.72 According to Brown, the name “cottage hospital” was deliberately adopted from “the hospitals in the Scottish Highlands and Islands Medical Service, in the hope that this would lead to better funding from the UK government.”73 Although the Scottish cottage hospitals were cited as the principal model for the Newfoundland system, the scheme differed in significant ways. First, the Newfoundland cottage hospitals were governmentowned, albeit with a great deal of local involvement. In order to economize, communities were obliged to volunteer land, labour and building materials.74 These requirements contributed to a strong feeling of community ownership despite the fact that these institutions were owned and maintained by the Department of Public Works.75 In addition, the government set up local hospital boards to assist in administration and staffing, and for the collection of premiums, thus reducing the obligations of the public service in the administration of the hospitals. Indeed, in the early post-Confederation period, the Government of Newfoundland was able to finance 40% of the operating costs from the collection of

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premiums.76 The comparatively large government expenditure for the operation of the cottage hospitals in Newfoundland is a second characteristic that distinguished these institutions from their Scottish counterparts. As noted above, very little financial assistance was provided by the authorities to the cottage hospitals in Highlands and Islands. Third, rather than converting existing buildings into hospitals, the origins of many British and VON cottage hospitals, the Commission of Government designed its own facilities. As Crellin notes, this policy was expedient for it is unlikely that suitable facilities for conversion would have been found in any of the outports that were considered for a hospital.77 Despite these differences, there were important similarities between the NCHS and both the Scottish cottage hospitals and the HIMS. First, the original cottage hospitals established by the Commission of Government were relatively small facilities containing between 10 and 30 beds.78 As noted above, in 1935 the cottage hospitals in the most rural areas of Scotland had a capacity between 6 and 30 beds. Second, patients paid an annual fee to use the facilities—as was practiced in some cottage hospitals in the UK affiliated with contributory schemes that collected fees via payroll deductions or house collections.79 The annual premium, set at $5 per family in 1936, entitled patients to “free” hospital, nursing, and medical care at the local cottage hospitals, as well as access to specialist services in the General Hospital in St. John’s upon referral.80 As noted above, a similar arrangement existed in Newfoundland for the payment of medical services in the so-called “book system.” Third, similar to the HIMS, doctors received the bulk of their income directly from the state, albeit through a salary as opposed to an annual grant. Fourth, the domiciliary nursing service established by the Commission of Government to take over the voluntary activities of NONIA was similar to the District Nursing Associations subsidized by the HIMS, integrated with the medical service provided by the NCHS. Martin suggests that the Commission of Government ought to have followed the lead of the International Grenfell Association and concentrated more of its efforts and resources on establishing nursing stations rather than on physician-staffed cottage hospitals.81 Crellin identifies the difficulty of recruiting nurses and the growing recognition of the benefits of modern hospital medicine as likely factors in this policy decision.82 The perceived importance of hospital medicine would have been reinforced in Commission of Government thinking by the reversal of the HIMS policy of increasing the number of Scottish cottage hospitals in favour of centralization and larger facilities in order to better realize the advance of hospital medicine. Martin’s aforementioned criticism and the scholarly focus on the doctors who served in cottage hospitals appear to have overshadowed how much the Commission of Government’s plans for rural health care emphasized the role of nurses as a result of the

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difficulties of attracting doctors. Similar to the HIMS, the Commission of Government had considerable success in recruiting nurses.83 Ultimately, the NCHS drew upon a number of influences, including both the Scottish health services and the local medical traditions of Newfoundland. But many of its characteristics were the result of the specific circumstances and directives of the Commission of Government, namely to minimize the requirement for government intervention in the area of health through the requirement for community participation in the construction, operation and financing of the hospitals. The annual fee of $5 per year was significant in a period when social assistance payments—otherwise known as “the dole”—were but $0.65 per day.84 This policy guideline of minimizing direct government intervention fit well with the general objectives of the Commission of Government to reduce expenditures and the public debt; while at the same time, the new hospital system provided an element of legitimacy to the non-democratic regime. This became an issue of critical importance following the protests of May 1935 for better social programming by the St. John’s Committee for the Unemployed. THE TWILLINGATE PLAN

As several scholars have suggested, the development of the NCHS was also influenced by a prepayment plan introduced in 1934 at Notre Dame Bay Memorial Hospital in Twillingate.85 To avert the closure of the hospital as a result of a reduction to the institution’s annual hospital grant, the facility’s newly appointed American medical director introduced an innovative hospital and medical services plan. Dr. John Olds’ scheme had two components. First, a plan for the area’s wealthy residents (e.g. merchants) was implemented, whereby for a $10 annual fee, a family received unlimited medical, hospital, and surgical care. A second “community” or “blanket contact” was based on population, whereby Notre Dame Bay and its environs were organized into districts and hospital committees with the responsibility for raising funds equivalent to $44 per hundred people in any one district; residents paid a flat rate of $0.44 for unlimited medical and hospital care and received a 50% reduction for surgical operations.86 Olds did not reveal his sources of inspiration for his plan that provided hospital and medical care to 20,000 residents. According to his own account of the establishment of the Twillingate scheme, Olds came up with the idea during his return voyage to Twillingate from an unsuccessful trip to St. John’s to persuade the government to restore funding to the Notre Dame Bay Hospital.87 J. T. H. Connor suggests that Olds may have been motivated by the Farmers’ Union Hospital Association co-operative of Elk City, Oklahoma, established during the early Depres-

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sion, but more likely the teachings and activism of Dr. Henry Sigerist (1891-1957),88 physician-historian at his alma mater Johns Hopkins University medical school.89 Sigerist was a leading proponent of so-called socialized medicine in the United States and Canada, and had a particular interest in rural health care. However, the concept of universal medical and hospital services plan at Twillingate appears to have existed long before Olds arrived on the Island and subsequently introduced his scheme. Indeed, the idea appears to have originated with Olds’ predecessor Charles E. Parson, medical director of Notre Dame Bay Memorial Hospital (1924-34), who declared in his first hospital report in the “Twillingate Sun” that “there are enough people in Twillingate and Fogo districts so that if every person gave fifty cents a year to the hospital we might go ahead confidently whether he might be able to pay or not.”90 The Twillingate plan operated until it was superseded by the institution of Canada’s national Medicare system in 1969. THE COTTAGE HOSPITAL SYSTEM AND NATIONAL HOSPITAL INSURANCE

After Confederation, the government of Premier Joey Smallwood continued the policy of state ownership of hospital facilities, and with the assistance of federal National Health Grants constructed or acquired additional cottage hospitals. By 1956, 47% of the population was covered by the NCHS.91 Thus Newfoundland and Labrador were well positioned to take advantage of the Hospital Insurance and Diagnostic Services Act (1957) that provided cost shared funding to provinces with their own hospital insurance plans.92 More significantly, by virtue of the cottage hospital system, the Government of Newfoundland had a vested interest in, and was a public supporter of, federal assistance for universal, tax-supported public hospital insurance. As noted by Boychuk, the Governments of Saskatchewan, Alberta, British Columbia, and Newfoundland served “as the principal counterweight to the withering allure of compulsory hospital insurance among the six provinces where employment-based health plans were becoming the dominant force in hospital finance.”93 The Government of Newfoundland was one of six provinces which declared their intention to participate in the federal program along with the three western-most provinces, Ontario and Prince Edward Island to fulfill the federal cabinet’s requirement that a majority of provincial governments representing a majority of the Canadian population endorse a hospital insurance scheme before it would back the federal hospital insurance plan of Paul Martin Sr.94 Newfoundland was thus among the six recipients when in July 1958, the new Progressive Conservative Government issued its first hospital insurance contributions.95 Similar to other Canadian provinces, the introduction of universal hospital insurance was welcomed by organized medicine in New-

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foundland, whereas the build-up to and implementation of Medicare involved considerable debate and conflict. In Newfoundland, much of this conflict concerned the continuation of salaried medical practice. THE COTTAGE HOSPITAL SYSTEM AND PHYSICIAN REMUNERATION

While the foregoing sections of this paper have sought to describe the history and operational context of the NCHS, it is important to note that one of the most controversial characteristics of this system was the employment of physicians on a straight salary. This payment method was an on-going point of friction between organized medicine and the Government of Newfoundland and Labrador. Initially, annual salaries were based on a percentage of the fees collected in a district plus a stipend from the government; doctors were also permitted to collect fees for non-contract services.96 Standard salary scales were subsequently introduced after 1956. Salaried physicians employed at cottage hospitals were later barred from private practice,97 although this restriction appears to have been lifted to appease the Newfoundland Medical Association (NMA) which recommended that doctors be paid on a combined a FFS basis and government subsidy.98 This position was supported by the Royal Commission on Health, chaired by Lord Russell Brain, who investigated health care in Newfoundland at the invitation of Premier Smallwood in the years leading up to Medicare. The Brain Commission recommended FFS in its final report of 1966 based on the belief that this method would attract more doctors; in contrast, the Deputy Minister of Health Leonard Miller argued that the retention of medical personnel would be improved by the introduction of pensions, more holidays, and more opportunity for post graduate study.99 The private practice of cottage hospital doctors appears to have increased over the years. G. Harvey Agnew notes in his description of the scheme in the late 1960s that “many of the physicians, however, engaged in private practice and spent only a portion of their time in the hospital.”100 To deter a mass exodus of salaried doctors to FFS practice with the introduction of Medicare in 1969, the Department of Health offered increases in salary, study leave, and pensions.101 These efforts suggest that FFS was indeed viable in some areas of Newfoundland, yet with certain incentives, doctors were willing to work on a salaried basis. In 2004, 40% of Newfoundland’s physicians were paid on salary, one of the obvious legacies of the NCHS.102 CONCLUSION

The received historical wisdom has been that the Newfoundland cottage hospital system was modeled on the Highlands and Islands Medical

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Service (HIMS) and the Scottish cottage hospitals in particular. The HIMS was essentially a primary health care scheme. The cottage hospitals envisaged by the architects of the HIMS and which inspired the Mosdell Commission were never established in Scotland. While the Newfoundland cottage hospitals may have been inspired by the existing Scottish institutions, they differed considerably in terms of ownership, financing and construction. These differences were the result of practical considerations, the legacy of local forms of health care financing and delivery pre-dating the NCHS, and the particular conditions of 1930s Newfoundland. Moreover, while the HIMS provided a model for the provision of state-financed medical and nursing care in an isolated and thinly populated area, the NCHS was also clearly influenced by, and consistent with, pre-existing local prepayment schemes in Newfoundland such as the ‘book system’ and the Twillingate Plan. The NCHS laid an important foundation for government engagement in the provision of publicly funded health care services and in turn the achievement of National Hospital Insurance in Canada. ACKNOWLEDGMENTS

The authors wish to thank Greg Marchildon, John Stewart, Edward Tompkins, and two anonymous reviewers for their comments on an early draft of this article. We also wish to thank Megan Davies for lending us her copy of the minutes and evidence of the Dewar Committee. Some of the research for this article was presented at the Society for the Social History of Medicine Annual Conference 2008 in Glasgow, UK, 3-5 September 2008, in a paper entitled “The Highlands and Islands Medical Service: The Model for Newfoundland’s Cottage Hospital System?”. NOTES 1 The Dominion of Newfoundland, which constituted the territory of Labrador and the Island of Newfoundland, joined Canada on 1 April 1949. During the 1930s and 1940s, Newfoundland was recognized as a separate Dominion of the British Commonwealth associated with the Dominions Office of Great Britain. 2 Between 1936 and 1952, 14 cottage hospitals were constructed. An additional nine hospitals were acquired or built after 1952. John Martin, Leonard Albert Miller, Public Servant (Markham: Associated Medical Services Inc. & Fitzhenry and Whiteside, 1998), p. 131-32. 3 Terry Boychuk, The Making and Meaning of Hospital Policy in the United States and Canada (Ann Arbor: University of Michigan Press, 1999), p. 108. 4 There is no universally accepted terminology to describe Newfoundland’s cottage hospitals and the services that they provided. These institutions and services are referred to as a Newfoundland Cottage hospital “system” “scheme,” or “plan” in the historiography of Newfoundland and the health services. See for example, Peter Neary, Newfoundland in the North Atlantic World: 1929-1949 (Kingston: McGill-Queens University Press, 1988), p. 52; Martin, Leonard Albert Miller, p. 119; Christina Bates, Dianne Dodd, and Nicole Russeau, On All Frontiers: Four Centuries of Canadian Nursing (Ottawa:

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University of Ottawa Press, 2005), p. 6; Linda Kealey and Heather Molyneaux, “On the Road to Medicare: Newfoundland in the 1960s,” Journal of Canadian Studies, 41, 3 (Fall 2007): 90-111; and Malcolm G. Taylor, Health Insurance and Canadian Public Policy: The Seven Decisions That Created the Canadian Health Insurance System (Montreal: McGill-Queen’s University Press, 1978), p. 170. Greg Marchildon, Health Systems in Transition: Canada (Copenhagen: WHO Regional Office for Europe on behalf of the European Observatory on Health Systems and Policies, 2005), p. 19; Boychuk, The Making and Meaning of Hospital Policy, p. 41-42, 76-77. C. David Naylor, Private Practice, Public Payment: Canadian Medicine and the Politics of Health Insurance, 1911-1966 (Kingston and Montreal: McGill-Queens University Press, 1986), p. 33, 50-1, 244-46. See for example, Kealey and Molyneaux, “On the Road to Medicare,” p. 95; and John K. Crellin, A Social History of Medicines in the Twentieth Century (New York: Pharmaceutical Products Press, 2004), p. 14. Royal Commission on Newfoundland, Report (St. John’s: King’s Printer, 1933), chap. 10, “medical services” (para. 492); and Leonard Miller, “The Cottage Hospital Plan in Newfoundland,” NMA Newsletter, Special Issue (1974): 25. NONIA was established in 1920 to finance and deliver nursing services to the outports of Newfoundland. The organization financed its operations through the manufacture and sale of clothing hand-knit by the women of these communities using materials sourced in Great Britain. In 1934, NONIA’s nursing functions were transferred to the Department of Public Health and Welfare; the industrial operations were maintained and continue to this day. http://www.nonia.com/history.htm. Accessed 24 February 2008. Royal Commission on Newfoundland, Report, (para. 594). On the International Grenfell Association, see Ronald Rompkey, Grenfell of Newfoundland: A Biography (Toronto: University of Toronto Press, 1991); The Labrador Memoir of Dr. Harry Paddon, 1912-1938 (Montreal and Kingston: McGill-Queen’s University Press, 2005); Martin, Leonard Albert Miller, ‘The International Grenfell Association,” chap. 13, p. 104-11; and C. Short, “Cod And God: Dr. Wilfred Grenfell in Newfoundland,” Journal of the Royal College of Physicians of Edinburgh, 37 (2007): 181-88. Newfoundland Commission of Government, Annual Report of 1936 (St John’s: Kings Printer, 1937), p. 8. N. Rusted, Medicine in Newfoundland c. 1497 to the early 20th Century (St. John’s: Faculty of Medicine, Memorial University of Newfoundland, 1994), p. xiv; R. A. MacKay, ed., Newfoundland: Economic, Diplomatic and Strategic Studies (Toronto: University of Oxford, 1946), p. 173-74; and Royal Commission on Newfoundland, Report, (para. 593). Royal Commission on Newfoundland, Report, (para. 593). Martin, Leonard Albert Martin, p. 119; John K. Crellin, The Life of a Cottage Hospital: The Bonne Bay Experience (St. John’s: Flanker Press, 2007), p. 23; and Crellin, A Social History of Medicines, p. 14. L. E. Keegan, “Medical History of Newfoundland,” in J. R. Smallwood, ed., Book of Newfoundland (St. John’s: Newfoundland Book Publishers, 1937), p. 118; and Royal Commission on Newfoundland, Report, (para. 596, 599). E. House, Light at Last: Triumph over Tuberculosis in Newfoundland and Labrador, 1900-1975 (St. John’s: Jesperson Press, 1981); and John K. Crellin, The White Plague in Newfoundland: Medical and Social Issues, c. 1900 to 1970 and Beyond (St. John’s: Memorial University of Newfoundland, 1992). Mary Taylor, “A Far Sited Excursion into Socialized Medicine or a Bureaucratic Perversion of Medical Practice: Newfoundland’s Cottage Hospital System 1934-1949,” Honours thesis, Memorial University of Newfoundland, 1984, p. 10. See Jeff Webb, “Collapse of Responsible Government, 1929-1934” (2001: Memorial University of Newfoundland) for a concise history of the events leading up to, and a description of the riot. http://www.heritage.nf.ca/law/collapse_responsible_gov .html. Accessed 7 April 2008. Royal Commission on Health and Public Charities, Interim Report (St. John’s: King’s Printer, 1930), p. ii.

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20 On Mosdell, see Robert H. Cuff, Melvin Baker, and Robert D. W. Pitt, eds., Dictionary of Newfoundland and Labrador Biography (St. John’s: Harry Cuff Publications, 1990), p. 236; and Encyclopaedia of Newfoundland and Labrador, Vol. 3, p. 628-29. 21 Royal Commission on Health and Public Charities, Interim Report, p. 6. 22 Royal Commission on Health and Public Charities, Interim Report, p. 6. 23 The Dewar Committee had been established to consider “how far the provision of medical attention in districts situated in the Highlands and Islands of Scotland is inadequate and to advise on the best method of securing a satisfactory medical service therein.” Report of the Highlands and Islands Medical Service Committee (Dewar Report), Cd. 6559, (1912). For a detailed analysis of the evidence gathered by the Dewar Committee, see Megan J. Davies, “Rural Medicine in the Scottish Highlands and Islands before 1939,” Canadian Society for the History of Medicine, 2002, unpublished manuscript. 24 Royal Commission on Health and Public Charities, Interim Report, p. 9. 25 Royal Commission on Health and Public Charities, Interim Report, p. 9. 26 Morrice McCrae, The National Health Service in Scotland: Origins and Ideals (East Lothian, Scotland: Tuckwell Press, 2003), p. 14-15. 27 McCrae, The National Health Service in Scotland, p. 1-4. On the history of the Highlands and Islands Medical Service, see McCrae, The National Health Service in Scotland, “The Highlands and Islands Medical Service,” chap. 1, p. 1-29; Jacqueline Jenkinson, Scotland’s Health: 1919-1948 (Oxford: Peter Lang, 2002), p. 123-31, 412-13; Sir John Brotherston, “The Development of Public Medical Care: 1900-48” in Gordon McLachlan, ed., Improving the Common Weal: Aspects of the Scottish Health Services, 1900-1984 (Edinburgh: Edinburgh University Press, 1987), p. 53-55; A. Shearer, “The Highlands and Islands Medical Service: What It Is, and What It Has Done,” Public Administration, 9, 2 (1931): 161-75; David Hamilton, “The Highlands and Islands Medical Services,” in McLachlan, ed., Improving the Common Weal, p. 483-90; “The Early History of the Highlands and Islands Medical Scheme,” Scottish Medical Journal, 24, 1 (1979): 64-68; and The Healers: A History of Medicine in Scotland (Edinburgh: Cannongate, 1981), p. 246-52. 28 Quoted in McCrae, The National Health Service in Scotland, p. 15. 29 The National Health Insurance Act of 1911 established a free general medical service for working-class patients in the United Kingdom who earned less than £160 per annum. The scheme was financed by tripartite payments from the insured, employers, and the state. Dependents and children were excluded. Participating general practitioners were remunerated by capitation. See Anne Digby, The Evolution of British General Practice, 1850-1948 (Oxford: Oxford University Press, 1999), p. 307. 30 On the cottage hospitals in Britain see Steven Cherry, “General Practitioners, Hospitals and Medical Services in Rural England: The East Anglia Region c. 1800-1948,” in Joseph L. Barona and Steven Cherry, eds., Health and Medicine in Rural Europe (1850-1945) (Valencia: Seminari d’Estudis sobre la Ciccia, Universitat de Valencia, 2005), p. 171-94; Cherry, “Change and Continuity in the Cottage Hospitals c. 1859-1948: The Experience in East Anglia,” Medical History, 36 (1992): 271-89; and M. Emrys Roberts, The Cottage Hospitals 1859-1990 (Motcombe: Tern Publications, 1991). 31 Cherry, “General Practitioners, Hospitals and Medical Services in Rural England,” p. 184; and “Change and Continuity in the Cottage Hospitals,” p. 274. 32 Steve Cherry, Medical Services and the Hospitals in Britain: 1860-1939 (Cambridge: Cambridge University Press, 1996), p. 37. 33 Cherry, “Change and Continuity in the Cottage Hospitals,” p. 272-73. 34 John Kinnaird, “The Hospitals,” in McLachlan, ed., Improving the Common Weal, p. 216; and Sir H. Burdett, Burdett’s Hospitals & Charities (London, 1902), p. 537, 559. 35 Kinnaird, “The Hospitals,” p. 222. 36 The Lawson Memorial Hospital (1901), Golspie, Scotland, with a capacity of 10 beds, was established and endowed by Mr. Alexander B. Lawson of Clynelesh. Testimony of Dr. James Bertie Simpson (8 October 1912), Minutes of Evidence taken before the Committee on Medical Service in the Highlands and Islands of Scotland, p. 187 (para 8724-25); and Jane E. Benson, “Community Hospital History Project” (May 2006) Centre for Rural Health Research Policy, University of Aberdeen, p. 10. http://abdn.ac.uk:8080/crh/

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documents/CommunityHospitalHistoryProjectFinalReport.pdf. Accessed 23 February 2008. Davies, “Rural Medicine in the Scottish Highlands,” p. 14; and Testimony of Mr. George Dick (23 August 1912), Minutes of Evidence, p. 107. Cherry, “General Practitioners, Hospitals and Medical Services in Rural England,” p. 184. McCrae, The National Health in Scotland, p. 172-73. Royal Commission on Health and Public Charities, Interim Report, p. 18. Royal Commission on Health and Public Charities, Interim Report, p. 18. Hamilton, “The Highlands and Islands Medical Services,” p. 481. McCrae, The National Health Service in Scotland, p. 17-18, 21. Royal Commission on Health and Public Charities, Interim Report, p. 18. See for example, Crellin, The Life of a Cottage Hospital, p. 6. Report of the Highlands and Islands Medical Service Committee (Dewar Report), Cd. 6559. (1912) Quoted in Royal Commission on Health and Public Charities, Interim Report, p. 21-22. Royal Commission on Health and Public Charities, Interim Report, p. 22. Royal Commission on Health and Public Charities, Interim Report, p. 21. Royal Commission on Health and Public Charities, Interim Report, p. 22-23. McCrae, The National Health Service in Scotland, p. 18. Hamilton, “The Highlands and Islands Medical Services,” p. 487. Jenkinson, Scotland’s Health: 1919-1948, p. 126-27. McCrae, The National Health Service in Scotland, p. 19. Jenkinson, Scotland’s Health: 1919-1948, p. 128. The first VON “cottage” hospital was established in Regina in 1898. The administration of these facilities was gradually transferred to the local communities in which they resided and became so-called municipal hospitals. http://www.von.ca/about_history.html. Accessed 24 February 2008; and Jean E. Dryden, “Victorian Order of Nurses,” The Canadian Encyclopedia, http://www.the canadianencyclopedia.com/index.cfm?PgNm= TCE&Params=A1ARTA0008363. Accessed 24 February 2008; and Sheila Penney, Victorian Order of Nurse for Canada: A Century of Caring, 1897-1997: The History of the Victorian Order of Nurses for Canada (Ottawa: Victorian Order of Nurses, 1999), p. 33-36. Kathy Hardhill, “From the Grey Nuns to the Streets: A Critical History of Outreach Nursing in Canada,” Public Health Nursing, 24, 1 (2007): 92. Crellin, A Social History of Medicines, p. 14; and Henry C. Burdett, Cottage Hospitals: General, Fever and Convalescent: Their Progress, Management and Work in Great Britain and Ireland and the United States of America (London: Scientific Press, 1896). Rompkey, Grenfell of Newfoundland, p. 168-70. We are grateful to Edward Tompkins for bringing this text and relevant pages to our attention. Rompkey, Grenfell of Newfoundland, 169-70. Martin, Leonard Albert Miller, p. 121. Royal Commission on Health and Public Charities, Interim Report, p. 112. The Reid Brothers’ plans for the establishment of cottage hospitals were interrupted by World War I although the government did use their donation of $100,000 to provide services to tuberculosis patients. See “Hospitals,” in the Encyclopedia of Newfoundland and Labrador (St. John’s: Newfoundland: Newfoundland Book Publishers, 1984) Vol. 2, p. 1047. See Melvin Baker, “The Second Squires Administration and the Loss of Responsible Government 1928-1934,” (1994). www.ucs.mun.ca. Accessed 7 April 2008. The Royal Commission on Newfoundland was chaired by Barron Lord Amulree (a Scottish Labour peer), Charles McGrath (nominated by the Government of Canada) and Sir William Stavert (a Canadian banker nominated by the Government of Newfoundland). The report of the Commission was published in November 1933. On the Amulree Commission, see J. Overton, “Poverty, Dependence and Self Reliance: Politics, Newfoundland History and the Amulree Report of 1933,” in G. Fizzard, ed., Amulree’s Legacy: Truth, Lies and Consequences (St. John’s: The Newfoundland Historical Society, 2001), p. 47-73. Royal Commission on Newfoundland, Report, (para 595).

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64 Royal Commission on Newfoundland, Report, (Para 600). 65 Royal Commission on Newfoundland, Report, (para 634). 66 The establishment of the Commission of Government resulted in the suspension of responsible government in Newfoundland. Three of the Commission’s members were from Britain, and three were from Newfoundland. The Governor of Newfoundland acted as chair, and all Commissioners decided upon measures and initiatives that were ultimately signed into law by the Governor. Jeff Webb notes that, “Newfoundland remained a dominion in name, and continued to be a responsibility of the Dominions Office in London, but its constitution was now similar to those in force in the empire’s Crown colonies. Though the Commission was Newfoundland’s government, its powers were circumscribed: in practice it needed permission from the Dominions Office for any major policy initiative, including the budget.” See Jeff Webb, “The Commission of Government, 1933- 1949,” in Government and Politics Biography (2001: Memorial University of Newfoundland). www.heritage.nf.ca/law/commission_gov.html. Accessed 24 February 2006. See also Richard Leon Clark, Newfoundland 1934-1949—A Study of the Commission of Government and Confederation with Canada, PhD thesis, University of California, 1951. 67 For an account of the events which led to the establishment of the Commission of Government and an evaluation of its major policies, see Peter Neary, Newfoundland in the North Atlantic World: 1929-1949 (Kingston: McGill-Queens University Press, 1988). 68 Peter Neary, “Venereal Disease and Public Health Administration in Newfoundland in the 1930s and 1940s,” Canadian Bulletin of Medical History, 15 (1998), p. 131. 69 On Puddester, see Cuff et al., eds., Dictionary of Newfoundland and Labrador Biography, p. 280. 70 Taylor, “Newfoundland’s Cottage Hospital System 1934-1949,” p. 26-27. 71 Department of Health and Welfare, GN38 56-1-1, File 26, “Report on Activities Since 1935,” p. 6; and quoted in Taylor, “Newfoundland’s Cottage Hospital System,” p. 22. 72 The Commission of Government formally recognized the IGA’s responsibility for delivering health services in Labrador, along the coast of northern Newfoundland south to Port Saunders in the Strait of Belle Isle and south to Point St. John in White Bay. A small grant-in-aid that had been discontinued in 1932 was reinstated to supplement the IGA’s endowment and fund-raising activities. See Neary, Newfoundland in the North Atlantic World, p. 53; Martin, Leonard Albert Miller, p. 31; and Rompkey, Grenfell of Newfoundland, p. 274. 73 Malcolm C. Brown, “Public Finance of Medical and Dental Care in Newfoundland— Some Historical and Economic Considerations,” Journal of Social Policy, 10, 2 (1981): 213; and quoted in Stephen M. Nolan, A History of Health Care in Newfoundland and Labrador (St. John’s: Newfoundland and Labrador Health and Community Services Archive and Museum, 2004), p. 160. 74 As a condition for the construction of a hospital, the Commission of Government stipulated that “residents of the locality must provide without charge a site for the construction of any Cottage Hospital where a suitable one is not available on Crown Land. An area of at least 4 acres is required…. During the course of construction every able bodied man is expected to contribute voluntary labour to the greatest extent possible and to cooperate by all available means in keeping down building costs….” Public Archives of Newfoundland and Labrador (PANL) Department of Public Health and Welfare, GN 38, S6 1 1, File 5. Letter, H. H. Mosdell to Commissioner of Public Health and Welfare, 5 February 1935. 75 Crellin, The Life of a Cottage Hospital, p. 19. 76 Martin, Leonard Albert Miller, p. 123. 77 Crellin, The Life of a Cottage Hospital, p. 3. 78 Jenny Higgins, “Health Care under the Commission Government,” Newfoundland and Labrador Heritage Web Site (2007: Memorial University of Newfoundland) http://www.heritage.nf.ca/law/health_care.html. Accessed 17 August 2008.

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79 Steve Cherry, “Beyond National Health Insurance. The Voluntary Hospitals and Contributory Schemes: A Regional Study,” Social History of Medicine, 5, 3 (1992): 455-82; and Martin Gorsky, “Hospital Governance and Community Involvement in Britain: Evidence from before the National Health Service” (February 2006). http://www.historyandpolicy.org/papers/policy-paper-40.html. Accessed 24 February 2008; and Martin Gorsky, John Mohan, Tim Willis, Mutualism and Health Care: British Hospital Contributory Schemes in the Twentieth Century (Manchester: Manchester University Press, 2006). 80 There were additional fees for maternity cases and dental extractions. See Martin, Leonard Albert Miller, p. 122. 81 Crellin, The Life of a Cottage Hospital, p. 6; and Martin, Leonard Albert Miller, p. 122. 82 Crellin, The Life of a Cottage Hospital, p. 6. 83 The Nursing Service grew from 8 to 54 nurses between 1934 and 1936. See Neary, Newfoundland in the North Atlantic World, p. 52. 84 The annual premium of $5 per family introduced in 1936 gradually increased to $15. Higher amounts were charged in larger centres. Single adults paid half the family premium. See Martin, Leonard Albert Miller, p. 123. 85 J. H. T. Connor, “Twillingate: Socialized Medicine, Rural Doctors and the CIA,” Newfoundland Quarterly, 100, 1, Issue 424 (2007). http://www.newfoundlandquarterly .ca/issue424/twillingate.php. Accessed 24 February 2008. See also Gary L. Saunders, Dr. Olds of Twillingate: Portrait of an American Surgeon in Newfoundland (St. John’s: Breakwater, 1994). 86 Saunders, Dr. Olds of Twillingate, p. 101. 87 Saunders, Dr. Olds of Twillingate, p. 98-99. 88 On Sigerist, see Jacalyn Duffin and Leslie A. Falk, “Sigerist in Saskatchewan: The Quest for Balance in Social and Technical Medicine,” Bulletin of the History of Medicine, 70 (1996): 658-83; and Jacalyn Duffin, “The Guru and the Godfather: Henry Sigerist, Hugh MacLean and the Politics of Health Care Reform in 1940s Canada,” Canadian Bulletin of Medical History, 9 (1992): 191-218. 89 Connor, “Twillingate.” 90 Charles E. Parson, “N. D. B. Memorial Hospital: Facts in Connection with its maintenance, an appeal for Assistance,” Twillingate Sun, 14 October 1924. Reproduced in John C. Loveridge, Presenting John McKee Olds…forty years of medical services in Notre Dam Bay, 1930-1970 (Twillingate: NFLD, Twillingate Chamber of Commerce, 1970), p. 15. 91 Boychuk, The Making and Meaning of Hospital Policy, p. 108. 92 Kealey and Molyneaux, “On the Road to Medicare,” p. 95. 93 Boychuk, The Making and Meaning of Hospital Policy, p. 104. 94 Boychuk, The Making and Meaning of Hospital Policy, p. 109, 114. 95 Boychuk, The Making and Meaning of Hospital Policy, p. 114. 96 Martin, Leonard Albert Miller, p. 127-28; Editorial, “The Cottage Hospitals of Newfoundland,” Canadian Medical Association Journal, 70 (June 1954): 686; and Noel Murphy, Cottage Hospital Doctor: The Medical Life of Noel Murphy (St. John’s: Creative Publishers, 2003), p. 41. 97 Martin, Leonard Albert Miller, p. 61. 98 Martin, Leonard Albert Miller, p. 70. 99 Kealey and Molyneaux, “On the Road to Medicare,” p. 102. 100 G. Harvey Agnew, Canadian Hospitals, 1920 to 1970: A Dramatic Half Century (Toronto: University of Toronto Press, 1974), p. 52. 101 Martin, Leonard Albert Miller, p. 129. 102 Jenny Manzer, “Salaried in Newfoundland” in Primary Care Reform: Reshaping Health Care in Canada (Ottawa: Canadian Medical Association, 2005), p. 30. http://www .cma.ca/index.cfm/ci_id/44700/la_id/1.htm. Accessed 26 February 2008.

12 The Partnerships between the State and For-Profit Hospitals in Quebec, 1961-1975: A Disappointing Experiment ALIN E CH ARL E S A ND FRA NÇO IS G UÉRAR D

INTRODUCTION

In the area of hospitalization, the establishment of partnerships between the state and the private sector is presently the subject of debates in Quebec and elsewhere in Canada. There are two opposing points of view regarding the place of the private sector in health care: (1) health care viewed as a service provided by the public sector and where the quest for profit is contrary to the collective interest, and (2) health care viewed as an economic sector where business enterprises hold a legitimate place.1 Beyond these debates, however, the door is already open to public-private partnerships, particularly in Quebec.2 These partnerships are generally regarded as new to the Canadian landscape,3 but this is not the case. Such partnerships have been attempted in the past. During the 1960s, the governments of a number of provinces, in accordance with federal legislation regarding hospital insurance, signed contracts with for-profit hospitals, and public insurance funded these establishments for a portion of its clientele. By making these partnerships the subject of this study, we are discussing one of the most controversial aspects in the establishment of public health insurance, in particular, the role the private sector can or must play in publicly funded healthcare systems. Before going any further, a few clarifications need to be made. Today, just like in the 1960s and 1970s, the term “private hospital” is used when referring to for-profit establishments. However, this term can lead to some confusion: the private sector includes both for-profit and non-profit establishments. For example, until the 1970s, the majority of Quebec hospitals were privately owned by religious communities and philanthropic institutions, but did not aim to make profits.4 For this study, it is the history of for-profit private establishments that will be examined.

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The rise of public health insurance in Canada since World War II and the diminished role of the private sector has been described by a number of researchers. However, it was mostly the positions taken by the medical profession and the various political parties that were examined.5 The history of state-hospital partnerships has not caught the attention of Canadian historians. To find studies on the matter, one must turn to countries where these partnerships have been longer lasting. However, most of these studies examine a more recent period. In the United States, researchers have shown that the Medicare and Medicaid programs established in 1965 were responsible for the sensational development of the for-profit private sector that until then had not been very profitable.6 It is when the state started financing their activities through these aid programs that for-profit hospitals, establishing hospital chains, really came into their own.7 In France, it is also after the government formalized in 1970 the relationship between public insurance and for-profit hospitals that large financial groups helped the latter to obtain a bigger share of the health-care market.8 Since then, the differences between for-profit and non-profit hospitals in these countries have decreased, partly because, in this competitive context, a market-driven logic has imposed itself. The effects that the extension of this profit-oriented logic has on access to health care, its quality, and its cost are controversial.9 At a time when the transfers of public funds to the for-profit hospital sector were increasing rapidly in the United States and France, both the Canadian and Quebec governments were reducing such transfers. Overall, their health-care policies would reduce the role of the private sector. According to Antonia Maioni, for all of Canada, and Joseph Facal, for Quebec alone, this can be explained by differences in the structures of the political institutions that are more favourable in Canada to social democratic reforms.10 In contrast, Michael Bliss turns the matter into a question of national pride that allows Canadians to differentiate themselves from their American neighbours.11 A number of authors, including Maioni, also point to the influence of successful experiments with public insurance in Saskatchewan before such programs were expanded across the country. However, experiments with public-private partnerships in Canada, particularly in Quebec and Ontario, have gone unnoticed. The successful experiments that became the foundation for major national policies, rather than those that failed, have been examined and remembered. Less visible and absent from the historiography, these failures nonetheless shed light on the choices made at the time. Two Canadian studies provide us with some avenues. Megan Davies and James Struthers examined partnerships established in a related industry—aged-care facilities—in British Columbia and Ontario, respectively.12 The long-time association of health and social services in Canada makes all the more relevant this parallel between such facilities and hos-

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pitals.13 The cities of Vancouver and Victoria, during the 1920s and 1930s, and Toronto during the 1940s and 1950s paid a per diem allowance to “private hospitals” and “nursing homes” to free up public hospitals by taking care of chronically ill patients and seniors. During the decades that followed, cases of abuse and inadequate services resulted in stricter legislation and government controls. Eventually, when public insurance started to massively fund these private establishments, business became much more interested and the industry expanded. However, in Ontario at least, the partnership got off to a rocky start, with the government having to take tough action to ensure that the profit motive did not adversely affect patients. Did the same problems arise in Quebec? How did the state and the private sector negotiate their partnerships? To what extent, how quickly, and why were these partnerships abandoned? We propose new answers to these questions by analysing underused documentation on these 1960s partnerships: government archives,14 correspondence from forprofit hospital associations, and newspaper articles. This chapter will begin by describing the terms and conditions of the partnerships established between the state and the private sector before the creation of public hospital insurance, as well as the state of for-profit hospitals in 1961—the year public insurance was established in the province. We will examine the relationships that evolved within these public-private partnerships and point out the numerous instances where tensions arose. We will show that, in contrast with today’s coverage, these tensions received little public attention at the time. The paper will conclude by showing how these partnerships in the 1960s and 1970s were problem-plagued, provided little incentive for a large-scale deployment, and resulted in the decline of for-profit hospitals. PARTNERSHIPS BEFORE THE ESTABLISHMENT OF PUBLIC HOSPITAL INSURANCE

Contrary to what many believe, recourse to partnerships between the state and for-profit hospitals is not a recent practice in Quebec. In 192526, the federal Department of Soldiers’ Civil Re-establishment had an agreement with the Mount Royal Hospital in Montreal and the Hôpital Saint-Luc Ltée in Quebec City to admit a few veterans suffering from tuberculosis. There were also instances where a municipality would sign an agreement with a for-profit hospital to provide special services. For example, in 1928, the City of Quebec rented approximately 15 beds from the Hôpital Sainte-Marie at a monthly cost of $1000 to receive patients suffering from contagious diseases who could not be treated at the local civic hospital.15 In Trois-Rivières, at the end of the 1910s, there was an agreement between the town and the Hôpital Normand et Cross regard-

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ing ambulance services, and an annual subsidy was even awarded during the latter half of the 1930s for care given to the poor.16 However, because the different levels of government preferred to reach an accord with non-profit establishments, these types of agreements remained of marginal importance. Until 1961, these public-private partnerships involved mostly nonprofit establishments owned by philanthropic organizations or religious communities. For example, the federal government signed contracts with several establishments regarding the care of foreign sailors. Until 1921, the Government of Quebec made yearly lump-sum payments to several charitable establishments. From then on, under the Loi de l’Assistance publique (Public Charities Act), these establishments were allocated an amount for each day of hospitalization of an indigent person. It should be noted that the hospitals recognized by l’Assistance publique also welcomed paying patients, which considerably increased their revenues.17 However, for-profit hospitals did not have access to these public funds, so their services were entirely paid for by the patients. Public hospital insurance continued this tradition of partnerships with non-profit hospitals. It was established in Quebec after a decade of crisis in the hospital system in which non-profit establishments faced rising deficits year after year and had to increase their rates for paying patients. Individuals who lacked private insurance but were not poor enough to qualify for state aid had trouble getting access to health care.18 The crisis was resolved when the province adhered to the joint hospital insurance program as proposed by the federal government since 1957. Established in Quebec in January 1961, the program guaranteed free access to hospitals to the entire population. In order to do so, the federal legislation authorized the provincial governments to sign agreements with both non-profit and for-profit hospitals.19 Quebec, like Ontario, took advantage of this to establish several partnerships with profit-oriented establishments, a practice that was uncommon until that time. FOR-PROFIT HOSPITALS IN 1961: A HETEROGENEOUS GROUP OF ESTABLISHMENTS

In 1961, at the time when these partnerships were becoming common practice, what was the state of for-profit hospitals in Quebec? The answer is not clear—no contemporary list distinguished between “nonprofit” and “for-profit” establishments. Therefore, ad hoc lists had to be drawn up for the purpose of this study to provide an overview of the situation. The list of hospitals published annually by the Dominion Bureau of Statistics (DBS) was the primary source used to this end. The “private” hospitals it mentioned did not receive public funds and were for the most part profit-oriented establishments. However, some “company”

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or “industrial” hospitals did not aim to make a profit—at least not directly. By comparing the annual DBS list with other sources,20 it was possible to determine which were not for-profit. Therefore, the total number of for-profit hospitals determined here differs from the one that can be calculated using DBS documents alone. Thus, in 1961, nearly all of the 135 for-profit hospitals could be placed in one of these three major categories: general hospitals (41), maternity hospitals (26), and establishments for the chronically ill, convalescents, and the elderly (67). As discussed below, the last category should be viewed with caution, since it includes establishments that offered basic living accommodations, and it was precisely the rapid development after World War II of a new market for such accommodations for seniors that inflated the number of “hospitals” listed.21 Although some categories remained vague until 1961, from then on the ministries responsible for health and social affairs revised and tightened the criteria for classification and removed the establishments that could not be considered hospitals. With few exceptions, the hospitals were small—they had an average of 27 beds (excluding cribs). In fact, quite a number of these tiny hospitals occupied private homes. Although for-profit establishments represented 37.8% of all hospitals in the province, they accounted for only a small proportion of the beds available—5.9% of adult and child beds and 12.1% of cribs. The diversified nature of ownership, management, and clientele makes it difficult to provide a single description of these profit-orientated hospitals. The first image that comes to mind is that of a small hospital run by one or a few physicians catering to an affluent clientele. Some hospitals offering general medical care and surgery services did indeed correspond to this image, but many others served the less affluent. Often, physicians neither owned nor managed them. The maternity hospitals and those for the chronically ill as well as convalescents and the elderly were often run by women, some by nurses, and others by women with few specific qualifications. Some of these maternity hospitals were specialized in the delivery of unwed mothers from less affluent backgrounds, allowing them to escape from the moral framework in place in hospitals run by religious communities. In many regards, notably in terms of “respectability,” there were wide gaps between the various types of establishments. In summary, when public hospital insurance was established in 1961, for-profit hospitals in Quebec formed a heterogeneous group of establishments run by different types of management, offering diverse care services to a varied clientele. ATTEMPTS AND CONFLICTS: A DIFFICULT PARTNERSHIP

Starting in 1961, the Quebec provincial government began signing con-

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tracts with for-profit hospitals, and all those listed in 1966 by the Dominion Bureau of Statistics were funded by the public hospital insurance service.22 In return, contracting hospitals had to respect standards regarding safety, quality, and costs of care. But for services that were not medically required, they were free to fix their own fee schedule and charge patients directly.23 The government of Ontario had been permitting the same practices since 1959 when it had established its public hospital insurance and had signed agreements with 55 “private hospitals” and 29 “nursing homes” to admit chronically ill patients at pre-established rates.24 However, in Quebec, establishing such partnerships did not go smoothly or quickly, and the 1960s became a decade of transition and experiment. The government was reviewing its own structure, transforming the health-care system to make it accessible to all, and testing new ways of supervising hospitals. For-profit hospitals, meanwhile, alternating between anxiety and optimism, had to revise how they operated in a context where the state regularly became their required interlocutor. Overall, both parties were willing to take a chance on this integration into the public network because both saw advantages to such an arrangement. For-profit hospitals gained access to a new source of funding, and the state saw the possibility to further extend hospital care services. Yet, beyond agreeing on this principled position, everything else was up for negotiation. Permits, government funding, range of services, clients served, hospital management, work conditions, and security standards were regulated, contested, and renegotiated several times. This first true experiment with such partnerships in the hospital sector was marked by intense negotiations. Asymmetric Definitions The first stumbling block between the state and proprietary hospitals was defining for-profit hospitals. The definitions proposed remained stubbornly vague, reflecting the complex realities of the time as well as the underlying political issues at stake. In contrast, before 1961, questions regarding definitions and terminology had not been problematic in Quebec. The state paid little or no attention to proprietary hospitals, and their respective owners remained discreet. Comparisons between forprofit and non-profit hospitals were also rare, since all patients—with the exception of indigents—paid for the care they received, whether it was provided by a for-profit hospital or a public establishment. This changed fundamentally with the introduction of public health insurance in 1961. Offering public funding while imposing more state control, this measure created a contentious situation. During the 1960s and 1970s, conflict focused especially on how to define for-profit hospitals. If, at the time, ministers, public servants, and owners preferred to refer to these estab-

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lishments as “private hospitals,” this designation led to a wide range of interpretations and much controversy. What defined a “private” hospital? Legislation, regulations, ministerial briefings, and official policy declarations tended to emphasize that private hospitals were run neither by the government nor by a non-profit corporation and were comparable to a “business enterprise.”25 However, the private hospital associations that emerged during the 1960s and 1970s fought hard against what they called “bad” legal and government definitions. They deemed it completely unacceptable to be defined by their quest for profit instead of their “service” to patients and regarded the “for profit” expression as absurd, vicious, and even “outrageously archaic.”26 They thought it was equally abusive to describe them as the opposite of public hospitals, since they also held permits, respected “equivalent” standards, and charged rates approved by the state. These groups frequently proposed alternate definitions they wanted to see enshrined in legislation. Yet the ministries responsible always rejected their suggestions, like this one drafted in 1969 by the Association des hôpitaux privés du Québec (AHPQ, Quebec Private Hospital Association): The private establishment is a service enterprise, privately initiated and owned by individuals or by a corporation, dedicated to the treatment, safe keeping, care and wellbeing of patients and other residents; it is recognized as such by the ministry responsible; it reinvests or redistributes its operational surplus and fixes the rates for its services conjointly with the ministries responsible or, as the case may be, with the patients and residents.27

This was more than a war of words; it touched on real issues. In Quebec, the 1960s and 1970s saw the failure of private (for-profit and nonprofit) initiatives in the health-care sector. After decades of experiments, religious communities and philanthropic organizations, for-profit hospital administrators and insurance companies were deemed incapable of providing hospital care to everyone everywhere. Only the state seemed apt to deliver such care effectively, be it in public hospitals or through regulated for-profit ones. To this end, for the first time, it imposed on the latter stricter quality and security norms as well as standards of uniformity. Under these circumstances, a precise definition of such establishments became crucial. In 1973, the Ministry of Social Affairs made the following distinction: the owner of a “private” establishment is an “investor [who expects] to generate a return on his investment”; public establishments, however, are “trustees of the community” and “the use of their properties is the only expected return.”28 The owners of “private” hospitals constantly opposed this kind of distinction. Associating some health establishments with profit-making—even slightly—would only put them at a disadvantage in a sector increasingly considered as a public service. This was also a question of strategy for the future. Now that

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the state provided free, universal quality, and province-wide hospital care in public establishments, the presence of private establishments in the same field might one day be considered unnecessary. And it was not at all clear if these establishments would remain sustainable without state support. Beyond these specific discussions, it should be noted that the entire Quebec health-care sector used the term “private” in a highly ambiguous way in the 1960s and 1970s.29 It covered and mixed diverse concepts, ranging from the type of ownership to the search for profit, including the absence of state support and pricing policies. More often, the word designated proprietary hospitals, owned by individuals who collected profits while being partially funded by government through public hospital insurance. However, the same term was used for the handful of hospitals that did not seek a profit and received no government funding. That was the case of establishments owned by philanthropic corporations or those owned by companies and reserved exclusively for their employees. To further complicate matters, the majority of public hospitals—non-profit and funded by the state—offered patients, if they wished, more luxurious services in “private” rooms or departments; however, the revenues generated could be used only to improve the spectrum of care or to avoid a deficit. The concept of “private” establishments was not the only one to cause problems. The definition of “hospital” did as well. In this case, public servants, ministers, and for-profit hospital associations unanimously decried the imprecise nature of the official texts on the subject.30 For everyone, the term amalgamated various types of institutions into a heterogeneous catch-all, making it quite difficult to distinguish between hospitals and other institutions such as clinics, nursing homes, hospices, convalescent homes, maternity institutions, or seniors housing and “hotel-like” accommodations. It also muddled health-care services with custodial care. It even confused ministerial jurisdictions and the field of application of laws to the point that it was difficult to know if a particular establishment fell under the jurisdiction of the Ministry of Health or the Ministry of Family and Social Welfare, if it was governed by the 1935 Loi concernant les hôpitaux privés (Private Hospitals Act) or the 1962 Loi des hôpitaux (Hospitals Act). However, it was precisely these distinctions that determined several essential matters, including the establishments’ classification, permits, clientele, and funding. Once again, the terminology reflected the complex realities and the political issues of the time. On the one hand, it was difficult for both the representatives of the state and the owners of for-profit hospitals to clarify the distinction between hospitals and homes. Seniors suffering from a loss of independence often ended up needing medical care, while the chronically ill and handicapped children also required both medical

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treatment and custodial care. In the 1970s, major reforms and the creation of a ministry “des affaires sociales” (of social affairs)31 confirmed a well-established trend in Quebec that integrated health and social services, much like in the rest of Canada.32 On the other hand, it was essentially civil servants who sought to clarify the characteristics of a “hospital”; hospital owners were much more interested in defining what was a “private” establishment. Although decrying it publicly, they seemed in fact to appreciate a measure of ambiguity, probably because it gave them more flexibility to follow changes in their clientele. As we shall see, in 1961 proprietary establishments started to lose two major market sectors: general hospitals and maternity hospitals.33 In this new context, their activities concentrated all the more on providing a mixture of health and residential care, aiming at a clientele composed of chronically ill patients, seniors, convalescents, and people in rehabilitation. For-Profit Hospitals: A Legitimate Place? Well beyond the terminology used, the future of profit-oriented establishments in what had become a largely public hospital sector was an issue throughout the 1960s. The AHPQ perfectly understood what was at stake. It regularly proclaimed that its members had a legitimate place (“droit de cité”), a right to do business, a right to obtain “guarantees for the future” in the name of “justice” and “fairness.”34 Passionately praising the private sector, the AHPQ claimed that it was guided by only one principle: providing quality care to its patients at the lowest possible cost. It further claimed to be so “convinced of the merits and inherent dynamism of the private sector system that it was ready at any time to show the public its superiority by taking over a major public establishment.”35 Although worried about what the future might hold, managers of proprietary hospitals did have a few reasons for optimism, since the public authorities showed some openness. In 1963, the director of the Hôpital de Crawford Inc. was happy to state publicly that there was now “more leeway, a longer term view, more humanity, a better dialogue,” and more consideration for private general hospitals, “this poor cousin of public hospital insurance.”36 Later, in 1966, the return to power of the Union Nationale signalled the possibility for further cooperation, since the party was known for being more reluctant to increase government intervention and powers than the Quebec Liberal Party led by Jean Lesage. Indeed, in 1968, at the request of the Minister of Family and Social Welfare, Jean-Paul Cloutier, some “encouraging” meetings between the Council of Deputy Ministers and the AHPQ took place.37 Later, in 1969, officials from the ministries of health and family and social welfare once again reassured AHPQ members when they stated, “There are people who say that we want to see the private sector disappear … that’s not true.”38

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However, other signs emanating from the same ministries indicated that time was running out on profit-oriented hospitals. One such sign was the “freeze” on the issuing of permits, a move that was denounced on several occasions by the AHPQ. As prescribed by the 1935 Loi concernant les hôpitaux privés, every establishment had to obtain a governmentissued annual permit. Yet, beginning in 1963, the government practically stopped issuing permits to new establishments in the health and welfare sector.39 Thereafter, no new general or maternity hospital appeared on the list compiled by the DBS. Only a few hospitals for chronically ill and convalescent patients managed to obtain permits. Furthermore, the permits of established hospitals were not renewed. That was the case in 1971 for the Clinique St-Martin in the Gaspésie region—the very last of the private maternity hospitals.40 The owners of for-profit hospitals were up in arms over this permit freeze, which they saw as an underhanded way of preparing for their “extinction” and the “disappearance of private enterprise” in the health and welfare sector.41 In fact, acute care for-profit hospitals were the ones most at risk of disappearing. Minister J.-P. Cloutier recognized the fact at the 1969 AHPQ conference, while holding out hope for better times to come by stating that there would be new development opportunities for businesses offering other types of services: In what field could the expansion of the private sector be seen as desirable? Frankly, I doubt it would be in the hospitalization or intensive care sectors because of the strict standards, the requirements imposed by the intergovernmental agreements, and the relations with professional corporations in the hospital sector. However, in other fields such as residential care, childcare, and foster care, there is a considerable need that could be filled through private initiatives.42

Private enterprise’s “legitimate place” would thus be in custodial care, living accommodations for seniors, and the institutional long-term care of children and adults. However, in the same speech, the minister stated that the idea was probably not in the best “public interest” because of the “concern for profitability” that necessarily preoccupied AHPQ members and that “could conflict with the quality of services provided to people in your care.”43 Therefore, the direction the government wished to take was not clear, and choices were still open. The government’s message was ambiguous, and it remained that way throughout the 1960s. While reassuring for-profit hospitals about their future, the government introduced measures prohibiting their expansion or forcing them to withdraw from certain fields of activity. Some AHPQ managers viewed this as a “barely concealed form of euthanasia,” an “undeclared” strategy to “starve” them and to make them disappear more quickly.44 However, it might be more appropriate to speak here of hesitation or trial and error. While reorganizing the health and social welfare services

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to make them essentially public-sector activities, the Quebec government was also attempting to integrate for-profit establishments. Although it proceeded with caution in giving them only a small place, it was not trying to exclude them from the publicly funded health system. Still, making this integration work was a laborious and complex undertaking. A Laborious Integration into the Public Health Network Integrating for-profit hospitals into the public health system was clearly not an easy task. The various establishments had to be listed along with their individual characteristics, permits had to be issued, categories of services insured and not insured by the state had to be defined, rates paid out by the government to the establishments had to be fixed depending on the clientele served and the services administered, and specific security and quality standards had to be drawn up for these establishments. Also, regular inspections had to be made, bills sent to the state and to patients had to be verified, work conditions had to be supervised, staff qualifications had to be verified, and negotiations had to be undertaken with the owners’ associations. This required significant administrative resources and the creation of a rather large bureaucracy to oversee a group of generally small establishments that made up only a minimal part of the beds available in Quebec. No other action by the Quebec government in the 1960s better illustrated its desire to attempt to create partnerships with the private sector. As things were, this undertaking required for-profit hospitals to open their doors, their books, their admission records, and their employee files to public servants. A number of them vigorously opposed this. They protested all the more energetically in that this kind of regulation was unprecedented and rapidly imposed. Until then, the various levels of government had been lax about issuing permits and did not always make serious inspections. They never intervened in the management of establishments and their staff. They did not impose very precise quality and rate standards. In only a few years beginning in 1961, all this changed for for-profit hospital owners. Frustrated by a bureaucracy they viewed as suffocating, they complained about the various ministries “interfering” in a “sector, that until now, has benefitted from the economical and quality services of private enterprise.”45 The owners further asked, “Why do some bureaucrats insist on treating us as if we were public establishments or the state’s creatures, and why do they relentlessly try to impose upon us a series of inappropriate constraints!”46 The control the government exerted over their personnel management attracted the same criticism. For example, the obligation to hire qualified nursing assistants caused much indignation in 1968: “helpers could do just as good a job” and “we want our staff to be made up of

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simple, charitable people, capable of rehabilitating sick patients through small acts of human caring.”47 However, these complaints did not last very long. Even in a female-dominated field of employment such as health care, it was becoming more difficult to haggle over skills and qualifications at a time when women professionals and technicians were getting better recognition of their qualifications. Furthermore, during the 1960s, labour unions were organized at one hospital after another, for one job category after another. Negotiations regarding work conditions were no longer held on a local level: they involved hospital associations and trade union federations representing entire regions and, eventually, the entire province. The state moreover imposed itself as management in all negotiations and stamped its mark on all the collective agreements.48 As was almost inevitable, these upheavals affected the “private” hospitals. They, too, were forced to deal with trade union federations, sign province-wide collective agreements, and accept government officials at the bargaining tables. This new environment forced them to change their tactics. Instead of complaining about public servants interfering in their operations, they found new reasons to demand an increase in the per diem allowance they received from the provincial government. On the one hand, they claimed to be forced to reduce staff, incapable of paying “reasonable salaries,” obliged to shoulder an unfair burden, and having to settle for “starvation wages” because the state had “frozen” their revenues.49 On the other hand, the “astronomical” costs resulting from unions’ demands and collective agreements required “immediate” financial assistance from the government.50 Finally, they demanded parity of wage and working conditions with the public sector: “We are sick and tired of being suppliers of employees to public hospitals. Can we blame employees for crossing the street to be hired in a public hospital where, for the same work and with the same qualifications, they will earn higher wages?”51 The government acceded to most of their demands, “standardizing” the wages and work conditions of for-profit hospitals, and “adjusting” per diem allowances to take into account the costs generated by the collective agreements.52 It should be noted that, at this point, labour unions had not begun openly criticizing for-profit hospitals. In 1965, for instance, a representative of one of the major unions—the CSN—stated that the labour movement did not have a firm opinion on the issue, but nevertheless demanded proof that the proprietary hospitals were essential.53 Unions seemed to have nothing more to say on the subject. Of course, a few establishments were unionized, some collective agreements were signed, certain grievances were filed, and a few strikes were launched, but little else. For unions, the pressing issues were elsewhere at the time, in the public sector, because it was in the public sector that the vast

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majority of hospital staff worked and where the negotiations trying to strike a balance between decent work conditions and free care services took place. There was much more tension between the Quebec government and for-profit hospitals owners. In the name of the public good and free hospital care, the former funded the latter, but imposed in return its standards, its supervision, and its public salary framework. The forprofit establishments, meanwhile, demanded—in the name of free enterprise—more autonomy, but also more money for the services for which they billed the state and the population. In fact, throughout the 1960s and 1970s, the issue of billing was seen as the most problematic. According to the Loi de l’assurance hospitalisation, the government paid out “day/patient rates” (per diem) to for-profit hospitals with which it had signed contracts. Rates were fixed according to the cost of comparable services in public hospitals.54 Of course, this remained open to interpretation and was the subject of disputes. It is not surprising, then, that the AHPQ and its successor, the Association des directeurs d’établissements privés de bien-être et de santé (ADEP) chose this as their main battleground, especially since the per diem allowance paid by the state was now the main source of revenue of their members. Every year, they demanded an increase (sometimes between 25% and 40%) in the per diem allowance. They claimed that the amounts allotted were discriminatory compared to public hospitals and prevented the owners from hiring sufficient staff at a competitive wage.55 Each time, the same arguments were invoked. On the one hand, they claimed that since “private hospitals were not the property of the state,” they should be paid a “suitable” price for the services they provided.56 On the other hand, they claimed that a “fair ” per diem allowance was vital to the “survival” of several establishments.57 Furthermore, since in their view this was a question of rescuing an entire industry in peril, other demands followed: “bonuses for improvement and merit,” “guarantee of sufficient surpluses,” “guarantee on capital loans by the state,” protection against the “competition” from public establishments and huge private corporations, and safeguarding of family assets invested by the owners in the case of bankruptcy.58 Struggling for more government funding was as important as fighting for new permits in their quest for a “rightful place.” And since the AHPQ and the ADEP were well aware that such demands might not go over well in a sector that had long been seen as charitable and was now considered public, they took great care to denounce the “prejudice” expressed about the “shameless and fabulous” profits of their members.59 New government standards were also a bone of contention. In fact, profit-oriented hospitals were slow to comply and debated all matters, from rate schedules and service quality to patient admission, personnel management, and accounting standards. Even after lengthy negotia-

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tions, results were, however, mixed at best. Almost one-third of the 88 establishments under contract in 1966 were found to have “irregularities” by the Service de l’assurance hospitalisation, including illegal billing and incorrect proportion of beds allocated to hospital insurance cases.60 In 1968, the Service des normes hospitalières indicated that, over the past two years, it had been able to make owners more diligent about respecting quality standards, but noted already some “complacency” setting in. Furthermore, it pointed out the urgency of not letting the result of “such hard work” go to waste.61 That same year, a public servant from the Ministry of Family and Social Welfare identified other types of problems, such as overstaffing for which the establishments demanded compensation, and admission of seniors without the required services being available.62 Throughout the decade, ministry officials also complained of not being able to verify the use of the funds awarded because several establishments refused to provide them with the necessary figures. These complaints led for-profit hospital associations to adopt several strategies. At first, they kept asking that the private sector be treated “respectfully” by the government and that their members be exempted from the obligation of opening their accounts to public servants.63 Over time however, persistent non-compliance with service quality norms or staff qualifications regulations became increasingly difficult to support. Finally, the associations urged their members to demonstrate greater rigour and discipline: “In the future, you will not stay in business if you don’t show more competency and transparency.… Gone are the days when you could sweep under the rug embarrassing matters.”64 Clash over Powers to Self-Regulate During the 1960s, the AHPQ had two main strategies: to participate in the decision-making process for matters that directly affected their interests, and to be the only voice speaking on behalf of for-profit hospitals. They felt that if various standards and controls were necessary, it was only fair that they have a hand in their development, and if they were to participate, they intended to act as a go-between for the state and the establishments. Therefore, the association made a hodgepodge of demands, requesting the creation of a “joint” Standards Committee, an annual renegotiation of hospital standards, the appointment of an ombudsman overseeing the “autonomous hospital” sector, seats on the appeal body that suspended permits, the right to suggest candidates for successive deputy ministers of health, and the possibility to be heard if another establishment was planning to provide services in the vicinity of a “private hospital.”65 It also demanded that the government modify the Loi des hôpitaux to refer explicitly to the association by name. Furthermore, the AHPQ requested that the government always use it as the go-between when dealing with its members. Although it was unsuc-

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cessful in having all its demands met, it was nonetheless able to sit on various joint committees set up by the two ministries responsible. The thin line between participation in the decision-making process and self-regulation was, moreover, quickly crossed. In 1965, the AHPQ demanded the power to establish its own standards and to enforce them. The minister of social welfare bluntly turned down this demand, stating that the Ministry assumed all the costs and that it had to look out for a clientele largely made up of “defenseless people, weakened by old age and modest means.”66 He therefore refused to entrust such powers to the association. The AHPQ kept battling on nevertheless. In 1968, it laid on the minister’s desk a piece of legislation that would make it a professional corporation: la Corporation des administrateurs et des établissements privés de santé et de bien-être (CAEP).67 With its 23 preliminary considerations and 261 clauses, the draft endowed the CAEP with extensive powers. It would have established the body as the sole voice of “private establishments” that provided care and welfare services, and only its members would have had the right to run such establishments. Acting jointly or not with the various departments concerned, the corporation would have issued and revoked the permits, inspected the establishments, drawn up its own “code of ethics” and imposed it on its members, and established standards for quality of care, management, staff qualifications, and building safety. Furthermore, the CAEP would have been able to offer training programs and courses as well as issue diplomas. In some respects, the proposed legislation was just a reiteration of the AHPQ demands to be part of the decisionmaking process. But it was also staking a claim to entirely new territory. By requiring ruling authority and self-regulation over an entire sector, the AHPQ was trying to become much like professional orders with exclusive rights to practise certain professions (e.g., physicians and nurses). That such demands were being made in 1968 was no coincidence, since the Commission of Inquiry into Health and Social Welfare (Castonguay-Nepveu Commission) was sitting at the time (see below). As this body was specially mandated to examine the corporations system in the health sector, certain professions—notably female ones—were taking the opportunity to request corporate status.68 If the demands of the AHPQ can be seen as a reflection of the time, they would nonetheless be deemed unacceptable by the Ministry of Family and Social Welfare and the Ministry of Health. The public servants responsible concluded that the project contravened legislation on several points. It encroached on the jurisdictions of both ministries, it did not establish the representative nature of the association, and it went beyond its jurisdiction: There is nothing wrong with managers of charitable institutions and private

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hospitals uniting to claim their rights and defend their interests. However, they should let the government legislate and regulate those institutions and hospitals. It is a matter of public interest that cannot be left in private hands.69 HEADING TOWARDS THE DISAPPEARANCE OF PROFIT-ORIENTED HOSPITALS

While the 1960s were marked by hesitation, the 1970s were a decade of decision-making. Government managers would draw conclusions from the tensions and conflicts that marked the experiments with partnerships. Moreover, for-profit hospitals faced increasing criticism. A first round of criticism called into question their ability to ensure the safety of their residents. A well-publicized tragic event in December 1969 drew attention to the matter and influenced public perception.70 Approximately 40 residents of a boarding home for seniors—le Repos du vieillard—died in a fire at Notre-Dame-du-Lac (Témiscouata county). A government inquiry was undertaken into the safety of senior homes and for-profit hospitals. In its report, the inquiry described the situation as alarming: inadequate fire-protection systems and means of evacuation, poor recordkeeping of the residents, no overnight supervision, and a lack of staff, including qualified personnel.71 The inquiry called for stricter safety regulations in welfare establishments and all hospitals, while pointing out that many small establishments would not have the financial means to comply with such regulations without government assistance. The real question was whether the small private hospitals had a strong enough financial position to ensure the safety of residents and patients. A year after that deadly fire, and shortly after another blaze claimed 17 more victims,72 the Minister of Health, Family and Social Welfare, Claude Castonguay, announced to the National Assembly that, following the report of the inquiry, standards for the issuing of permits would be tightened up.73 For-profit care and welfare establishments faced even more criticism from the Castonguay-Nepveu Commission. The Commission was set up in 1966 to investigate the health and social welfare system in Quebec and to propose reforms. Headed by Gérard Nepveu, the Commission published in 1970 a report that was largely opposed to continued public support of profit-oriented hospitals.74 The commissioners stated that these establishments were incapable of respecting the safety and quality of service standards imposed on public hospitals. They emphasized the difficulties encountered by the provincial government in “subjecting the for-profit sector to rigorous standards and its inability, when these standards existed, to control their application.”75 Furthermore, the Commission predicted that if the government continued funding for-profit hospitals, the result would be constant recriminations and never-ending negotiations. Taking a broader view of the situation, the report stated

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that the private sector “had motivations and objectives that were incompatible with the fundamental principles guiding the development of … the proposed health and social welfare system.”76 Here the market-oriented nature of for-profit establishments was the target of the commissioners’ attacks. Another problem was that they envisioned a health and social welfare system based on strong government planning, a kind of planning that the intervention of private interests made all the more difficult. They thus described the for-profit hospital network as “a parallel sector that thwarts the balanced development of resources, and that constantly hinders the development of a rational plan.”77 For all the reasons mentioned, the Commission bluntly recommended that “the system of direct and indirect subsidizing of profit-oriented hospitals and welfare establishments end as quickly as possible.”78 In the health care sector, the recommendation had the backing of powerful stakeholders—the medical profession and labour unions. In 1967, in a report referred to by the Nepveu report, the College of Physicians and Surgeons of the Province of Quebec criticized for-profit hospitals for being “an anachronism” and recommended that all establishments be under the authority of non-profit corporations.79 By then, labour unions had become clearly opposed to for-profit establishments. A few days after the blaze at the Repos du vieillard, Norbert Rodrigue of the CSN described the establishments as “sickness and old-age merchants” that managed 800 private hospitals and senior homes in Quebec, adding that hospital services should not be ensured by the “operation of private interests.”80 In 1970, with a strike looming in that sector, the head of the CSN labour union, in a letter addressed to the minister responsible, Claude Castonguay, and sent out to the media, spoke of “a system that funds with taxpayer’s money an individual or a for-profit corporation that exploits a business involving children, seniors and sick people who are forced to take refuge in these establishments.”81 The “private hospitals strike” that broke out a few months later did nothing to make labour unions change their position. Although modest compared to other great conflicts in the public sector, the strike affected around 50 establishments, lasted 11 weeks, and involved 3000 employees—mostly women—and three employer associations, including the ADEP.82 Wage parity with employees working in public establishments was the main issue at stake. The conflict affected a diverse range of establishments. The “private hospitals” concerned included both forprofit and non-profit establishments. They also included institutions for the chronically ill, senior homes, daycare centres, institutions for the deaf and the blind, and establishments for handicapped children. Once again, what was “private” and what was a “hospital” were ambiguous notions and, as discussed earlier, this ambiguity clouded the situation as well as the issues. In addition, although the staff working in these estab-

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Figure 1. For-profit hospitals in Quebec, 1956-1981

Source: List of Canadian Hospitals, published annually by the Dominion Bureau of Statistics until 1971 and then by Statistics Canada. Title changes.

lishments won their case, the conflict fuelled the unions’ criticism against the “private sector.” The “social agencies strike” that began almost at the same time aroused even more animosity against private corporations funded by the state to offer social services.83 At this point, for-profit hospitals appeared to be isolated. The escalation in ADEP rhetoric makes this clear. Continuing all the while to invoke its members’ good faith and to list improvements made over the years, the association nevertheless strongly criticized the College of Physicians’ position and, on a more strident note, judged the Nepveu report suitable for a “totalitarian and communist State.”84 But all in vain. For-profit hospitals appeared to be isolated. With the exception of long-term care facilities, they would not survive the Quiet Revolution. The number of hospitals in operation (figure 1) as well as those under contract with the public insurance plan had already declined throughout the 1960s. The number of hospitals receiving public funds dropped from 108 in 1961 to only 70 in 1969.85 The decrease did not affect all types of establishments equally, and all categories did not follow the same timeline. Maternity hospitals were the first to leave the stage, their number decreasing from 26 in 1961 to only 4 in 1966. By 1971, only 1 was still in operation, and by the following year, none were left. In fact, the entire maternity sector escaped from the for-profit sector, whether in general or in specialized

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hospitals. In Montreal, the number of births registered in profit-oriented establishments collapsed—dropping from 7594 births in 1960 to 237 in 1969.86 General hospitals did not escape the trend either, although the timeframe was somewhat longer: 41 were in operation in 1961, 15 still remained a decade later, and only 2 were left in 1976. How many disappeared because the government refused to renew their annual permit and how many chose to close because they were not profitable or for other reasons? Were for-profit hospitals abandoned by a clientele that simply had more confidence in major hospital establishments? The reasons behind their disappearance would need to be examined more closely, but we suggest a few hypotheses. The disappearance of profit-oriented maternities can be explained partly by the fact that women could now give birth free of charge in not-for-profit hospitals without having to prove they were married. Furthermore, the difficulties encountered by small establishments in finding the necessary financial resources, the growing complexity of health-care services that had to be provided, the ever-increasing cost of hospital equipment, and the need to meet more rigorous government standards undoubtedly all played a role in the decline of acute care facilities. It is also possible that the government freeze on issuing new permits discouraged financial groups able to establish large, well-equipped establishments, much like they did in the United States and France. However, in the long-term care sector, proprietary hospitals remained in business. Although the number of establishments did not grow (figure 1), the number of beds did increase, accounting in 1970 for 27.9% of the beds available in long-term care facilities in Quebec.87 But in the 1980s, what was not so long ago a diversified group of profit-oriented hospitals no longer existed. Acute care hospitals almost disappeared. The same situation could be observed in the other provinces. According to Statistics Canada, in 1983, Ontario and Quebec were the only provinces where “for-profit hospitals” were still in operation (18 in Ontario, 41 in Quebec); in both provinces, these were long-term care establishments. Of course, whether they really met the definition of a “hospital” remains an open question. CONCLUSION

The arrival in Quebec of public health insurance in 1961 did not immediately result in the disappearance of for-profit hospitals. On the contrary, the provincial government chose to spend considerable sums funding these establishments, as was permitted by the hospital insurance program. For general hospitals and maternities, this partnership only lasted 15 years. Hospitals providing long-term care, however, made it through these difficult beginnings and managed to survive until the present.

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For all stakeholders, the 1960s were a period of hesitation, with various types of partnerships negotiated and tested between the state and for-profit hospitals. These experiments were laborious and not very successful. Tensions grew that marred relations between the ministries responsible and the establishments as well as their associations. Public servants did stop issuing new permits, but the hospital managers’ lack of transparency about how they spent public funds discouraged officials from making more room for their enterprises. The private hospital association and its members, worried about their future, made endless demands regarding benefits, guarantees, and even privileges they believed they were entitled to receive. Furthermore, they complained about the rates paid by the government, financial audits, quality and safety standards, and the attitude of public servants. During the 1970s, faced with this situation, the government finally seemed ready to end this first major public-private partnership experiment in the hospital sector. To fund barely 2.9% of the beds in the province in 1970s88 under such conditions seemed to be too inefficient. Public servants, ministers, labour unions, and the medical profession all came to the same conclusion—for-profit hospitals no longer had a place providing services in the health-care system, at least not when it came to acute care. It should be noted that this consensus seems not to have resulted from an ideological reaction, since it occurred after more than a decade of attempts to establish a private-public partnership in the hospital sector. Fewer in number and offering a much smaller variety of services, forprofit hospitals never were as important and visible as their public sector counterparts. Nevertheless, their presence and the agreements these establishments signed with the government throughout the 1960s and until the middle of the 1970s indicate that a state takeover of the health sector was not—even during the Quiet Revolution—the only path considered. If it had not been for the public funding they received, these profit-oriented hospitals would have seen their clientele flock to public establishments offering free services. This tends to qualify and contradict the historiography of Quebec in the 1960s that places the state in the spotlight, but neglects the public-private partnership experiments that also took place. Barely on the public radar screen at the time, for-profit hospitals and failed public-private partnerships have largely been erased from Quebecers’ collective memory. In the current debate concerning a potential role for private enterprise in public health care, few seem to remember these experiments and the accompanying bouts of wrangling. Among those who surely do, however, are some leading proponents of what would be a return of the private sector. Such apparent amnesia is not surprising. What, however, is more intriguing is that the historians, sociologists, and political scientists who have studied the major reforms in

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the health-care system have not examined these partnerships either. Failed experiments tend to go unnoticed; they are at best relegated to the status of minor setbacks or glitches. In the current health-care debate, however, such bygone difficulties may well be worth a backward glance. ACKNOWLEDGMENTS

We would like to thank Greg Marchildon for his interest in this article, as well as for having it translated. We are also indebted to Thomas Wien who helped revise this translation. And, finally, we acknowledge with thanks the financial support of the Social Sciences and Humanities Research Council of Canada. NOTES 1 Louise-Maude Rioux Soucy, “Partenariat public-privé: L’histoire de l’hôpital de Brampton devrait inciter le Québec à la prudence,” Le Devoir, 9 January 2008, p. A4; and Marcel Boyer (Vice-president of the Institut économique de Montréal), “Pour un système de santé public et accessible, faisons une place au privé!,” Le Devoir, 21 August 2008, p. A7; and Marco Bélair-Cirino, “Une trentaine de médecins font un plaidoyer en faveur du régime de santé publique,” Le Devoir, 21 August 2008, p. A7. 2 Louise-Maude Rioux Soucy, “Un partenariat contesté entre le public et le privé: La clinique privée Rockland peut commencer à opérer,” Le Devoir, 3 February 2008, p. A5; and Marie-Claude Prémont (law professor at the ÉNAP), “La mutation des politiques québécoises en faveur du développement de marchés privés de la santé,” Le Devoir, 21 August 2008, p. A7. 3 Rioux Soucy, “Un partenariat contesté,” Le Devoir, 3 February 2008, p. A5. 4 See the distinction established in Yves Vaillancourt, Denis Bourque, Françoise David, and Edith Ouellet, La privatisation des services sociaux, Rapport no. 37 (Québec: Commission d’enquête sur les services de santé et les services sociaux, 1987), p. 8. 5 Some of the principal authors are Alvin Finkel, Social Policy and Practice in Canada: A History (Waterloo, Ont.: Wilfrid Laurier University Press, 2006); C. David Naylor, Private Practice, Public Payment: Canadian Medicine and the Politics of Health Insurance, 1911-1966 (Montreal and Kingston: McGill-Queen’s University Press, 1986); Malcolm Gordon Taylor, Health Insurance and Canadian Public Policy: The Seven Decisions That Created the Canadian Health Insurance System and Their Outcomes (Toronto: Institute of Public Administration of Canada, 1987). 6 Rosemary Stevens, In Sickness and in Wealth: American Hospitals in the Twentieth Century (New York: Basic Books, 1989), p. 297-300. 7 J. Rogers Hollingsworth, Controversy about American Hospitals: Funding, Ownership, and Performance (Washington: American Enterprise Institute for Public Policy Research, 1987). 8 Nicolas Tanti-Hardouin, L’hospitalisation privée : crise identitaire et mutation sectorielle (Paris: La Documentation française, 1996). 9 Bradford H. Gray, ed., For-Profit Enterprise in Health Care (Washington: National Academy Press, Committee on Implications of For-Profit Enterprise in Health Care, 1986); Donald W. Light, “Corporate Medicine for Profit,” Scientific American, 255, 6 (December 1986): 38-45; and Nancy Wolf and Mark Schlesinger, “Access, Hospital, Ownership, and Competition between For-Profit and Nonprofit Institutions,” Nonprofit and Voluntary Sector Quarterly, 27, 2 (June 1998): 203-36. 10 Joseph Facal, Volonté politique et pouvoir médical: La naissance de l’assurance-maladie au Québec et aux États-Unis (Montréal: Boréal, 2006); Antonia Maioni, Parting at the

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Crossroads: The Emergence of Health Insurance in the United States and Canada (Princeton: Princeton University Press, 1998);. Michael Bliss, “Health Care without Hindrance: Medicare and the Canadian Identity,” in David Gratzer, ed., Better Medicine: Reforming Canadian Health Care (Toronto: ECW Press, 2002), p. 31-43. Megan Davies, Into the House of Old: A History of Residential Care in British Columbia (Montreal and Kingston: McGill-Queen’s University Press, 2003); James Struthers, “Reluctant Partners: State Regulation of Private Nursing Homes in Ontario, 1941-72,” in Raymond B. Blak, Penny E. Bryden, and J. Frank Strain, eds., The Welfare State in Canada: Past, Present and Future (Concord, Ont.: Irwin, 1997), p. 171-92. Mariana Valverde, “The Mixed Social Economy as a Canadian Tradition,” Studies in Political Economy, 47 (Summer 1995): 33-60. Several of the documents are those of the Ministère des Affaires Sociales (E8, S2) kept at the Bibliothèque et Archives nationales du Québec, Centre d’archives de Québec. These documents will be identified in the Notes by the abbreviation BANQ and their call number. Gouvernement du Canada, Rapport du Ministère du rétablissement des soldats dans la vie civile pour l’année terminée le 31 mars 1926 (1927), p. 11; and Cité de Québec, Procès-verbal du Bureau d’hygiène, 28 June 1916 to February 1928, Archives de la Ville de Québec, QC31B/540, VM-6-174. See at the Archives de la Ville de Trois-Rivières: records of meetings from the town council, 4 August 1913, 18 March 1918, 5 October 1936, 20 December 1937, 4 July 1938, 23 January 1939, 17 April 1939, 26 December 1939, 27 January 1941, and the related documents of the standing committee. See also Hôpital Normand et Cross to the mayor and aldermen of Trois-Rivières, 29 January 1940. Several studies have dealt with this organization of hospital services. See, for example, François Guérard, “La formation des grands appareils sanitaires, 1800-1945,” in Normand Séguin, dir., Atlas historique du Québec: L’institution médicale (Québec: Presses de l’Université Laval, 1998), p. 75-115. See François Guérard and Yvan Rousseau, “Le marché de la maladie: soins hospitaliers et assurances au Québec, 1939-1961,” Revue d’histoire de l’Amérique française, 59, 3 (Winter 2006): 293-329. Excluding establishments for people with tuberculosis and the mentally handicapped. Conférence catholique canadienne, Les hôpitaux de la province de Québec (Ottawa: Conférence catholique canadienne, 1961); Province de Québec, Comptes publics, 19601961. Press clippings, local and regional history studies, annual reports from the Service de santé de la Ville de Montréal, address directories, etc., were also used. In 1958, the report indicated that several institutions included in the lists because they had been issued hospital permits in Quebec should in fact be excluded from these lists. In 1960, a number of establishments that provided mostly living accommodations and care were struck from the lists. However, in 1961, several institutions that mostly provided these types of services were still included in the lists. See Province de Québec, Comptes publics 1965/66, p. 572; and Comptes publics 1966/67, p. 568; and Government of Canada, Dominion Bureau of Statistics, List of Canadian Hospitals and Related Institutions and Facilities (Ottawa: Dominion Bureau of Statistics, 1966). “Règlements de la Loi sur l’assurance hospitalisation,” in Conférence catholique canadienne, Les hôpitaux de la province de Québec, p. 76-81. Ontario Hospital Services Commission, Annual Report of Hospitals for the Year Ended December 31, 1959 (Toronto: Ontario Hospital Services Commission, 1960), p. v. Loi instituant l’assurance-hospitalisation, S.Q., 1960, c.78; Loi des hôpitaux, S.Q., 1962, c.44; and Gouvernement du Québec, Ministère de la Santé, Division de l’AssuranceHospitalisation, Rapport annuel (Québec: Ministère de la Santé, 1961): 205-206. Association des directeurs d’établissements privés de bien-être et de santé (ADEP), Rapport [aux membres] de l’entretien de l’ADEP avec les représentants du Ministère au sujet

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du retrait, de la modification et du non renouvellement des permis concernant une dizaine de ses membres, 28 June 1971, p. 5, BANQ, 7B12 04-06-003A-01, 1960-01-484/636. See also, for instance, Dr A. D. Archambault, Allocution au Congrès de l’Association des hôpitaux privés du Québec, Quebec City, 15 July 1967, p. 2, BANQ, 2B11-1604A, 1960-01-580/91. AHPQ, Liste des questions et demandes particulières, 1969, p. 5, BANQ, 2B11-1605A, 196001-580/92. Ministère des Affaires sociales, Mémoire sur le régime applicable aux établissements privés d’affaires sociales, 28 May 1973, p. 9, BANQ, 7B013 02-01-001B-01, 1960-01-484/886. A number of authors established this fact for all health and social services. See, for instance, Yves Vaillancourt and Michèle Charpentier, eds., Les passerelles entre l’État, le marché et l’économie sociale dans les services de logement social et d’hébergement pour les personnes âgées (Montréal: Laboratoire de recherche sur les politiques et les pratiques sociales, UQAM, 2005), p. 1-2. Gouvernement du Canada, Bureau fédéral de la statistique, Statistique des hôpitaux (Ottawa: Bureau fédéral de la statistique, 1955): 102; AHPQ, Mémoire soumis à l’Honorable Émilien Lafrance, Ministre du Bien-être et de la Famille, December 1964, p. 7, BANQ, 2B111604A, 1960-01-580/91; Gouvernement du Québec, Commission Castonguay-Nepveu, Commission d’enquête sur la Santé et le Bien-être social: Les établissements à but lucratif, vol. 7, t. 2 (Québec: Commission Castonguay-Nepveu, 1970), p. 11; and Mémoire de l’Association des directeurs d’établissements privés—santé et bien-être—de la province de Québec (ADEP) à la Commission parlementaire des Affaires sociales, September 1974, p. 28, BANQ, 7D 038 04-01-003B-01, 1960-01-484/1008. In 1985, the name was changed to ministère de la Santé et des Services sociaux. Davies, Into the House of the Old; Jean Turgeon, Hervé Anctil, and Joël Gauthier, “L’évolution du Ministère et du réseau: continuité ou rupture?,” in Vincent Lemieux, Pierre Bergeron, Clermont Bégin, and Gérard Bélanger, eds., Le système de santé au Québec (Québec: Presses de l’Université Laval, 2003), p. 94-117; Valverde, “Mixed Social Economy,” p. 33-60. A similar evolution is observed in British Columbia, but for a different period—between World War I and World War II. See Davies, Into the House of the Old, p. 66, 70. See, for instance, Association des Hôpitaux Privés du Québec Inc., Mémoire soumis à l’Honorable Éric Kierans, Ministre de la Santé, February 1966, p. 1, BANQ, S2-91, 196001-580/91; Bulletin de l’Association des Hôpitaux Privés du Québec Inc., 1, 2 (1969): 1-3, BANQ, 2B11-1605A, 1960-01-580/92. These quotations can be found in Jean-Paul Deslierres, AHPQ Administrator, to JeanJacques Bertrand, Office of the Premier, 24 September 1969, BANQ, 2B11-1605A, 196001-580/92; and Association des Directeurs et des Établissements Privés (ADEP), Document de travail présenté à l’Honorable Claude Castonguay, Ministre de la Santé, du Bien-être social et de la Famille de la Province de Québec, 28 August 1970, p. 12, BANQ, 2B11-2101A, 196001-580/93. The ADEP is the association that succeeded the AHPQ in 1969. Dr. A. D. Archambault, director general at the l’Hôpital Crawford Inc., “Aide ou entrave à la qualité des soins,” L’hôpital face aux exigences 1963: Travaux du deuxième Congrès de l’Association des Hôpitaux Catholiques de la Province de Québec, June 1963, p. 73, 75. Document tabled at the AHPQ general assembly with a letter from Marcel Roy, Association Secretary, to Benoit Levasseur, Ministère du Bien-être et de la Famille, 0113-1969, BANQ, 2B11 1605A, 1960-01-580/92, file July 1968 to May 1969 included, Association des hôpitaux privés du Québec, Normes de financement, vol. 6. AHPQ, Compte rendu d’une réunion tenue le 24 avril 1969 au Restaurant Sambo avec les sousministres pour l’explication des Modalités de Financement, 24 April 1969, p. 5, BANQ, 7 B 012 04-06-003A-01, 1960-01-484/636. This can be explained in part by the reluctance of the government to fund private establishments that did not exist before the passing of the Hospital Insurance Act. See AHPQ, Compte rendu d’une réunion, p. 5. Lionel Rioux, La vie et les misères d’un médecin de campagne (Outremont: Québécor, 1995). AHPQ, Lettre du Président, 24 September 1965, p. 1, BANQ, 1960-01-580/91. See also A.

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Rouzier, Compte rendu du congrès de l’ADEP, Ministère de la Famille et du Bien-être social, 13 November 1969, BANQ, 2B11-1605A, 1960-01-580/92; “Pour les hôpitaux privés: moment crucial,” Montréal-Matin, 25 September 1964, p. 2. Jean-Paul Cloutier, Ministre de la Santé, de la Famille et du Bien-être Social, “Allocution,” Congrès de l’Association des hôpitaux privés du Québec, Montréal, 7 November 1969, p. 12, BANQ, 2B11-1605A, 1960-01-580/92. Cloutier, “Allocution,” p. 3. “Québec: les hôpitaux privés souffrent de ‘l’hospitalose,’” Le Devoir, 21 June 1966, p. 3 (the article quotes Claude Gauthier, then president of the AHPQ). See also AHPQ, Lettre du Président, p. 1. AHPQ Inc., Mémoire soumis à l’Honorable Éric Kierans, p. 3; and Claude Gauthier, Mémoire de l’Association des hôpitaux privés du Québec présenté à l’Honorable Émilien Lafrance, 19 May 1965, p. 2, BANQ, 2B11-1604A, 1960-01-580/91. AHPQ Inc., Mémoire soumis à l’Honorable Éric Kierans, p. 4. Denise Boucher, “Les hôpitaux privés entendus à la Commission Castonguay,” Le Devoir, 21 February 1968, p. 3. For all these elements, see Aline Charles, “Des hôpitaux et des femmes,” Quand devienton vieille? (Québec: Presses de l’Université Laval, 2007), p. 87-104; Luc Desrochers, Une histoire de dignité-FAS (CSN) 1935-1975 (Beauport: MHN, 1997); Nadia Fahmy-Eid, Aline Charles, Johanne Collin, Johanne Daigle, Pauline Fahmy, Ruby Heap, and Lucie Piché, Femmes, santé et professions (Montréal: Fidès, 1997). AHPQ-Comité des Classes S-1, S-2, et S-3, “À Monsieur le Ministre du Bien-être social et de la Famille,” December 1965, p. 7, BANQ, 1960-01-580/91; and AHPQ Inc., Mémoire soumis à l’Honorable Éric Kierans. Minutes des réunions entre l’A.H.P.Q. et le ministère de la Santé et des Établissements privés de bien-être, 29 July 1966, p. 5, BANQ, 1960-01-580/91. See also AHPQ-Comité provincial de négociation, Les négociations collectives dans les institutions privées de santé et de bienêtre, 4 October 1966, p. 3, BANQ, 2B11 1604A, 1960-01-580/91; and Jean-Paul Deslierres, ADEP Administrator, to Gilles Gaudreault, Assistant Deputy Minister, Professional Relations, 8 December 1970, BANQ, 7B12 04-06- 003A-01, 1960-01-484/636. Claude Gauthier, President of the AHPQ, “Discours, Réunion générale spéciale d’urgence avec les représentants des ministères de la Santé, du Bien-être et de la presse,” February 1966, p. 3, BANQ, 1960-01-580/91. See also AHPQ-Comité provincial de négociation, Les négociations collectives; Yvon Daoust, “Allocution,” Congrès de l’Association des hôpitaux privés du Québec: “L’hôpital de demain,” Québec, 15 June 1967, p. 2, BANQ, 2b11-1604A, 1960-01-580/91. Cloutier, “Allocution.” Jean Francoeur, “Faut-il étatiser les hôpitaux privés?,” Le Devoir, 26 April 1965, p. 1. Québec (Province), “Rapport du Service de l’assurance hospitalisation pour l’année 1961,” Rapport annuel du ministère de la Santé, 1961, p. 206. See, for instance, AHPQ, Mémoire soumis à l’Honorable Éric Kierans; AHPQ Inc., Rapport de l’Association des Hôpitaux Privés du Québec—Classe S-3 au Ministère du Bien-Être et de la Famille, 30 May 1966, 4 p., BANQ, 1960-01- 580/91; Jean Francoeur, “Les hôpitaux privés se disent la cible d’une politique de ‘spoliation larvée,’” Le Devoir, 8 April 1965, p. 1; Gauthier, Mémoire de l’Association; Joseph Moulin, “Allocution,” Congrès de l’Association des hôpitaux privés du Québec: “L’hôpital de demain,” Quebec City, 15 June 1967, p. 3, BANQ, 2b11-1604A, 1960-01-580/91; “Pour les hôpitaux privés,” p. 2. See, for instance, AHPQ Inc., Mémoire soumis à l’Honorable Éric Kierans, p. 9. See, for instance, AHPQ Inc., Rapport de l’Association des Hôpitaux Privés du Québec, p. 1; “Pour les hôpitaux privés,” p. 2. See, for instance, AHPQ, “Commentaires à M. Roger Marier, sous-ministre, et à ses collègues,” 5 September 1968, BANQ, 2B11-1605A, 1960-01-580/92; AHPQ, “Liste des questions et demandes particulières,” 1969, p. 9, BANQ, 2B11-1605A, 1960-01-580/92; Claude A. Gauthier, President of the AHPQ, to Éric Kierans, Minister of Health, 26 March 1966, BANQ, 1960-01-580-91.

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59 See, for instance, AHPQ Inc., Mémoire soumis à l’Honorable Éric Kierans, p. 1; and Daoust, “Allocution.” 60 Paul Lessard, Hospital Insurance Administrative Services Director, Relevé concernant les hôpitaux publics et privés, 29 June 1966, p. 34, BANQ, 2B11 1604A, 1960-01-580/91. 61 Clément Carter, director, Rapport du Service des normes hospitalières, October 1968, p. 4, BANQ, 7B13-5303A, 1960-01-580/118. 62 P.-Paul Archambault, assistant general director, to Camille Blier, assistant deputy minister (Ministère de la Famille et du Bien-être Social), 2 July 1968, p. 3, BANQ, 2B11-1605A, 1960-01-580/92. 63 See, for instance, AHPQ Inc., Livre Blanc en arriération mentale, June 1966, p. 71-72. 64 AHPQ, Compte rendu d’une réunion. 65 AHPQ Inc., Mémoire soumis à l ’Honorable Émilien Lafrance; AHPQ Inc., Mémoire soumis à l’Honorable Éric Kierans; J. P. Deslierres, AHPQ Duty Officer, to the Honourable JeanJacques Bertrand, Office of the Premier, 24 September 1969, BANQ, 2B11-1605A, 196001-580/92; M. Roy, AHPQ Inc. Secretary, to B. Levasseur, Deputy Minister (Bien-être et de la Famille), 13 January 1969, BANQ, 2B11-1605A, 1960-01-580/92. 66 Emilien Lafrance, Ministre du Bien-être social, internal note, April-May[?] 1965, BANQ, 2B11-1604A, 1960-01-580/91. 67 Projet de loi F-4. Corporation des Administrateurs et des Établissements Privés de Santé et de Bien-être, 1968, p. 40, BANQ, 2B11-1605A, 1960-01-580/92. 68 Aline Charles, “Des champs de pratique à constituer et à protéger: le cas du Québec,” in Fahmy-Eid et al., Femmes, santé et professions, p. 167-90. 69 A. Desjardins, director of litigation, to Camille Blier, Assistant Deputy Minister, Ministère de la Famille et du Bien-Être Social, 9 September 1968, p. 3. See also Suzanne Mathieu, lawyer and research officer, to C. Blier, Assistant Deputy Minister, Ministère de la Famille et du Bien-Être Social, 9 September 1968, BANQ, 2B11-1605A, 1960-01-580/92. 70 See, among the many articles, Normand Lépine, “René Lévesque: ce foyer devait être ‘condamné,’” Le Devoir, 2 December 1969, p. 1; N. Lépine, “Une enquête complète s’impose sur la tragédie de Notre-Dame-du-Lac,” Le Devoir, 3 December 1969, p. 1; C. R., “La tragédie de Notre-Dame-du-Lac,” Le Devoir, 3 December 1969, p. 4; N. Lépine, “M. Cloutier le reconnaît: plusieurs institutions ne répondent pas aux normes ‘idéales,’” Le Devoir, 4 December 1969, p. 1; N. Lépine, “Repos du Vieillard: pour une ‘enquête complète, impartiale,’” Le Devoir, 13 December 1969, p. 2; N. Lépine, “Le Repos du vieillard: sept enquêtes sont en cours,” Le Devoir, 17 December 1969, p. 9. 71 Raymond Gendron, Rapport commenté suivi des recommandations appropriées des travaux faits à date par la Mission d’Inspection sur l’état actuel de sécurité d’une grande partie des foyers et des hôpitaux privés de la province de Québec, 1 September 1970, BANQ, 2B11-1605A, 196001-580/93. 72 Paul Sauriol, “L’hécatombe de Pointe-aux-Trembles,” Le Devoir, 6 November 1970, p. 4. 73 Ministerial statement made by Mr. Claude Castonguay, ministre de la Santé, de la Famille et du Bien-être social, to the National Assembly, 15 December 1970, BANQ, 2B11-1605A, 1960-01-580/93. 74 Commission Castonguay-Nepveu, Les établissements à but lucratif. 75 Commission Castonguay-Nepveu, Les établissements à but lucratif, p. 44. 76 Commission Castonguay-Nepveu, Les établissements à but lucratif, p. 43. 77 Commission Castonguay-Nepveu, Les établissements à but lucratif, p. 45. 78 Commission Castonguay-Nepveu, Les établissements à but lucratif, p. 47. 79 Brief cited in Commission Castonguay-Nepveu, Les établissements à but lucratif, p. 46. 80 “‘Un système à repenser’: un dirigeant syndical s’en prend aux ‘commerçants de la vieillesse,’” Le Devoir, 5 December 1969, p. 7. 81 Marcel Pépin, President of the CSN and President of the Fédération Nationale des Services Inc., Norbert Rodrigue, to Claude Castonguay, 25 May 1970, BANQ, 7B125601A, 1960-01-484/664; “Hôpitaux privés, Castonguay s’engage à réétudier le dossier,” Le Devoir, 26 May 1970, p. 3. 82 Besides the ADEP, the Association des foyers pour adultes (AFA) and the Association

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des institutions pour enfants (AIE) were also involved. Concerning this strike, see, for instance, “Hôpitaux privés, Castonguay s’engage à réétudier le dossier”; “Grève dans 50 hôpitaux privés, Le Devoir, 1 June 1970, p. 3; Jean-Luc Duguay, “Hôpitaux privés: fin de la grève,” Le Devoir, 18 August 1970, p. 1. See also Desrochers, Une histoire, p. 25962. Desrochers, Une histoire, p. 259-62. Board of Directors of the Association des Établissements Privés du Québec (ADEP), Première analyse critique du Rapport Nepveu, 9 November 1970, BANQ, 7B012 04-06-003A01, 1960-01-484/636. Province de Québec, Ministère de la Santé, Rapport du Ministère de la Santé 1961, 1962, p. 211, and Rapport annuel 1969, 1970, p. 52. The data include a number of industrial hospitals that were not retained as for-profit establishments for this study. Annual reports from the Service de santé de la Ville de Montréal, relevant years. Commission Castonguay-Nepveu, Les établissements à but lucratif, p. 18. Commission Castonguay-Nepveu, Les établissements à but lucratif, p. 18. The percentage includes the number of cribs.

PART THREE Oral History and the Birth of Medicare

Witnesses to Medicare in Saskatchewan: Medicare Workshop at the University of Saskatchewan—Wednesday, 20 May 2007

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13 The Struggle to Implement Medicare ALL AN BL AKE N EY

The Saskatchewan provincial election of 1960 was fought on the issue of introduction of a single-payer type of medical care insurance in Saskatchewan. It was a bitterly fought campaign, the most bitter that I have experienced in my eight campaigns, and in three or four other election campaigns when I was not a candidate, but which I followed with interest. What made it so hotly contested was the intervention of the organized medical profession. Operating under the name of the College of Physicians and Surgeons, they spent more money on electronic and print media than any political party. Their campaign was aimed against the Co-operative Commonwealth Federation (CCF) government of Saskatchewan. Following the election victory of the CCF in 1960 and the report by the Thompson Committee appointed to examine the proposal, the Medical Care Insurance Act was introduced and passed in 1961 and implemented in 1962. The opposition voted in favour of the bill on second reading—the decision in principle. The Act provided for the plan to be administered by a Medical Care Insurance Commission (MCIC). We were unclear how the medical profession would react to the legislation. I felt that the election had been fought on virtually a single issue. The electoral system had elected a government. The government had done what it had said it would do. And that the profession should be willing to accept the will of the voters and not take the position that the law did not apply to their profession, however distinguished. I was clearly naïve. The first sign of trouble was that the College of Physicians and Surgeons [the College] declared that it would not appoint any members to the Commission. Appearing before the federal royal commission—the Hall Commission—the College said that their members would not practise under the plan but would continue to serve their patients. I will not try to deal with all the twists and turns during the first few months of 1962.

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I’m not sure we fully understand the College’s strategy. One possibility was that they would continue to practise, send bills to patients and urge them to send the bills to the government. This would mean that either the government would pay any amount physicians billed or alternatively that the patients would receive only partial recovery depending upon the amount billed. Either result would have destroyed any single-payer concept of Medicare. To counter this strategy, we enacted legislation in April to give the Medical Care Insurance Commission the power to negotiate with members of the College on behalf of patients on the value of the services rendered. This is perfectly standard practice. If your car is involved in a collision, you take the car to an auto body shop and, at least in Saskatchewan, SGI (Saskatchewan Government Insurance)—the insurer—does the bargaining with the auto body shop. If a workman is injured, he goes to a doctor and the Workers Compensation Board—the insurer—does the bargaining with the doctor about his fees. The same was true for medical services provided to medical indigents. The legislation made clear that the same rules would apply to the Medical Care Insurance Commission in its role as an insurer. The College responded with a mass rally timed to coincide with the resignation of one of our cabinet colleagues—Walter Erb. It was a pep rally to solidify support for a doctors’ strike. This was in early May. Alarm was growing among the public fed by an unbelievable scare campaign run by the media, particularly the Regina Leader-Post, the Saskatoon Star-Phoenix and most of the weeklies.1 We began to prepare in earnest for a strike. The Cabinet divided its duties. Premier Woodrow Lloyd was leading the team; Minister of Health Bill Davies and the MCIC were planning to maintain medical services. My job was to help Woodrow meet the countless delegations, later to take the many press conferences, and to devise strategies to ward off possible legal attack. Other cabinet ministers had other duties. Maintaining medical services included lining up as many British doctors as we could who would come to Saskatchewan if there was a strike. A fair number signed up in response to our ads in the British medical journal Lancet, and were interviewed by the Saskatchewan Agent General in London—Graham Spry—an under-appreciated great Canadian in many ways. A Saskatoon alderman, the late George Taylor, in his capacity as a member of the MCIC, went to London and helped with this work. The reason for the push for British doctors was that, in theory at least, they had a legal right to practices in Saskatchewan on showing simply that they were qualified to practise in Britain, whereas, in the case of US doctors, the College had the right to check their training and credentials. We felt that if we had recruited senior doctors from the Mayo clinic in Rochester, Minnesota or from Johns Hopkins in Baltimore, it would have taken the College many weeks to determine that they were

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qualified to practice in Saskatchewan. Nonetheless, we had a Plan B. If there was a near complete walkout, we lined up doctors from the Auto Workers medical plan in Detroit and the Steel Workers plan in Pittsburgh who would come. If there was a total break down, we felt that nobody would be quibbling about whether the College had found them to be qualified. Fortunately, that did not prove to be necessary. We tried to plan for the eventuality of the Lieutenant Governor dismissing the government and calling an election on his own. That would have been completely unconstitutional but we were not sure that the Lieutenant Governor knew his constitutional role. This was the same Lieutenant Governor who in 1962 would not sign a bill because he didn’t like its contents—he felt it was unfair to oil companies. And without any instructions from Ottawa, he reserved it for consideration by the federal Cabinet. This had never been done in any province in Canada before or since. Even with instruction from Ottawa, it had not been done for decades. We tried to plan for what would happen if an application was made to a court to have the Medical Care Insurance Act declared unconstitutional. There were absolutely no grounds for this, but with one or two of the judges, that might not have mattered. It would have taken us weeks to overturn a rogue decision. I devised a plan where we would pass an order-in-council under other existing legislation to provide another legal basis for the plan. That approach might have been open to legal question but it would have taken time to attack and the strategy would have bought us time. Meanwhile, we were losing the war of public opinion. As a measure of this, I cite that when T. C. Douglas ran in the federal election of June 1962 in Regina city, which was a C.C.F. stronghold, he received just 29% of the vote. This was certainly not encouraging. July 1 dawned bright and clear. And most doctors’ offices were closed. They stayed closed. Public concern mounted. It was clear that we had a full-blown strike on our hands with a skeletal emergency service in a few major hospitals involving about 125 of the 1000 or so doctors who normally served patients. The provincial press began publishing horror stories. It was a very tough few days. But then, British doctors began to come in—a good trickle of them. A nice problem for the College. They dragged their feet a little. But with the papers predicting doom, it was not easy to delay the licensing of these professionally and legally qualified doctors for long. In order to give the British doctors a venue for practice, community clinics were organized in Prince Albert—that is a story of its own—in Saskatoon, in Regina, and in other locations. Several survive today. And another thing happened. Reporters streamed in from all over the world. A doctors’ strike was news. There were reporters from the

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Canadian dailies, from the New York Times, the Washington Post, the London Times and many other papers. And about a week into the strike they began reporting on the two strikes that were going on—the one that the reporters were seeing and reporting on, and the other strike which was being reported by the Leader-Post and the Star-Phoenix. The Winnipeg Tribune, bless them, about a week into the strike, ran an editorial on how badly the Leader and the Star were reporting the strike. The Leader responded that these reporters from outside didn’t understand the issues and therefore couldn’t do a good job of reporting. For the Regina Leader-Post—hardly a world leader in journalism, then or now—to opine that the specialized health reporters of the New York Times, or the London Times or the Washington Post could not do a proper job on reporting was not a promising line of argument. Under the withering scrutiny of the world press, the Leader-Post and the Saskatoon Star-Phoenix had to amend their reporting and give at least some regard for the facts as observed by some of the world’s best medical reporters. Premier Lloyd had two press conferences a day with 50—60—70 reporters at each—more than I’ve ever seen before or since at a provincial press conference. Woodrow also had other things to do—he was out of the province for over two days without the press finding out— that’s a great little story. I took many of the press conferences in my role as the government’s legal joe-boy. It was fun. The tone of reporting began to shift from the day-to-day events to the propriety, or otherwise, of doctors going on strike. Gradually the tide began to turn. I feel that the tipping point was the rally organized by the Keep Our Doctors Committee—the KOD—in front of the legislature building on 11 July. It drew 4500-5000 people—not the predicted 20,000. The rally speakers were using a public address system hooked to the legislative building and operated by the Wascana Centre Authority. If necessary we could have cut off the PA system. Just before the KOD rally, Father Athol Murray had given one of his fiery and intemperate speeches in Saskatoon to a large audience. It was widely reported. The line that got lots of electronic coverage went something like this: “If the government doesn’t withdraw this Act—the Medical Care Insurance Act—there will be blood running in the streets—and God help us if it doesn’t.” Now this is pretty strong stuff from a clergyman at a public meeting in tense times. And I think it was too strong for many of the opponents of the Act. And I think it affected the turnout at the KOD rally. I felt we should have sent Father Murray a Friends of Medicare Medal. You know the rest. Rural doctors began to trickle back to their offices and serving patients. The community clinics were thriving—and on 17 July—the College, as I term it, sued for peace. Enter Stephen, Lord Taylor, who appointed himself as mediator and

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hammered out a compromise—the Saskatoon Agreement. It was certainly not what the College wanted. They conceded the key point—single-payer medical care insurance. It did not contain everything the government would have wanted—easier methods of transition to other modes of practice. But it brought peace. It brought relief to a stressed population and it brought Medicare to Saskatchewan and soon to Canada. It’s our job to take the next steps forward.

14 Working for Medicare BETSY BURY

I lived during the hungry thirties on a farm on the edge of the Dust Bowl. Being the seventh child in a family of ten, I learned the advantages and disadvantages of being poor. I joined the RCAF Women’s division when I became of age. I was able to go to the University of Guelph and graduate as a chef to serve in the air force for three years. During that time I became aware that there were no shortages of anything. Why did it take a war to make this happen? After the war, I came home to find the CCF under T. C. Douglas was the Government of Saskatchewan. Their policy was to improve conditions and to make medical care available to all regardless of their ability to pay. I then spent three years in Wisconsin from 1950 to 1953. This was the period when Senator Joseph McCarthy accused any left supporter of being Communist. As a supporter of the CCF and Medicare, I was warned to say I was a liberal with a small L. When I returned home to Canada, I was pleased to become part of the enthusiastic workers for Tommy Douglas and the CCF. I worked in the party all through the 50s as Councillor and Vice-President, travelling to homes throughout the province. Everyone had a story to tell of a child, a parent, or a friend who had had a problem getting good medical care when needed. But many had already felt the benefits from the Hospital Plan after 1947. Political debates began to heat up when the legislation for Medicare was announced. A group of citizens decided to organize clinics as cooperatives where patients would be partners with the providers, with the objective being a comprehensive program and that the physicians would be paid on salary as part of the team. When the date of 1 July 1962, for the implementation of public medical care insurance was finally set … all hell broke loose. For example, women in their last stages of pregnancy were told their doctors were

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leaving the province and would be replaced by “the garbage of Europe.” People who supported the program were called Communists and received death threats. A local Priest stated that there would be blood flowing in the streets if the program was implemented. Families were divided out of fear and confusion. By this time, Tommy Douglas had left for federal politics, but I never had any doubt there would be a change of heart in the party under Premier Woodrow Lloyd. He brought a calmness and stability with such force, that those of us who were in the ranks speaking at kitchen table meetings had complete confidence that we would succeed. There was massive opposition by the profession to which he would comment, “We are doing things together for the benefit of all.” Although we were disappointed that all of our objectives were not met, when the strike ended, we were glad to have the first step toward universal care and went on working to reach that goal, thus the community clinics were set up as co-operatives to achieve it. Because there was intense community interest at the time, we were able to introduce a number of preventive health programs such as a weight loss club, an anti-smoking group, and a volunteer prenatal education class. This gave us hope that these programs would become a part of the universal health programs envisioned in 1962. A decade later, in 1972, we successfully renegotiated the method of payment from fee-for-service payment to individual doctors to a global clinic budget, and nutrition and foot care were added to our clinic programs. Now that the determinants of poor health are recognized as a component of universality, the big question for me is, will there be political will to move in that direction or will the stake holders continue to demand the status quo?2

15 A Physician on the Front Line of Medicare JOHN D . BURY

I qualified as a physician in England on 30 March 1948 and started my internship just three months before the National Health Service started on 1 July. I graduated a little later from the London Hospital Medical College, University of London. After internship, I performed my National Service for two years in the Royal Army Medical Corps. Then, when three and a half years as a resident in O and G convinced me that I would never be a great gynaecological surgeon, I entered a partnership with an established general practitioner in a mixed urban and rural practice 30 miles east of London in Essex. Here, I built up a practice of 2000 patients in eight years. I was active in medical affairs, was a member of the executive of the Mid-Essex branch of the British Medical Association, and became the first secretary of a newly formed local learned Medical Society. I tell you all this as evidence that I was considered to be a quite respectable member of my honoured profession before emigrating to Canada. While serving in the army, I had met Dr. John Garson and we became reacquainted when we discovered we were practising within a few miles of each other. In October 1962, he attended a conference organized by the Medical Practitioners Union where Dr. Sam Wolfe spoke of a cooperative Community Clinic in Saskatoon, owned and operated by a group of patients, in which staff, including the physicians, were paid by salary, and which intended to widen the range of services that would be more able to deal with the social factors that present themselves in primary care practices. In February, John told me that he was thinking of joining the Community Clinic in Saskatoon and would I like to go as well. I quickly agreed. An 11:30 p.m. phone call to Dr. Wolfe resulted in two new recruits for the Saskatoon Community Clinic. And that is how we arrived with our two families at the Saskatoon Railway Station at eight o’clock in the morning on 13 June 1963, where a crowd of over 100 people were waiting to greet us.

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The Saskatoon Community Clinic had developed as part of a movement that developed as the government and doctors moved towards a stalemate over the implementation of the Medical Care Insurance Act. The doctors threatened not to work under the Plan. This stimulated citizens to organize clinics for health professionals that would provide services. In all, 25 community clinics were developed. By the time the 1 July 1962 implementation day arrived, community clinics in Prince Albert (under Dr. Orville Hjertaas) and Saskatoon were opened. Because of the holiday weekend, the first patient in Saskatoon was not seen until 3 July. There were simply two doctors with their medical bags and one nurse in a room on the third floor of the Avenue building with a telephone and a few chairs. Folding tables from the Union Centre with mattresses became examining tables and they were busy until midnight. With the exception of three physicians, all the doctors in the city shut their offices. Emergency services were provided by a roster of doctors at the hospitals. Gradually the Community Clinic was reinforced by two doctors brought over in the airlift from Britain that Dr. Wolfe, as a Medical Insurance Commissioner, had helped to organize by an expedition to England in June. By the time we arrived in Saskatoon a year later, the clinic was fully functioning with seven doctors and a full nursing reception and records staff. There was an X-ray department and a minor surgery. With Dr Garson, myself and a surgeon who gave up his lucrative practice in Windsor, we were eight. With this background, Dr. Garson and I approached the College of Physicians and Surgeons to be licensed. We were warned that the College did not like the community clinic and that we should be careful. Of the doctors, Dr. Wolfe had hospital admitting privileges at both City and St. Paul’s Hospitals. Dr. Margaret Mahood, who had been the deputy Superintendent of the North Battleford Mental Hospital, only had privileges at City Hospital. We were denied privileges at St. Paul’s as no member of the staff would sponsor us. The next step was to obtain privileges at City. We were interviewed by the Chief of Staff and the Administrator. I was told that this hospital was run properly and did not put patients on the roof like they did in the National Health Service. They accepted my references and sent them off to England by surface mail to delay the process. This resulted in J. F. Goldenberg, the senior partner of our lawyer and a scion of the Liberal Party establishment, attending the Board Meeting of the Hospital with the newly minted Diefenbaker Charter of Human Rights tucked under his arm to demand that we be given admitting privileges. He failed, but eventually our ship came in with our referees’ replies and we were granted privileges after a two-month delay. However, once in the hospitals, every thing was far from sweetness

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and light. The medical staff put community clinic doctors in Coventry and removed themselves from the coffee room in the surgical suite to the nurses coffee room. Our surgeon exacerbated this arrangement by spending most of his free time in the morning just sitting in the coffee room reading the paper. The nurses eventually got fed up with having the doctors around and threw them out. Many of the medical staff would not ride in the elevator with us; the chief of one service was particularly strict in this observance, so when our surgeon got fed up with reading the paper in the coffee room, he and his surgical assistant would each occupy one of the two elevators and enjoy the chief popping in and then quickly popping out when he spied the offending “commie” doctor. These childish games relieved to some extent the stress of practising in the hostile environment. Nurses were not impartial observers to our presence. Many, if not most of clinical nurses, had stood by “their” doctors during the strike and that attitude persisted in the hospital. Visiting patients and trying to find one’s way around hospital procedure was awkward and often the nurses were frankly unhelpful. Of the 10 head nurses, there were only three who behaved professionally and with whom you could have open discourse. The first patient I admitted to hospital was in her last weeks of pregnancy with toxaemia. When I saw her in the office, I immediately sent her to the hospital for admission. When my office was over I went to the ward to give orders. Observed by the head and another nurse, I took the order board to write my orders. I prescribed strict bed rest, restricted fluid intake, fluid balance chart, and wrote the usual orders for aperients as required. I showed the nurses the orders, for I hadn’t written a hospital order sheet for over eight years. Every thing seemed okay. The next morning the patient was somewhat improved. The blood pressure was down and she had some diuresis. I saw her again that evening. The improvement was maintained. On the morning of the third day she was much better. I told her that if this continued she might be able to go home. “Was there anything she wanted,” I asked. “Yes,” she said, “Could I have something to eat?” She had been given nothing to eat or drink except the small amount of water that I had ordered for the nearly 48 hours she had been in hospital. I asked the Head Nurse why that was, “You didn’t order any,” she replied. It was because of things like this and the behaviour of some of the medical staff that for a time the community clinic doctors took to doing rounds in pairs to check on each other’s orders. One consultant would see our patients but not give us his opinion. We reported him to the College and he was reprimanded. We were able to provide a good service due to the few medical staff who treated us with proper professional courtesy and assistance. Even

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though they had been fierce opponents of Medicare, they nevertheless took our consultations, and some even went out their way to give us helpful tips. Things in hospital did not quieten down until after Mr. Justice Woods’ Royal Commission reported that physician behaviour within the hospitals, spurred on by a hostile College, was unacceptable. Because the sponsorship system operated in all the hospitals in Regina, the Community Clinic doctors had no admitting privileges. The result of this was that 13 of the clinic’s patients had their babies delivered at home rather than hospital, including Anne, the wife of Allan Blakeney, the Minister of Health. The matter was eventually settled by Davy Stewart, the Liberal Minister of Health. At a meeting of community clinic representatives, he reported that he had said to the Saskatchewan Medical Association and College, “I have a business in Prince Albert and if a competitor opens up across the street I don’t go around saying how bad they are or interfere with how they do business, I just try and do better than them and that is what I think you should do.” He got us our privileges. However, we were not quite out of the woods. Just before Christmas of 1966, Dr. Samuel Wolfe, our clinic’s medical director, received a summons from the College of Physicians and Surgeons to appear before the Disciplinary Committee charged with unprofessional conduct for unethical advertising. The cause was a pamphlet that the Community Health Association had published entitled, “How to Use the Clinic,” that described the services, hours of operation, and other details. Every member patient would receive a copy of this. One had been lying on the bed of a clinic patient in hospital when it was seen by one of our opponents who took it to the College. Our lawyer applied for an injunction against the College for their attempt to act against the physicians for something done by another party, i.e., the Saskatoon Community Clinic. That injunction has never been answered. Soon afterwards, cooler heads prevailed and we gradually became partly integrated into the system. I, along with my other colleagues, became members of committees in the hospitals and even in the Saskatchewan Medical Association. However, some 15 years later in1977, when the recent honours graduate from the University of Toronto I had recruited for the Saskatoon Community Clinic went to register, the Registrar of the College said to her, “That she was joining that commie clinic and that she should watch her step.” Paranoia has a long prognosis.

16 My Experience in the Medicare Battle and the Woods Commission ROY ROM AN O W

In the 1960-62 period of the Medicare debate, I was still a student at the College of Law at the University of Saskatchewan. Like the province as a whole, the campus community was sharply divided over Medicare. Some of the divisions sprang from pure political forces of difference; others feared change from the known to the unknown; and still others, favoured choice and competition over public payment and delivery of healthcare (a political, but also a philosophical divide). When Premier Tommy Douglas came to campus during this period to explain and defend his policy, the meeting room—at the upper level of the student union building– was overflowing down the stairwell and to the lower floors. By that time, I had already decided I would support the CCF, and Medicare reflected an important aspect of the party’s political philosophy. As I chaired that raucous meeting, my convictions were not so strong as to be apprehensive about the student reactions—pushed by all the reasons I’ve stated and inflamed by fear engendered by the statements of the doctors, the Liberal party and the KOD. Sometime in the summer of 1962, Don Woloshyn, a student friend, and I travelled to Regina to see what we might do to assist the government and its supporters during the doctors’ strike, already in full bloom. My sojourn was brief—several days as I recollect it—but memorable. I had never been in an environment where anxieties, worries, anticipations were so elevated. The activities reflected the gravity of the situation and I was struck—I might even confess to fear—by the cleavages in the wider community. Maybe for this reason, I returned to Saskatoon—and anxiously watched the developments unfold. Later, I returned to Regina in summer of 1963 to work as a junior assistant in the Department of Health. By this time, the Saskatoon Agreement had ostensibly resolved the crisis—but, I was soon to learn that this “resolution” was only on the surface. The undercurrents were strong and swift moving, as those who opposed Medicare so vehemently per-

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sisted to undermine it and the government. One major undercurrent was the issue of hospital privileges and the College of Physicians and Surgeons’ recurring rulings that Medicare doctors—primarily recruited from the UK—were somehow not qualified to be granted hospital privileges. Of course, with no hospital privileges being granted (or, at least, very few), the community clinics, the people who formed them, and the doctors who joined them—the network of support for Medicare— would fade. I’m not certain why I was asked to serve as Assistant Secretary to Ed Wahn, secretary, of the Woods Royal Commission on Hospital Privileges. Premier Lloyd established this inquiry to determine precisely the reasons for so many rejections. But I was thrilled to join Ed as his assistant and share living accommodations in Regina. I was also honoured to be a member—however junior—of the team that made up the Woods Commission. Mervyn Woods, the Commission Chair, had been a professor at the University of Saskatchewan’s College of Law but was appointed to the Court of Appeal by the Diefenbaker government. I knew him as a law teacher. He was a gentleman in his demeanour; humorous in a dry and, sometimes, cutting way; he could recite poetry endlessly; and he was scrupulously honest. Ed Wahn had been an early proponent of Medicare and had been involved in the Saskatchewan government in the early planning. His was a sparkling mind, but unassuming. Although he suffered from a severe case of arthritis, the disease did not impair his tennis or his thought processes. The Commission’s legal counsel was Derril McLeod of Regina. Tenacious, tough, and articulate, Derril led the witnesses in examination. As a young law student, I was highly influenced by both McLeod and Woods. As assistant secretary, I did what Ed requested which was to assist in the file-keeping, recording-keeping, and note-taking. Occasionally, I read early drafts for the Commissioner’s final report. That was the unimportant work. The important work was shouting, when Woods walked into the hearing room—“Order, order, the Commissioner.” He wanted this degree of formality, although he once said to me—“Roy, next time you yell ‘order, order’ I’m going to respond—“Bacon and eggs.” Our hearings were in Saskatoon, Estevan, and Regina—all involving pro-Medicare doctors whose credentials to practice in hospitals were challenged by the College. In almost every case, counsel for these proMedicare doctors was George Taylor of Saskatoon. Taylor was a longtime socialist. He advised Premier Lloyd on legal issues and was active in giving political advice to government. A veteran of the Spanish Civil

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War—on the side of the Mac Paps (as they were called), there was little that could intimidate him. His cross-examinations were relentless and withering. This, then, was my introduction to Medicare. I was supposed to be neutral but, in truth, deep down, I was not. I saw the College of Physicians and Surgeons of Saskatchewan as mixing its professional obligations with its political agenda, an agenda that unfortunately did not die with the signing of the Saskatoon Agreement. It is true that Woods essentially found the same thing. His key recommendation was to establish an appeals committee for the College’s decisions. Lloyd did so. The functions of the College were divided, essentially—one was professional assessment; the other was the establishment of the political arm, the Saskatchewan Medical Association (SMA). This remains the case, but after Lloyd’s defeat in 1964, the Appeal Tribunal was dismantled by the Liberal government under Premier Ross Thatcher. But what was not dismantled—although there were some questionable actions like user fees (by this time I was in Legislature in Opposition)—was Medicare. The medical establishment and their civil society supporters knew that the game was over—at least for a time. Many years later, in the years preceding and following my time as Chair of the Commission on the Future of Health Care in Canada Commissioner, I saw the opposition to Medicare arise again. The attacks on my Commission’s report by the anti-Medicare establishment; the election of Canadian Medical Association President, Dr. Brian Day—a long-time proponent of private, for-profit health and an owner/operator of the private Cambie Surgical Clinic in Vancouver; the Chaoulli Supreme Court decision—these are all signs that this great, redistributive program we call Medicare may not yet be safe. One lesson is clear to me: as difficult as it is to gain, progressive change, like Medicare, maintaining it may be even more difficult and challenging. The old arguments have a strange way of arising to, again, present themselves as the new.

17 A Brief Retrospective on the Royal Commission on Health Services JACK B OA N

In many parts of Canada, but categorically not in Saskatchewan, Justice Emmett Hall is thought to be the father of Medicare. This is because the enlightened solution to the provision of medical services that we enjoy came as the result of the recommendation of the Royal Commission on Health Services of which Hall was the Chairman. There is another reason to introduce Hall in this setting: he and Tommy Douglas were good friends. To illustrate this, Fr. Anthony Hall, his young brother, told a cute story at the inaugural Justice Emmett Hall Memorial Lecture, in 1997. It seems that Tommy was in the Civic Hospital, and Emmett was in town on business, and asked to be driven to the hospital to see Tommy. Father Hall said, “I waited outside in the car, and, when Emmett came out he was chuckling, so I asked him … why are you so happy? And he told me that Tommy was asleep when he went into the room, but, the patient in the other bed … said go ahead, wake him up, he won’t mind. So, Emmett woke him up and then Tommy Douglas exploded in astonishment and said, ‘so, you’re here too, Emmett….I’m in heaven that’s what I’m dreaming about, but how did you get here?’”3 My remarks will be on the work of the Commission and something about the character and personality of the Chairman. At another time and place, I want to write on why I think Hall matters, but that will take us further a field than appropriate for today. The Commission came into existence through an Order-in-Council dated 20 June 1961. There were six commissioners in addition to the Chairman, Justice Emmett Hall. They came from one end of the country to the other, representing medicine, dentistry, and nursing: the others were appointed for other good and sufficient reasons. They got organized before I got involved, having appointed a Director of Research, Bernard Blishen, and a Secretary, Norman LaFrance, both of whom served with distinction. In late November 1961, the Secretary called me and asked me to submit an application, and in due course, I was appointed and became the last one to join the five-man research staff.

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With the exception of the Director, we saw nothing of the Commissioners: they were out on the road, holding public hearings, and we were all too busy with our assignments. We would hear things about them, especially concerning the Chairman. For example, later on, during the time that the Report was being written, chapters of it would be duplicated and sent home with the Commissioners to read. When they came together, some of them hadn’t read it, saying they lacked time. Evidently Hall’s big fist came down on the boardroom table, as he shouted, “I can read faster with my one eye than you can with two!” I did get a chance to associate with him, though, in the fall of 1962. He had been invited to address the American Association of Group Medical Clinics meeting in conference in Portland, Oregon, and as I had been studying the phenomenon of Group Medical Practice, word came down that he would like the names of several such clinics that he might visit en route. He asked me to accompany him. He made an excellent impression when he spoke at the convention. I was impressed with his grasp of the issues. I was impressed also with his forthright approach. I recall his asking the doctors at the Group Medical Clinic in Wenatchee, Wash., whether it would make any difference to the way they practised if they were reimbursed by a public body rather than an insurance company. As you might expect in that setting, it was treated as a rhetorical question. Early on, it was decided that the Commission would not depend solely on submissions and public hearings, but that it would enlist the experts across the country to tell the story as they saw it from their distinctive professional perspectives. On my first day at the Commission, the Director of Research called me in and asked me to make up an outline of a study on voluntary health organizations in Canada. I gave this some thought and turned in a draft outline consisting of an introduction, several chapter headings, the logical subheadings, and a conclusion. He thanked me and sent it off to Professor Betty Govan at the University of Toronto. Back it came with a few minor changes and that became the basis for her contract. After that success, I was called on to do the same for other studies: three in dentistry, two in pharmacy and nursing, and several others. Then, I got the job of seeing them through to completion, trouble-shooting so to speak, and at the end, when they were ready for number crunching, I was running all over Ottawa using practically every IBM facility in the city to process their data along with those of studies in psychiatry, tuberculosis, and others. When we were in the final stages and trying to put a final report together, Bernard Blishen, the director of research came along and said that the Chairman was insisting on a Health Charter. This was something that had not been thought of until then and was a bit upsetting. Eventually a Health Charter for Canadians appeared, forming pages 11-

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15 in the Report. It makes for interesting reading today. It shows Hall to be pretty idealistic in retrospect. The Charter says, inter alia, “We are opposed to state medicine … We recommend a course of action based upon social principles and the co-operation and participation of society as a whole [and at this point reference is made in a footnote to John XXIII, Mater et Magistra, 1961] in order to achieve the best possible health care for all Canadians, an aim that Canadians by their individual efforts cannot attain.”4 One wonders what he would have thought of the bureaucratic monster we have created and the endless political wrangling of the provincial premiers that Romanow tried—in vain, in his report—to circumvent. Or the fact that most of the 256 recommendations made in the Report have been taken over by events in a few instances or totally ignored? All of these frustrations are quite a step removed from the kind of co-operation that Hall envisaged. Be that as it may, academics of that time paid the Hall Report the compliment that it comprised the most comprehensive study of the health services of any country that had been done up to that time. I found it interesting that this individualistic jurist, Emmett Hall, coming from one of the most conservative professions in our society, gradually becoming convinced, on the basis of the evidence presented, that a publicly sponsored medical insurance scheme would be the most efficient and just system. However, I need not have been surprised. Dennis Gruending, his biographer, quotes Roy Romanow who said, “He was a compassionate humanitarian and a progressive jurist [and] tended to lean toward those who felt that door-to-door democracy, as messy as it frequently is, was best able to sort out the competing rights and responsibilities of Canadian citizens.”5 Hall himself made his view of society quite clear in a speech he delivered to the Canadian Council on Welfare. It was shortly after he turned in the Hall-Dennis Report on Education (1968). He said: “The right to health services and to education are now entrenched rights. They are twin endeavours advancing mankind. [And] the ultimate aim is elimination, as much as lies with society’s power, of poverty, sickness, ignorance and want—the structuring of a society that willingly accept to distribute its wealth equitably to its citizens.” 6 Clearly, he thought that the purpose of government was to do those things that people could not do for themselves, among which is making it possible for every citizen to reach his or her full potential. The Justice Emmett Hall Memorial Foundation, sponsored by the Canadian Health Economics Research Association, was incorporated on 5 May 1997, to celebrate and recognize excellence in health economics policy research as articulated by the late Justice Hall—equity, fairness, justice, and efficiency. Its scope is limited by the size of the capital fund so far accumulated, and it continually hopes that somewhere, some place, there is someone with a deep pocket, or many people with mod-

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est pockets, or both, who will take advantage of the charitable tax receipt available, and help us to achieve greater things. In conclusion, it was a great experience to be associated with the Royal Commission on Health Services. It taught me that health economics could contribute a great deal towards solving problems arising out of implementing a single-payer health system and other related matters. Teaching and doing research in health economics has been deeply satisfying. Emmett Hall’s democratic outlook as well as his devotion to equity in society have been truly inspirational. Hope burns eternal, said Tennyson, and it is because of men and women like him that we struggle to make a better world, despite the odds. NOTES 1 My thoughts on this were published in “Press Coverage of the Medicare Dispute in Saskatchewan: I,” Queen’s Quarterly, 70, 3 (1964): 352-61. 2 In the SOS Medicare 2 Conference of 3 and 4 May 2007, the determinants of health were recognized as a component of universality. See Bruce Campbell and Greg Marchildon, eds., Medicare: Facts, Myths, Problems and Promise (Toronto: James Lorimer & Company, 2007). 3 See, “Forward to Basics,” in Proceedings of the 7th Canadian Conference on Health. Economics (Ottawa: Canadian Health Economics Association, 1997), p. 2. 4 Royal Commission on Health Services, Royal Commission on Health Services: 1964, Volume 1 (Ottawa: Queen’s Printer, 1964), p. 13. 5 Dennis Gruending, Emmett Hall: Establishment Radical (Markham, Ont.: Fitzhenry and Whiteside, 2005). 6 Gruending, Emmett Hall, p. 200.

Conclusion A New Prescription: Adding Historical Analysis to Health Policy HEATHER MACDOUGALL

Why draw on history and historians for policy input? As the noted British social historian Simon Szreter points out, Policy-makers in the health field are subjected to a plethora of forms of knowledge from the bio-medical, health economics, management and policy science fields, which appear to be able to predict in advance specified outcomes …, regardless of local contexts, and which purport to be sufficiently “scientific” and powerful as to be relied upon for guidance by decision-making funders, officials and ministers so they can set targets and deadlines for policy delivery … Such forms of context-free policy science promise interventions which will supposedly negotiate the process of change without unforeseen consequences and reactions. They are therefore severely handicapped as detailed guides in particular contexts with their specific local conditions and history … History provides a way of thinking about society and its component parts, about the messy, conflicted and negotiated process of change and about the difference between perspectives of different agents, a disposition which potentially can assist in the field of policy formulation and implementation.1

These comments are particularly relevant to the history of Medicare and Canadian health policy in general, because the purpose of this type of historical research is to advance knowledge and inform decision-making. By identifying the interests of various governments, the processes and institutions through which policy is developed and implemented, the views and values of the state and non-state actors who are at the negotiating table, and the attitudes and beliefs of patients, health-care professionals, administrators, activists, public servants and politicians, scholars can provide historically informed interpretations of contemporary issues. Accustomed to seeing history as a continuum in the stream of time, attuned to the ideological proclivities of themselves and their society, and alert to the silences and gaps in public discourse and media representations of health issues and policy, historians have a vital role to play in the development and assessment of health-care policy.2 But a

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new prescription for action is needed to realign historians’ skills and knowledge with the needs and objectives of health-care policy and decision-makers. DIVERGING PATHS: POLICY ANALYSIS AND ACADEMIC HISTORY, 1960S-2000S

As the wide-ranging articles in this collection demonstrate, contemporary Canadian historians, political scientists, and sociologists all have new insights to add to the history of Medicare. But why has their work been absent from recent policymaking? Prior to the 1960s, history was one of the humanities disciplines in which prominent civil servants had been trained, because educated generalists were thought to have the skills and savoir faire to be effective policymakers and administrators.3 But with the Glassco Commission’s recommendation for more “businesslike” government during the 1960s and American social scientific models such as the Rand Corporation and the Brookings Institution to emulate, the federal government’s hiring practices changed, with the result that economists, statisticians, and other technical experts became the dominant force in policymaking.4 This trend has continued to the present, with the result that there is little historical memory of past policies and their impact.5 In addition, frequent reorganizations of departments like National Health and Welfare (now Health Canada) and its provincial and territorial counterparts further limit recollections of the origins and intentions of policy changes. Furthermore, the pressure of daily administrative duties and the constant political challenges that Medicare has faced since its implementation have limited time for research into previous policy proposals or sustained critical reflection by senior bureaucrats on the choices that are available.6 Clearly, turning to professional historians would provide “powerful explanatory narratives for the present, suggest intriguing analogies to past events, and help build consensus around policy and management goals.”7 But are historians prepared to accept this call for collaboration? From the 1970s to the present, the political and constitutional focus that had dominated academic history was challenged by a younger generation who shifted attention to labour, women’s, minority, and Aboriginal history. Just as Canada was implementing key components of the “welfare state”—national pensions, old age security, hospital and medical services insurance—and celebrating its centennial, the academic consensus regarding the pivotal role of national history was beginning to fragment.8 The new social history with its emphasis on history “from the bottom up” had a profound impact on medical history, as studies of the evolution of nursing and allied health professions, the cultural context of medical practice and patient responses, the impact of regional differences in the provision and delivery of health services, and the place of

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hospitals in their communities and popular consciousness displaced the monographs on great men, institutions, and discoveries that had previously dominated.9 The new social history critiques a monolithic version of Canada’s past focusing on elite politics and policies as insufficient, if not deficient. Moreover, perspectives derived from Quebec nationalism, second wave feminism, Western alienation, multiculturalism, neo-liberalism, post-structuralism, and human rights challenged the very idea of national history. Indeed, one feature that these new fields shared was an open distrust of traditional politics and, by extension, the policymaking process.10 The result was that scholars who earlier would have been asked to sit on royal commissions or to serve as historical researchers for government departments generally were not invited to participate in policymaking from the 1970s onward.11 By ceding the analysis of policymaking to political scientists, economists, sociologists, psychologists, and anthropologists, historians lost their well-established role as “public intellectuals” and purveyors of national identity. Ironically, they found themselves outside the corridors of power, even though their work revealed the deep roots of many contentious social policy issues.12 Thus, the challenge now is to reintegrate historical analysis into the policymaking process so that the insights developed during the past 30 years of social history research can aid contemporary policy choices. MEDICARE, HISTORY, AND POLICY QUESTIONS

But what of the history of Medicare itself? Malcolm Taylor’s oft-cited study, Health Insurance and Canadian Public Policy (1978, 1987) and C. David Naylor’s well-known analysis of the role of the Canadian Medical Association (CMA), Private Practice, Public Payment (1986) have dominated the academic and policy worlds since their publication. Taylor’s monograph remains the quintessential work on the policy and programmatic nature of Medicare, while Naylor’s study is the foundation for evaluating the role of the CMA as a pressure group. But neither study devoted much attention to the changing role of the federal or provincial bureaucracies and the complex challenges that they faced in implementing and modifying Medicare. Recently, political scientist Stephen Brooks pointed out that policymaking in this country has evolved into a profession through a series of intellectual and situational developments spanning the 20th century. Starting with the slow creation of a merit-based bureaucracy that adopted Weberian efficiency through applying Keynesian policy to create an activist “welfare” state, the Ottawa mandarinate saw its influence diminish with the arrival of the Trudeau Liberals in 1968. Not only did Trudeau and his team distrust long-serving civil servants but they also believed that policy creation and management was part of a transferable toolkit. As a result, senior

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bureaucrats became peripatetic administrators rather than professional experts in a particular policy area such as health care.13 Since a similar practice began to occur among Cabinet ministers, the close relationships that had characterized policy making in the King, St. Laurent, and Pearson years (as illustrated in the chapters by Ostry, MacDougall, and Bryden) rapidly disappeared.14 What effect did this have on both the staff in the federal health department and federal policy development? Did it enable non-governmental groups such as the Canadian Medical Association to increase their influence or did the constant staff/politician turnover prohibit the type of personal relationships that had existed in the 1940s? By applying their experience in documentary research and oral history techniques to these topics, historians are in an excellent position to answer many crucial questions concerning Medicare’s political and administrative history. Similar research and interpretive expertise also needs to be applied to examining provincial activity both before and after the implementation of hospital and medical services insurance. These studies that will expand on the important insights offered by the articles in the second section of this collection should not only include careful analysis of the development of provincial health departments and their activities during the interwar period but also an assessment of the way that the implementation of hospital and medical services insurance programs contributed to expanding provincial staff and altering the long-established governmental focus on public health. For example, the role of the Saskatchewan experts who left that province in 1964 and went to New Brunswick to assist that province in planning and implementing medical services insurance deserves study.15 Likewise, the work of the Dominion Council of Health (DCH), an advisory group of provincial deputy health ministers, representatives of farmers’, labour, and women’s groups that usually met twice a year in Ottawa from 1919 to 1972 deserves close scrutiny, because it clearly provided a forum for exchanging information about current health issues, provincial programs and policies, and public opinion from concerned citizens and groups.16 Do the federal-provincial-territorial expert groups and organizations that exist today parallel the DCH in terms of providing strategic advice and guidance to health ministers and their deputies, or is that role filled by political assistants? As part of the “modernization” of the federal, provincial, and territorial health ministries in response to the Hospital and Diagnostic Insurance Services Act (1957), expert technical groups were established to develop national standards in fields such as hospital accounting, hospital construction, and health administration. Does this exemplify the growing faith in computerized record keeping and modern management techniques that dominated progressive administrations in the 1960s? What

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lessons do these developments have, given current difficulties in developing electronic health-care records? As Carolyn Tuohy has demonstrated, the political conflicts of the 1970s that originated with the OPEC crisis in 1973 played an important role in the development and implementation of the Established Programs Financing Act in 1977.17 But historians have yet to examine how the federal focus on constitutional change, Quebec nationalism, and Western alienation each contributed to the erosion of Medicare’s four founding principles and the rise of extrabilling and user fees during the decade.18 Like the insights into Saskatchewan’s experience with the implementation of medical services insurance that can be derived from the oral history section of this collection, interviews with federal and provincial health ministers and their deputy ministers as well as the finance ministers and their staff would demonstrate how policymaking unfolded and enable us to understand the historical forces that influenced their actions. Similarly, when did co-operative federalism become fiscal federalism, and how did this affect the relationship of provincial and federal civil servants?19 Did their professional training enable them to overcome loyalty to their departments and work for equitable solutions on health funding, or did they protect and promote regional interests at all times? The advent of neo-liberal economics under the Thatcher and Reagan administrations in the 1980s and the end of the “welfare state” era (1945-75) in Great Britain and the United States led to many demands for cuts to government spending in Canada. As the most expensive government program, Medicare was a prime target for cost reduction.20 How were federal and provincial health bureaucrats affected by the significant changes in economic policy during this era? Did they accept or reject the neo-liberal attacks on government services and rising healthcare costs? To fully understand the impact of the political decisions that resulted in funding cuts from the 1970s to the 1990s, further historical research is essential. For such research to be meaningful, however, it will need to include analysis of the rise of think tanks, non-governmental organizations, consulting groups, and citizen activism, since policymaking in our Westminster-style system has altered from a formal top-down, problem-oriented, expert-based approach to a more diffuse, process-oriented style that encompasses state and non-state actors in dialogue and decisionmaking.21 Comparing and contrasting the reports of right-wing think tanks such as the Fraser Institute and the Atlantic Institute for Market Studies with those from the left such as the Parkland Institute and the Canadian Centre for Policy Alternatives might illustrate the important role that non-state actors play in influencing the media, public opinion, and, by extension, policymakers as they contemplate changes to Canadian health-care policy at the federal and provincial/territorial levels.

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Historians have many questions to guide their research in this area. Why were these organizations created? How has their work affected the public’s faith in Medicare’s sustainability? Are the facts that their reports present historically accurate? How has policymaking in the health-care field been affected by neo-liberal ideology and the media, which present it for public debate?22 For example, has the partisan focus that underlay health-care politics in the 1950s and 1960s simply reappeared as left-wing or right-wing critiques of the welfare state from the 1980s to the present? Historians trained to analyse rhetoric and discourse are in a strong position to assess the impact of reports and media activities of think tanks and other non-state actors on policymakers and their choices. Another important and much debated question is when and why Medicare became a national icon and what effect this had on policy making. Was it the appearance of the Alberta Friends of Medicare23 during the controversy about the Canada Health Act that led to similar groups in other provinces, or was it federal funding, as Monique Bégin recounts in her memoir?24 As many of these groups celebrate significant anniversaries, historians should be interviewing former members and compiling documentary records of the tactics and strategies used to organize citizens to support and defend this cherished social program. They should also interview journalists and civil servants to determine the extent to which external pressure influences policymaking.25 Money and power have been the central point of conflict among Canadian governments since Medicare was implemented. Are current governments using the recession as an excuse to cut health spending by stealth rather than through public discussion and debate?26 Will we return to the controversies of the 1980s and 1990s as we face renewed pressure to cut health-care funding?27 Canadians have consistently supported the values underlying Medicare, and recent public opinion surveys demonstrate that it remains the best-loved program provided by our governments. But are such polls an accurate representation of public opinion, and to what extent do they influence politicians and policymakers?28 Although public opinion polling has become a significant feature of policymaking at all levels of government, historical research can provide the context for assessing the depth of support for proposed new approaches and initiatives such as user fees or medical savings accounts by tracking change and continuity over time. Combined with attention to media coverage in newspapers and the Internet, the historian’s use of the variety of sources discussed above and her or his understanding of the stages in the policy process will enrich the information base from which future policy options are created.29

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SHARING KNOWLEDGE AND DEFINING EXPECTATIONS

Nonetheless, historians and policymakers inhabit different worlds, use different terms to express their views, and have different priorities and objectives. How then can they overcome these intellectual and communication challenges? For historians, understanding the time pressures on policymakers and other potential “clients” is crucial. The slow, timeconsuming research process that results in historical monographs and articles does not parallel the limited “policy windows” that astute bureaucrats use to formulate or revise existing policies. As a result of the timing gap between the academy and the policy world, if history is used to justify policy change, it generally reflects the views of the policymakers, based on their selective recollections from university history courses, media-based historical “factoids,” or analogies suggested by their colleagues or political superiors.30 Rarely do policymakers actively seek historical input from professional historians. In part, this happens because policymakers are seeking to “solve” problems and hence need information that assists them to do this, rather than seeking conflicting interpretations of the past, or an overly simplistic cause-and-effect view of the way that events shape leaders and their followers.31 So what can historians do to contribute to health policy in the future? First, they can examine the stages of the policymaking process to determine where their research fits and to whom it should be directed. As Kenneth Kernaghan notes, there are reflective practitioners among the civil servants, and they should be cultivated by academics who truly wish to understand policymaking and to contribute to its effectiveness.32 Second, historians should not be afraid to research topics of current policy importance such as Pharmacare, home care, and fiscal sustainability. For example, Canadian business historians could study the history of the Canadian pharmaceutical industry to see how the growth of generic manufacturers has challenged the dominance of multinational corporations and whether the drug benefits plans in various provinces can be used as models for a national drug strategy as recommended in the Romanow Report (2002). Similarly, women’s and labour historians might examine the impact of elder care on the “sandwich generation” of women who are trying to raise families, care for their parents, and work. This is a social and health issue with significant future ramifications. Third, historians could examine the demographic models and the actual health status, practices, and beliefs of the baby boomers in contrast to previous generations to provide background for current discussions on the fiscal sustainability of Medicare.33 To further assist policymakers, historians can probe the presumptions on which current policy is based, provide analysis of the expected and

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unexpected consequences of previous decisions and the results of their implementation, and generally explain the context in which policymakers are working.34 To do so effectively, however, they will need to present their findings in language that is accessible to non-specialists and to summarize their results succinctly. In other words, they should be able to explain that policy is always history. Events in the past define the possible and the desirable, set tasks, and define rewards, viable choices, and thus the range of possible outcomes. As we move through time these choices reconfigure themselves and trends may establish themselves—but at any given point the “actionable” options are highly structured. It is the historian’s task to define those likelihoods. Most important, what history can and should contribute to the world of policy and politics is its fundamental sense of context and complexity, of the determined and the negotiated. The setting of policy is contingent, but it is a structured contingency … History cannot predict what will happen; it is a more useful tool for predicting what will not happen. Or to put it another way, defining non-choices is an important way of thinking about choices.35 CONCLUSION

History matters, especially with regard to health policy, because health is fundamental to all societies and their citizens. Throughout the 20th century, Canadians debated the shape and content of Medicare, and today we are faced with the challenge of redefining this social program for the future. Using the knowledge and skills of professional historians to examine neglected aspects of Medicare’s history will greatly enhance policymakers’ ability to develop responses that will fulfill public expectations while meeting politicians’ demands for change. History is not just about the lessons of the past; it can also be a source of imagination, inspiration, and admonition, because its goal is to describe “the complexity, subtlety and multidimensionality “of the human experience.”36 NOTES 1 Simon Szreter, “History, Policy and the Social History of Medicine,” Social History of Medicine, 22, 2 (2009): 235-44. 2 Virginia Berridge, “Public or Policy Understanding of History?” Social History of Medicine, 16 (2003): 511-23. 3 John English, “The Tradition of Public History in Canada,” Public Historian, 5 (Winter 1983): 47-59. See also Douglas Owram, The Government Generation: Canadian Intellectuals and the State, 1900-1945 (Toronto: University of Toronto Press, 1986); and J. L. Granatstein, The Ottawa Men: The Civil Service Mandarins, 1935-1957 (Toronto: Oxford University Press, 1982). 4 Stephen Brooks, “The Policy Analysis Profession in Canada,” in Laurent Dobuzinskis, Michael Howlett, and David Laycock, eds., Policy Analysis in Canada: The State of the Art (Toronto: University of Toronto Press for IPAC, 2007), p. 21-47. 5 Nicole Morgan, Implosion: An Analysis of the Growth of the Federal Public Service in Canada (1945-1986) (Montreal: Institute for Research in Public Policy, 1986).

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6 Kenneth Kernaghan, “Speaking Truth to Academics: The Wisdom of Practitioners,” Canadian Public Administration, 52 (December 2009): 503-23; Donald Savoie, Breaking the Bargain: Public Servants, Ministers, and Parliament (Toronto: University of Toronto Press, 2003). 7 Rosemary A. Stevens, “Introduction,” in Rosemary A. Stevens, Charles E. Rosenberg, and Lawton R. Burns, eds., History and Health Policy in the United States: Putting the Past Back In (Rutgers: Rutgers University Press, 2006), p. 1-9. 8 See Michael Bliss, “Privatizing the Mind: The Sundering of Canadian History, the Sundering of Canada,” Journal of Canadian Studies, 26 (Winter 1991-2): 5-17; J. L. Granatstein, Who Killed Canadian History? (Toronto: 1998); A. B. McKillop, “Who Killed Canadian History? A View from the Trenches,” Canadian Historical Review 80, 2 (June 1999): 269-300; B. Palmer, “Of Silences and Trenches: A Dissident View of Granatstein’s Meaning,” Canadian Historical Review, 80, 4 (December 1999): 676-86. 9 Important examples of the new medical history include J. T. H. Connor, Doing Good: The Life of Toronto’s General Hospital (Toronto: University of Toronto Press, 2000); Jayne Elliott, Meryn Stuart, and Cynthia Toman, eds., Place & Practice in Canadian Nursing (Vancouver: UBC Press, 2008); David Gagan and Rosemary Gagan, For Patients of Moderate Means: A Social History of the Voluntary General Hospital in Canada, 1890-1950 (Montreal and Kingston: McGill-Queen’s University Press, 2002); Kathryn McPherson, Bedside Matters: The Transformation of Canadian Nursing, 1900-1990 (Toronto: Oxford University Press, 1996); Wendy Mitchinson, Giving Birth in Canada, 1900-1950 (Toronto: University of Toronto Press, 2002); Geoffrey Reaume, Remembrance of Patients Past: Patient Life at the Toronto Hospital for the Insane, 1870-1940 (Toronto: Oxford University Press, 2000); Peter L. Twohig, Labour in the Laboratory: Medical Laboratory Workers in the Maritimes, 1900-1950 (Montreal and Kingston: McGill-Queen’s University Press, 2005); Peter L. Twohig, “Written on the Landscape: Health and Region in Canada,” Journal of Canadian Studies, 41 (Fall 2007): 5-17. Specific diseases and syndromes also received study. See Barbara Clow, Negotiating Disease: Power and Cancer Care, 1900-1950 (Montreal and Kingston: McGill-Queen’s University Press, 2001); Jacalyn Duffin and Arthur Sweetman, eds., SARS in Context: Memory, History, Policy (Montreal and Kingston: McGill-Queen’s University Press and Queen’s School of Policy Studies, 2006); Katherine McCuaig, The Weariness, the Fever and the Fret: The Campaign against Tuberculosis in Canada, 1900-1950 (Montreal and Kingston: McGill-Queen’s University Press, 1999). 10 The most articulate formulation of this perspective is found in Ian McKay, “The Liberal Order Framework: A Prospectus for a Reconnaissance of Canadian History,” Canadian Historical Review, 81, 4 (December 2000): 617-45. See also the articles supporting and refuting this view in Jean-François Constant and Michel Ducharme, eds., Liberalism and Hegemony: Debating the Canadian Liberal Revolution (Toronto: University of Toronto Press, 2009). 11 Gregory S. Kealey and Rosemary E. Ommer, “The Practical Historian,” Canadian Historical Review, 68, 3 (September 1987): 431-34. 12 In response to the perceived marginalization of Canadian history, a group of young scholars met in London in 2007 for the “Rethinking Canadian History Conference” sponsored by the Institute for the History of the Americas. The results of the conference appear in Christopher Dummitt and Michael Dawson, eds., Contesting Clio’s Craft: New Directions and Debates in Canadian History (London: Institute for the Study of the Americas, 2009). See especially Christopher Dummitt, “After Inclusiveness: The Future of Canadian History,” p. 98-122. 13 Stephen Brooks, “The Policy Analysis Profession in Canada,” in Dobuzinskis, Howlett, and Laycock, Policy Analysis in Canada, p. 21-47. 14 See Paul Martin, So Many Worlds, vol. 2 of A Very Public Life (Toronto: Deneau Publishers, 1985), for the Minister of National Health and Welfare’s discussion of the key roles played by his deputy minister, George Davidson (Welfare) and Don Cameron (health) in the creation of hospital services insurance.

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15 Lisa Pasolli, “Bureaucratizing the Atlantic Revolution: The ‘Saskatchewan Mafia’ in the New Brunswick Civil Service, 1960-1970,” Acadiensis, 38, 1 (2009): 126-50; Della M. M. Stanley, Louis Robichaud: A Decade in Power (Halifax: Nimbus Publishing, 1984), p. 9296. See also C. Alexander Pincombe, 40 Years under the Blue: A History of Blue Cross of Atlantic Canada (Fredericton: Maritime Hospital Association, 1985), p. 89-90. 16 See Janice P. Dickin McGinnis, “From Health to Welfare: Federal Government Policies regarding Standards of Public Health for Canadians, 1919-1945” (PhD diss., University of Alberta, 1980), for an introduction to the work of the Dominion Council of Health and to the pre-Medicare policy process. For a more critical assessment of the DCH and federal policy vis-à-vis maternal and child health, see Dianne Dodd, “Helen MacMurchy: Popular Midwifery and Maternity Services for Canadian Pioneer Women,” in Dianne Dodd and Deborah Gorham, eds., Caring and Curing: Historical Perspectives on Women and Healing in Canada (Ottawa: University of Ottawa Press, 1994), p. 135-62. 17 See Carolyn J. Tuohy, Policy and Politics in Canada: Institutionalized Ambivalence (Philadelphia: Temple University Press, 1992); Carolyn Hughes Tuohy, “Single Payers, Multiple Systems: The Scope and Limits of Subnational Variation under a Federal Health Policy Framework,” Journal of Health Politics, Policy and Law, 34, 4 (August 2009): 453-96. 18 For the most recent historical analysis of this period, see Heather MacDougall, Making Medicare: The History of Health Care in Canada, 1914-2007 / La lutte pour l’assurance maladie: L’histoire des soins de santé au Canada, 1914-2007, at http://www.civilization.ca/cmc/ exhibitions/hist/medicare/medic00e.shtml. 19 See Donald Savoie, Breaking the Bargain: Public Servants, Ministers, and Parliament (Toronto: University of Toronto Press, 2003). 20 Lawrie McFarlane and Carlos Prado, The Best-Laid Plans: Health Care’s Problems and Prospects (Montreal and Kingston: McGill-Queen’s University Press, 2002); Donald J. Savoie, The Politics of Public Spending in Canada (Toronto: University of Toronto Press, 1993). 21 Laurent Dobuzinskis, Michael Howlett, and David Laycock, “Policy Analysis in Canada: The State of the Art,” in Dobuzinskis, Howlett, and Laycock, Policy Analysis in Canada, p. 3-17. 22 For one historian’s view, see Michael Bliss, “Health Care without Hindrance: Medicare and the Canadian Identity,” in David Gratzer, ed., Better Medicine: Reforming Canadian Health Care (Toronto: ECW Press, 2002), p. 31-34. 23 Esther Steeves, “Extra-Billing and the History of Health Insurance in Alberta” (MA thesis, University of Alberta, 2008). 24 Monique Bégin, Medicare: Canada’s Right to Health (Ottawa: Optimum Publishing International, 1988), p. 127-29. 25 François Petry, “How Policy Makers View Public Opinion,” and Catherine Murray, “The Media,” in Dobuzinskis, Howlett, and Laycock, Policy Analysis in Canada, p. 37598, 525-50. 26 Wayne Kondro, “Federal Budget Light on Initiatives for Health, Research,” Canadian Medical Association Journal, doi:10.1503/cmaj/109-3201. 27 Karen Howlett, “The Trouble with Health Care,” Globe and Mail, 27 February 2010, F1, F6-7. 28 Nik Nanos, “Canadians Overwhelmingly Support Universal Health Care, Think Obama Is on Right Track in the United States,” Policy Options / Options Politiques (November 2009): 12-14; for an opposing view, see Jeffrey Simpson, “The Great Canadian HealthCare Evasion,” Globe and Mail, 5 January 2010, A15. 29 Our British colleagues have established a website for the History and Policy network based at Cambridge University, which can be accessed at http://www.historyandpolicy.org. The Canadian Historical Association also now supports a Political History Group, which indicates the renewed interest in political history and policymaking among younger Canadian historians. 30 Virginia Berridge, “Public or Policy Understanding of History?” Social History of Medicine, 16 (2003): 511-23.

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31 Virginia Berridge, “History Matters? History’s Role in Health Policy-making,” Medical History, 52 (2008): 311-26. 32 Kenneth Kernaghan, “Speaking Truth to Academics: The Wisdom of the Practitioners,” Canadian Public Administration, 52 (December 2009): 503-23. 33 Kate Allen, “Canadians Warm Up to Medical User Fees: Poll,” Globe and Mail, 7 June 2010, A2; David Gratzer, “Canadian Health Care Falls Short of What We Deserve,” Globe and Mail, 7 June 2010, A13; Robert Huish, letter to the editor, Globe and Mail, 8 June 2010, A18; Gary Mason, “This Health-care Crisis Will Require More Than Savings around the Edges,” Globe and Mail, 28 January 2010, A17; Gwyn Morgan, “Public Sector in for Some Wrenching Economic Truths,” Globe and Mail, 4 January 2010, B7; Eugene Vayda, letter to the editor, Globe and Mail, 8 June 2010, A18. 34 Richard E. Neustadt and Ernest R. May, Thinking in Time: The Uses of History for Decision Makers (New York: Free Press, 1986); Simon Szreter, “History, Policy and the Social History of Medicine,” Social History of Medicine, 22, 2 (2009): 235-44. 35 Charles E. Rosenberg, “Anticipated Consequences: Historians, History and Health Policy,” in Stevens, Rosenberg, and Burns, History & Health Policy in the United States, p. 28-29. 36 Philip Teigen, “‘A Kindly, Useful Mentor’: Applying the History of Medicine to Public Policy,” Journal of the History of Medicine and Allied Sciences, 54 (1999): 363.

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Contributors

Allan Blakeney was a key minister in the CCF government when medical care insurance was first introduced in Saskatchewan. As premier of Saskatchewan from 1971 until 1982, he introduced a pathbreaking children’s dental plan and a prescription drug plan. After retiring from politics, he joined the Faculty of Law at Osgoode Hall Law School, and subsequently the College of Law at the University of Saskatchewan. Mr. Blakeney died in 2011. Jack Boan was head of the economics department of the University of Regina during its formative years, after serving in the federal civil service, including time as a researcher with the Royal Commission on Health Services chaired by Emmett Hall. In 1983 he launched the Canadian Health Economics Research Association, now the Canadian Association for Health Service and Policy Research. Terry Boychuk is an associate professor of sociology at Macalester College in Saint Paul, Minnesota. His comparative research on the history of Canadian and American health policy was published as The Making and Meaning of Hospital Policy in the United States and Canada (University of Michigan Press, 1999). P. E. Bryden is an associate professor of history at the University of Victoria. She is the author of Planners and Politicians: Liberal Politics and Social Policy, 1957-1968 (McGill-Queen’s University Press, 1997), and “A Justifiable Obsession”: Conservative Ontario’s Relations with the Federal Government, 1943-1985 (University of Toronto Press, 2013). Betsy Bury worked as a CCF party activist with Tommy Douglas for many years where she saw the financial and emotional hardships

308

CONTRIBUTORS

families faced because of illness. Her dream was to see patients and providers of health care create a wellness society. She worked as a Health Ombudsman with the Saskatoon Community Clinic until her retirement. John D. Bury graduated from the University of London, 1948, and worked as a family physician in England. In the aftermath of the Doctors’ Strike, he moved to Canada to join the Saskatoon Community Clinic as part of a health team with emphasis on prevention from 1963 until he retired in 1988. He also helped design what became the Saskatchewan Prescription Drug Plan, and was co-chair of the Citizens for the Defence of Medicare. Aline Charles is a member of the history department at Laval University and the Centre interuniversitaire d’études québécoises. Focusing on gender and women’s history, her research explores different aspects of twentieth-century Quebec’s social history, including hospitals, the age cycle, work, social policies, and citizenship. François Guérard has taught history at the Université du Québec à Chicoutimi since 2003. Member of the Centre interuniversitaire d’études québécoises with a particular focus on the history of health, he has worked on public health as well as hospitals in the province of Quebec during the nineteenth and twentieth centuries. C. Stuart Houston is Professor Emeritus of Medical Imaging, University of Saskatchewan, and a past-president of the Canadian Society for the History of Medicine. Among his 12 books are two medical biographies (of T. A. Patrick and R. G. Ferguson) and two about the history of medicare, Steps on the Road to Medicare (2002), and Tommy’s Team: The People Behind the Douglas Years (2010) with Bill Waiser. Robert Lampard is a physician and avocational medical historian from Red Deer Alberta. He became interested in the Hoadley Commission health insurance proposals while researching his book on Alberta’s medical history. He was President of the historically focused Medical Foundation for eleven years. Gordon S. Lawson holds a doctorate in the history of science, technology, and medicine from Corpus Christi College, University of Oxford. He has served with the Commission on the Future of Health Care in Canada and the Office of the Chief Scientist at Health Canada. Dr. Lawson is currently senior consultant with Government Consulting Services, Public Works and Government Services Canada.

CONTRIBUTORS

309

Heather MacDougall is a member of the department of history at the University of Waterloo where she specializes in Canadian history, the history of medicine, public health, and health policy. She is the author of Activists & Advocates: Toronto’s Health Department, 1883-1983, and a long-standing member of the Canadian Society for the History of Medicine, serving as it vice-present, president, and past president from 2001 to 2007. Gregory P. Marchildon is a Canada Research Chair (Tier 1) and professor at the Johnson-Shoyama Graduate School of Public Policy, University of Regina. Prior to this, he was a professor at the Johns Hopkins University’s School of Advanced International Studies, Cabinet Secretary and Deputy Minister to the Premier of Saskatchewan, and Executive Director of the Commission on the Future of Health Care in Canada. Merle Massie recently completed a PhD dissertation on Saskatchewan forest-edge communities. A specialist in local, rural, environmental, and medical history, she is currently a post-doctoral fellow in the School of Environment and Sustainability at the University of Saskatchewan. Andrew F. Noseworthy is senior advisor to the president of the Atlantic Canada Opportunities Agency (ACOA). Before this, he had an 18-year career with the Government of Newfoundland and Labrador including Deputy Minister of Intergovernmental Affairs. In 2001, he was seconded to the Commission on the Future of Health Care in Canada. Since joining ACOA he has also led a federal task force on the establishment of the Public Health Agency of Canada. Nicole C. O’Byrne is assistant professor at the Faculty of Law at the University of New Brunswick. She is also an historian who has published on various aspects of constitutional and Aboriginal history and is currently completing her doctorate at the University of Victoria. Aleck Ostry is professor, Canada Research Chair (Tier 2) and Michael Smith Foundation for Health Research Scholar at the University of Victoria. Trained in history, health services planning, and epidemiology, he is the author of Change and Continuity in the Canadian Healthcare System. Felicity Pope is a freelance curator on the material culture of health care who lives in Cobourg, Ontario. She contributed her expertise on political cartoons to the Canadian Museum of Civilization for its exhibition on the history of health care in Canada.

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CONTRIBUTORS

Roy Romanow was assistant secretary of Saskatchewan’s Royal Commission on Hospital Privileges, which was established in the aftermath of the Doctors’ Strike of 1962. He was Deputy Premier and Minister of Justice in Saskatchewan in the Blakeney government, and subsequently Premier of Saskatchewan from 1991 until 2001, when he was appointed Chair of the Commission on the Future of Health Care in Canada.

Index

Aberhart, William, 44, 192 Advisory Committee on Child Welfare, 50 Advisory Committee on Health Insurance, 7, 41, 54, 58, 183; Report of the Advisory Committee on Health Insurance (the Heagerty Report), 55, 197 Advisory Committee on Portable Pensions (Ontario), 78 Agnew, G. Harvey, 242 Alberta, 6-9, 11, 30, 44-5, 79, 106-07, 183-200, 207, 210, 213, 215, 220, 241; Alberta Health Insurance Act (1935), 192; Alberta Hospital Act, 185; Alberta Medical Profession Act, 186; Health Insurance Act (1935, 1942), 197; Municipal Districts Act, 189; Municipal Hospitals Act, 184; White/Pattinson Legislative Inquiry, 187-90 Alberta Association of Registered Nurses, 190 Alberta Friends of Medicare, 300 Alberta Hospital Association, 190, 193 Alberta Medical Association (AMA), 185-87, 193-95; Alberta Medical Bulletin, 195 American Association of Group Medical Clinics, 292

American College of Surgeons, 186, 193 American Medical Association, 194 Amyot, Gregoire, 41-43 Anderson, A. F., 195 Anderson, Matt, 139 Archer, A. E., 60, 186-87, 189-90, 19293, 195, 197-98 Association des directeurs d’établissements privés de bienêtre de santé (ADEP), 261, 265-6 Association des hôpitaux privés du Québec (Quebec Private Hospital Association), 255, 257-58, 261-63 Atkinson, W., 190 Atlantic Charter, 55 Atlantic Institute for Market Studies, 299 Automotive Retailers’ Association, 219 Banks, Peter, 216, 219, 223 Barrett, Dave, 224 Barron, Sid, 100 Bates, Gordon, 42, 50, 55 Bégin, Monique, 8, 90, 106-07, 109, 300 Bennett, R. B., 44-45, 194, 196; Bennett’s New Deal, 44-46 Bennett, W. A. C., 7, 13, 92-93, 207-24

312 Bennettcare, 7, 13, 92, 207-24 Benson, Edgar, 84 Bercuson, David, 64 Bevan, Nye, 219 Beveridge, William, 56, 58; report, Social Insurance and Allied Services, 56 Bignold, Arnold, 233 Blakeney, Allan, 15, 95, 277-81, 287 Blakeney, Anne, 287 Blishen, Bernard, 291-92 Bliss, Michael, 250 block grants (from federal government to provinces), 114 Blue Cross (Canadian insurance plans), 195-96, 199, 200, 212 Boan, Jack, 15, 291-94 Bothwell, Robert, 64 Bourassa, Robert, 103-04 Bouvier, Émile, 61 Bow, Malcolm R., 185-86, 197 Boychuk, Terry, 11, 241 Boyle, James, 61 Bracken, John, 59 Brain, Russell, 242 British Columbia, 7-8, 11, 13, 30, 41, 44-45, 72, 79, 92, 188-91, 193, 195, 199, 207-24, 241, 250; British Columbia Hospital Insurance Service (BCHIS), 93, 209-13; British Columbia Medical Plan (BCMP), 217-19, 222-23; British Columbia Societies Act, 218; Medical Grant Act (1965), 218-19, 222; Medical Services Act (1967), 223; Medical Services Commission (MSC), 223 British Columbia Government Employees Medical Services Plan, 217-18 British Columbia Telephone Health Insurance Plan, 212 British Medical Association (BMA), 193, 284 British North America Act, 43-44, 53

INDEX

Brookings Institution, 296 Brooks, Stephen, 297 Brown, Alan, 50 Brown, Alan W., 218 Brownlee, John, 185; Brownlee scandal, 192 Bryce, R. B., 59, 80 Bryden, P. E., 10, 98, 298 Burak, William J., 140-01, 143-45, 169 Burke, F. S., 49 Bury, Betsy, 15, 282-83 Bury, John, 15 Bury, John D., 284-87 Caldwell, A. L., 140 Calgary Herald, 105-06 Calgary Medical Society, 186-07 Callan, Les, 90 Cambie Surgical Clinic, 290 Cammer, Pat, 145 Canada Health Act (1984), 5, 8, 89, 106-07, 114, 300 Canada Health and Social Transfer, 114 Canada Pension Plan, 77-79, 81, 85 Canadian Association of Adult Education, 55 Canadian Association of Social Workers, 58, 61 Canadian Broadcasting Corporation (CBC), 55, 137 Canadian Catholic Hospital Association, 61 Canadian Council on Welfare, 55, 58, 63, 293 Canadian Federation of Agriculture, 54, 57, 91, 161 Canadian Health Insurance Association, 215 Canadian Hospital Association, 25, 50, 58 Canadian Labour Congress, 55 Canadian Life Insurance Officers Association, 58

INDEX

Canadian Medical Association (CMA), 7-8, 10, 34-35, 44, 51, 56, 58, 60, 72, 76, 91-92, 115, 156, 19598, 290, 298; Canadian Medical Association Journal (CMAJ), 189; Committee of Economics report of 1934, 45, 48-50, 194; Health Insurance Plan (1934-35), 183 Canadian Medical Procurement and Assessment Board, 154 Canadian Museum of Civilization, 109 Canadian National Council for the Control of Venereal Disease, 42 Canadian Pacific Railway (CPR), 187-88; Canadian Pacific Railway health insurance plan, 212 Canadian Public Health Association, 55, 197 Canadian Red Cross, 236 Canadian Sickness Survey, 34 Canadian Tuberculosis Association, 50, 52 cancer, 197 Caouette, Réal, 99 Cape Breton, 61 Cardston municipal hospital program, 189 Cardston News, 189 Carroll, Lewis, 102 Castonguay, Claude, 264-65 Castonguay-Nepveu Commission, 119-20, 263-65 Catholic Hospital Council, 58 Co-operative Commonwealth Federation (CCF), 8, 12, 27, 29-30, 45, 56-57, 59-60, 63, 80, 95, 120, 151-54, 162-67, 171-75, 190-91, 208, 214, 277, 279, 282-83, 288; CCF Program for Saskatchewan (1943), 163-64; Handbook to the Saskatchewan CCF Platform and Policy (1937), 162-63 Centre for Policy Alternatives, 299 Chamber of Commerce, 60

313 Chaoulli case, Supreme Court of Canada, 3, 290 Charles, Aline, 14, 94 Chisholm, Brock, 62-63 Christian Science Association, 190 Clark, D. A., 42 Clark, Joe, 105 Clark, W. C., 57 Claxton, Brooke, 60, 62-63 Cloutier, Jean-Paul, 257-58 Collins, J. J., 155-56 Collins, John, 103-04 College of Physicians and Surgeons (by province), Alberta, 186-87, 190-95, 197, 200; Ontario, 56; Quebec, 265-6; Saskatchewan, 15, 95, 97, 151-57, 159, 161-63, 165-68, 170, 172, 174, 277-81, 285-87, 28990 Commission on the Future of Health Care in Canada, 15, 290, 301 community clinics, 15, 279-80, 283, 284-87 community health centres, 59 Connaught Research Laboratories (Toronto), 42, 50 Cooperative Press Association, 102 cottage hospitals, 7, 14, 138, 140, 22943 Credit Union and Co-operative (C.U. & C) Health Services Society, 219 Crellin, John K., 239 Cross, Wallace Warren, 185, 197 Davidson, George, 55, 58, 63 Davies, Bill, 278 Davies, Megan, 250 Davison, R. O., 140 Day, Brian, 290 Defries, R. D., 50 Dent, C. L., 158 Department of National Health and Welfare, 62 Deutsch, John, 48

314

INDEX

Di Bozsha program, 193 Diefenbaker, John, 7, 9, 99, 214, 285 Disraeli, Benjamin, 47 Doctors’ Strike (1962), 7-8, 12, 15, 71, 77, 79, 95-98, 109, 151, 207, 214, 277-87 Dominion Bureau of Statistics, 59, 252-54, 258 Dominion Council of Health, 46, 4950, 63, 65, 91, 298 Dominion-Provincial Conference on Reconstruction (1945-46), 7, 41, 49, 62, 73 Donato, Andy, 105 Douglas, T.C., 8, 27, 95-96, 99, 120, 137, 142-44, 151-54, 156-58, 160, 162, 164-75, 190-91, 219, 279, 282-3, 288, 291 Drew, George, 33, 59, 60 Duffin, Jacalyn, 164 Duhamel, Roger, 61 Duplessis, Maurice, 94-95, 99 Dymond, Matthew, 82, 102

territorial organizations, 298; Federal-Provincial Technical Conference on Medicare, 223; fiscal federalism, 299; shared-cost financing, 9-10, 12, 33-34, 65, 8081, 112-14, 222; spending power, 4-6 fee-for-service (physician) remuneration, 12, 14, 151-75, 191, 242-44; position of provincial CCF parties, 163; negotiations concerning, 218 Ferguson, G. Gordon, 172 Financial Post, 60 Fines, Clarence, 164 Finkel, Alvin, 64 Fleming, Grant, 50, 196 France, 188, 250, 267 Fraser Institute, 299 Fraser Valley Medical Services Society, 219 Friendly Societies, 23 Frost, Leslie, 33, 73, 78

Edmonton Academy of Medicine, 186 Edmonton Group Hospitalization Plan, 195, 199 Egbert, William, 187 Employment and Social Insurance Act (1935), 45, 196 English, John, 64 Epp Report (1986), Achieving Health for All, 114-17 Erb, Walter, 278 Established Programs Financing Act, 110, 114, 299

Gallup Poll, 33 Gardiner, Jimmy, 158 Garson, John, 284-85 Gathercole, George, 78 Germany, 188 Gibson, C. C., 167 Glassco Commission, 296 Goldenberg, J. F., 285 Gordon, Walter, 10, 74, 76-77, 79-80, 82, 84 Govan, Betty, 292 Granatstein, Jack, 64 Grauer, A. E., 47, 197; Grauer Report, 51 Great Depression, 9, 11-12, 26-27, 37, 44-46, 72, 137, 186, 194, 196-99, 236-37 Green Book (1945) proposals, 64, 73 Greenfield, Herbert, 184 group medical practice, 292

Facal, Joseph, 250 Fahrni, Gordon, 52 Feather, Joan, 142 federalism, 3-11; constitution, 11, 59; co-operative federalism, 33, 299; equalization, 81; federal-provincial-

315

INDEX

Group Medical Services (Regina), 27, 170 Gruending, Dennis, 293 Guérard, François, 14, 94 Hall, Anthony, 291 Hall, Emmett, 7, 15, 74, 99, 105, 106, 214, 291-94; Hall Commission (see Royal Commission on Health Services); Hall-Dennis Report on Education (1968), 293; Health Charter for Canadians, Hall’s insistence on, 292-93; Justice Emmett Hall Memorial Foundation, 293; Justice Emmett Hall Memorial Lecture, 291; Second Hall Report (1980), 106 Hammes, C. F. W., 167 Haydon, Charles, 140, 146-47 Heagerty, J. J., 10, 41-65, 198; author of Four Centuries of Medical History of Canada (1928), 42-43; proposed Dominion Health Insurance Act (1941), 52; Heagerty Plan, 10; Heagerty Report (also see Advisory Committee on Health Insurance), 7, 73, 183, 198 Health League of Canada, 43, 50, 55 health systems, 4 Hepburn, Mitch, 54 Hincks, Clarence, 196 Hirschman, Albert, 117 historical institutionalists, 21 Hjertaas, Orville, 144, 285 Hlynka, Anthony, 198 Hoadley, George, 7, 13, 54, 185-200; Hoadley Commission (1932-34), 12-13, 183-200; Hoadley/Fleming Study of the Distribution of Health Services, 196; Hoadley plan, 7, 13 Hogarth, H. C., 59 Holland, 188

Hospital and Charitable Institutions Act (Ontario), 26 Hospital Grants Program, 1948-59 (Government of Canada), 7, 9, 33, 37, 241; importance to Medicare, 30; impact on hospital building, 31-32, 37-38 Hospital Insurance and Diagnostic Services Act (1957), 5, 7, 14, 21, 34, 74, 89, 213, 229, 241, 298 hospitals (evolution of), 13-15, 21-38; closing of, 3; for-profit hospitals in Quebec, 249-69; Grosse Isle quarantine hospital, 42; Hôtel Dieu hospital (Montreal), 61; Hôpital Saint-Luc Ltée (Quebec City), 251; Mount Royal Hospital (Montreal), 251; Newfoundland cottage hospitals, 229-43 Houston, Clarence J., 165 Houston, C. Stuart, 12, 92, 168 Howes, J. E., 59 Hudon, Normand, 94-95, 99 Ilsley, J. L., 53 Innes, Tom, 106-07, 109 insurance companies, 52 Interdepartmental Health Insurance Finance Committee, 59 International Grenfell Association, 230, 236, 238 Johns Hopkins University (and Hospital), 143, 160, 241, 278 Johnson, A. W., 10, 80, 85 Johnson, Daniel, 83 Johnson, G. R., 186 Johnston, R. K., 152, 153, 155-57, 168 Judicial Committee of the Privy Council, 46 Just Society, 104 Keep Our Doctors (KOD) Committees, 97

316 Kent, Tom, 10, 74-77, 79 Kernaghan, Kenneth, 301 Keynesian theory, 57 King, Mackenzie, 10, 33, 42-43, 4648, 60, 62-63, 72-73, 196, 198, 298; Industry and Humanity, 72 Kjorven, Carl, 142, 144, 146-47 KOD (Keep Our Doctors Committee), 97, 280, 288 Ku Klux Klan, 97 Lafferty, J. D., 187 LaFrance, Norman, 291 Laidlaw, W. C., 185-86 Lalonde, Marc, 104 Lalonde Report (1974), A New Perspective on the Health of Canadians, 8, 105, 110, 113-15 LaMarsh, Judy, 10, 77, 79-80, 82, 90, 100 Lamontagne, Maurice, 10, 77 Lampard, Robert, 13 Lancet, 278 La Patrie, 61 La Presse, 99 Laval University, 50 Lawson, Gordon, 12, 14, 92 Le Courier de St. Hyacinthe, 61 Le Devoir, 94-95 Leech, C. B., 166 Leggatt, T. H., 52 Lesage, Jean, 94, 257 Liberal Party of Canada, 6, 8, 10, 46, 57, 60, 71-85, 98, 195, 197, 285; convention of 1919 and health insurance, 72; election victory of 1945, 63; Kingston Conference (1960), 10, 74-77; Liberal Plan for Health (1961), 75 Lipset, Seymour Martin, 151, 153, 161-63, 174; Agrarian Socialism, 162-63 Lloyd, Woodrow, 8, 71, 95-96, 278, 280, 283, 289-90

INDEX

London Free Press, 108 long-term care facilities (nursing homes), 122, 250-51, 254, 256-57, 264-65 Lougheed, James, 184 Low, David, 186 MacDermot, J. H., 189 Macdonald, Ian, 82 MacDougall, Heather, 10, 16, 90, 298 MacEachen, Allan, 10, 77, 82, 84, 222 MacEachern, Malcolm, 186-87 Mackenzie, Ian, 41, 47-48, 52-62, 91, 198 Mackid, H. G., 187 MacLaren, Murray, 44 MacLean, Hugh, 162-64, 172 Macleod, Wendell, 74-75 Macmillan, Cyrus, 57 MacNaughton, Charles, 83 Macpherson, Duncan, 89-90, 96-98, 100-03, 109 Mahood, Margaret, 285 Maioni, Antonia, 64, 250 Makaroff, P. G., 164 Manitoba, 7-8, 11, 54, 167, 184-85, 190, 195, 220 Manning, Ernest C., 8, 13, 215, 22021 Manningcare, 7-9, 13, 207-08, 215-16, 222 Marchand, Jean, 84 Marchildon, Gregory P., 13, 92, 98, 145 Marsh, Leonard, 55, 59; Report on Social Security for Canada (the Marsh Report), 57 Marshall, J. T., 59 Martin, Eric, 214, 216 Martin, Paul, Sr., 33, 241 Massie, Merle, 12, 92 Matthews, Vincent L., 146 Mayo Clinic, 140, 278 McCann, James J., 55

INDEX

McCarthy, Joseph, 282 McEachern, J. S., 189, 194-95 McGill University, 42, 50, 57 McGugan, Angus, 192 McLeod, Derril, 289 McLeod, Thomas H., 144, 164-65, 167 Medical Care Act (1966), 5, 8, 13, 8384, 89, 101, 222-23 Medical Practitioners Union (UK), 284 Medical Services Association (MSA), 217-19 Medical Services Incorporated (MSI), 27, 156, 170 Medicare (in Canada); Canadian model of, 3, 4, 9, 106, 111, 207; chronology and evolution of, 6-9, 73, 112-13; compulsory vs. voluntary, 210-16, 219-21; definition, 5, 9; editorial cartoons, 89-109; extra billing and user fees (exclusion of), 105-08, 114, 209, 214, 222-24; intergovernmental negotiations, 10, 28, 80-85, 207, 220-23; limitations of, 131; medical care insurance (national), 71-85; nature of, 5-6, 9-11; premiums, 211-14, 218; private sector, role of, 249-51; prohibition of private insurance, 12; public administration, 221-23; Saskatchewan Government Insurance (SGI), 278; Saskatchewan model, 9, 13, 35-8, 71, 207, 214, 216, 221-22; singlepayer, 6, 9-10, 13, 212, 215-16, 278, 281, 294; tax-based financing, 6, 9, 211-13; tin cup Medicare, 215; universality, 5, 9, 59, 76, 106, 213, 216, 220-3; values, 300 Melrose, Walter, 144 Mercier, Oscar, 61 Military Hospitals Commission (World War I), 184

317 Millar, Ross, 49 Miller, Leonard, 242 Montreal Gazette, 103-04 Montreal Neurological Institute, 140 Moore, P. E., 50 Moore, S. E., 159 Mosdell, H. M., 231-38; Mosdell Commision, see Royal Commission on Health and Public Charities Mott, Frederick M., 170-72 municipal doctor plan (Saskatchewan), 27, 29, 30, 71, 13743, 154-58, 161, 187; municipal doctor contracts (Alberta), 188, 199 Murray, Athol, 280 Murray, R. G., 123 National Committee on Mental Hygiene (NCMH), 196 Naylor, C. David, 4, 14, 52, 64, 151, 153-54, 162, 168, 174, 297; Private Practice, Public Payment, 14, 297 Neary, Peter, 237 Nepveu, Gérard, 264-65 New Brunswick, 7-8, 208 New Democratic Party (NDP), 97, 99, 104, 214-15, 224; also see CCF Newfoundland (and Labrador), 6, 8, 11, 229-43; An Act Respective Public Health and Welfare (1931), 236; Brain Commission, 242; Newfoundland and Outport Nursing and Industrial Association, 230, 234, 239; Notre Dame Bay Memorial Hospital (Twillingate), 240-41 Newfoundland Medical Association (NMA), 242 New York Times, 280 New Zealand, 186-87 Norris, Len, 93, 109

318 Northwest Mounted Police (NWMP), 187 Norway, 139 Noseworthy, Andrew, 14 Nova Scotia, 7-8, 61, 64 Nova Scotia Hospital Association, 61 Obama, President (United States), 3; Obamacare, 97 O’Byrne, Nicole C., 13, 92 Olds, John, 240-41 Ontario, 11, 13, 25-26, 31-33, 54, 5860, 73, 78-79, 82-83, 98, 102-03, 107-08, 184, 220, 241, 250, 267; Bill 163, 102; doctors’ strike (1986), 107-08; Health Care Accessibility Act (1985), 107; Hospital and Charitable Institutions Act, 26; Public Hospitals Act (1931), 26 Ontario Federation of Agriculture, 54 Ontario Hospital Association, 26, 58 Ontario Medical Association, 107-08 Ostry, Aleck, 92, 298 Owram, Douglas, 64 Palliser’s Triangle, drought, 137, 145, 193-94 Pankhurst, Emmeline, 42 Parkland Institute, 299 Parlby, Irene, 184-85, 190 Parson, Charles E., 241 Pattinson, Chris, 190 Patullo, Duff, 44, 72 Pearson, Lester B., 8-10, 74, 76-79, 81, 84-85, 99-100, 200, 219-21, 224, 298 Penfield, Wilder, 50 Peterson, David, 108 policy history (relevance of), 3, 16, 21, 43, 295-302 polio, 186, 197 Pope, Felicity, 10 postwar boom, 37

INDEX

Power, Charles, 46-47 Prince Edward Island, 7-8, 241 private hospitals, 23-26, 32, 249-69 Progressive Conservative Party of Canada, 7, 9, 59, 81, 90, 105, 241 Provincial Teachers’ Medical Services (British Columbia), 219 public policy, 4 public-private partnerships, 249, 259 Puddester, John C., 237-38 Putnam, Robert, 21 Quebec, 7-8, 10, 14-15, 61, 64, 90, 92, 94, 188; departments of community health (DSCs), 120; hospitals, 249-69; labour unions (e.g., CSN), 260-61, 265; Le Repos du vieillard fire, 264-65; local community services centres (CLSCs), 120; Loi de l’Assistance publique (Public Charities Act), 252, 261; Loi concernant les hôpitaux privés (Private Hospitals Act), 256, 258; Loi des hôpitaux (Hospitals Act), 256, 262; Quebec nationalism, 299; Quebec Pension Plan, 79; regional social service and health councils (CRSSSs), 120, 125-26; regionalization, 119-20, 124-31; Service de l’assurance hospitalisation, 262 Quiet Revolution (Quebec), 266, 268 Rand Corporation, 296 Rands, Stan, 163 Reagan, Ronald, 299 reconstruction (following World War II), 10, 53, 72-73, 160 Reconstruction Party, 45 Regina District Medical Society, 156 Regina Leader-Post, 166, 278, 280 regionalization, 10-11, 110-32 Reid, Richard Gavin, 185, 190

INDEX

Robarts, John, 7, 13, 78, 82, 98, 102, 220 Robertson, Stewart, 142, 145-46 Roblin, Duff, 13, 220 Rockefeller Foundation, 145, 189, 232 Rodrigue, Norbert, 265 Roman Catholicism, 60 Romanow, Roy, 15, 288-90, 293, 301; Romanow Report, see Commission on the Future of Health Care in Canada Routley, T. C., 52 Rowell, Newton, 47 Rowell-Sirois Commission, see Royal Commission on Dominion–Provincial Relations Royal College of Physicians and Surgeons of Canada, 44, 50, 186 Royal Commission on Dominion–Provincial Relations, 41, 47, 51, 65, 72, 196-97, 199; Report (Rowell-Sirois Report), 47, 51, 72 Royal Commission on Health and Public Charities (Newfoundland), 231-34 Royal Commission on Health Services, 7, 15, 74, 79, 99, 214, 216, 221, 291-94 Royal Commission on Hospital Privileges (Saskatchewan), 15, 287, 289-90 Sandwell, B. K., 45 Saskatchewan, 6-8, 11-12, 26-30, 54, 80, 83, 92, 95-98, 99, 120-31, 151-75, 184, 188, 190-91, 197, 207, 241, 250; assessment and placement agencies (APAs), 122; developments preceding Medicare, 137-47; election of 1960, 277; Health Districts Act (1992), 127; Health Services Planning Commission (HSPC), 7, 12, 28,

319 143, 151-55, 165-75; Health Services Survey Commission (also see Sigerist Commission), 120, 151, 160-62; home care boards, 121; hospital privileges, 285-90; Medical Care Insurance Act, 95-96, 277, 280, 285; Medical Care Insurance Commission (MCIC), 277-78; mental health districts, 123; municipal medical and hospital plans, 26-30, 138-43; Municipal Medical and Hospital Services Act (1939), 26-27, 139; Murray Commission’s report Future Directions, 123-24; regionalization, 120-31; Saskatchewan Health-Care Association, 122-23; Saskatchewan Hospital Insurance plan, 7, 28-30, 32, 282; Saskatchewan Mafia, 80, 298; Saskatchewan Medical Insurance Plan, 71, 215; Saskatchewan Reconstruction Council (1943-44), 160; Select Special Committee on Social Security and Health Services (1943-44), 158, 160; Social Assistance Health Services Plan (1945), 165-66; union hospital districts (UHDs), 26, 29 Saskatchewan Association of Rural Municipalities (SARM), 27, 153, 161-62, 167, 170, 172 Saskatchewan Federation of Agriculture, 161 Saskatchewan Medical Association (SMA), 156, 158, 159, 287, 290 Saskatchewan Old Age Pensioner’s Association, 161 Saskatchewan Teachers Federation, 153, 159 Saskatchewan Wheat Pool, 159 Saskatoon Agreement, 7, 12, 15, 281, 288, 290

320 Saskatoon Community Clinic, 28487 Saskatoon Medical and Hospital Benefit Society, 169 Saskatoon Star-Phoenix, 93, 96, 278, 280 Saturday Night magazine, 45 Sauvé, Paul, 90, 94-95 Schmitt, Henry, 139 Sebestyen, Ed, 92, 96; Is There a Doctor in the House? A Case History, in Cartoons, 96 Setka, W. H., 159, 172 Seymour, Maurice, 139, 186 Shane, George, 101-02 Sharp, Mitchell, 82, 84, 101-02 Sheps, Cecil G., 167 Sheps, Mindel, 143-44, 166-67 Shoyama, T. K., 80 Sigerist, Henry E., 143, 160-61, 166, 241; Sigerist Commission (Saskatchewan), 142-43, 155, 16062, 164, 166, 174 Sirois, Joseph, 47 Smallwood, Joey, 241-42 Smith, H. D., 50 Smith, Harvey, 193-94 Social Credit, 7-8, 13, 44-45, 57, 63, 183, 192, 197-200, 207-24 social democratic, 8 socialized medicine, meaning of, 163 Soviet health system, 166 Spanish Civil War, 289-90 Spanish flu epidemic, 184 spending power, see federalism Spry, Graham, 278 Squires, Richard A., 231, 236 St. John’s Committee for the Unemployed, 240 St. Laurent, Louis, 7, 33, 61, 298 stagflation, 104 Stangroom, E., 59 State Hospital and Medical League

INDEX

(SHML), 153, 158-59, 161-62, 164, 167, 171-72, 174 state medicine, 46 Stevens, Harry, 45 Struthers, James, 250 Swift Current Health Region (No. 1), 12, 71, 121, 137-38, 143-7, 169-72; Swift Current Medical Care Plan, 169-71 Szreter, Simon, 295 Taylor, George, 278, 289 Taylor, Malcolm G., 4, 11, 35, 62, 64, 151-52, 165, 168, 174, 297; Health Insurance and Canadian Public Policy, 297 Taylor, Stephen, 280-81 Tenniel, John, 102 Tennyson, Alfred, 294 Thain, T. H., 171 Thatcher, Margaret, 299 Thatcher, Ross, 290 Times (of London), 280 Tingley, Merle, 108 Toronto Star, 89-90, 96-98, 100-01, 104-05 Trades and Labour Congress, 57, 91, 171 Trudeau, Pierre, 104, 297 tuberculosis, 31, 52, 186, 197, 292 Tuohy, Carolyn, 299 Twillingate scheme, 240-41 Underhill, Frank, 75 Union Hospital Districts (Saskatchewan), 26, 29 Union Nationale (Quebec), 95, 103 United Church Mission Hospital, 192-93 United Farm Women of Alberta, 184 United Farmers of Alberta (UFA), 13, 44; UFA government (1921-35), 183-200

INDEX

United Farmers of Canada, Saskatchewan Section, 159, 161, 164 United Kingdom (Great Britain), 46, 55-57, 117, 144, 188, 190, 194, 219, 230-36, 278, 299; cottage hospitals, 232-36; Crofters Holding (Scotland) Act (1886), 232; Dewar Committee report, 232-36; doctors recruited during Doctors’ Strike, 278-79; Highlands and Islands Medical Service of Scotland, 230-36, 23839, 243; National Health Insurance Act (1911), 233; National Health Service (NHS), 14, 56, 58, 144, 28485; Poor Law, 233; Royal Army Medical Corps, 284; Royal Commission on Newfoundland (Amulree Commission), 237-38; Scottish Board of Health, 232 United States, 45-46, 116-18, 188, 207, 232, 267, 299; doctors, potential recruitment during Doctors’ Strike, 278-89; Farmers’ Union Hospital Association co-operative (Oklahoma), 240; Medicaid and Medicare, 250 Université de Montréal, 50, 61 University of Alberta, 186; University of Alberta Hospital, 185 University of Guelph, 282 University of London (London Hospital Medical College), 284 University of Saskatchewan, 74, 170, 275, 288 University of Toronto, 47, 192, 197, 292 Upper, Boyd, 76 user fees, 6, 8, 192 Vancouver Sun, 93-94 Victorian Order of Nurses, 236, 239

321 wage and price controls, 105 Wahn, Ed, 289 Washburn, W. T., 190, 195 Washington Post, 280 Watson, A. D., 50, 56-57 Weir, George, 48 welfare state, 296, 299 Western alienation, 299 Western Canada, 46 Wherrett, G. J., 50 Whitton, Charlotte, 55, 59-60; The Dawn of Ampler Life, 59 Wight, D. O., 189 Williams, W. A., 186 Wilson, W. A., 197 Winnipeg Tribune, 280 Winters, Robert, 82 Wodehouse, Robert E., 45, 49, 52 Wolan, Casimir, 146 Wolfe, Sam, 284-85, 287 Woloshyn, Don, 288 Wood, Henry Wise, 189 Woods, (Justice) Mervyn, 287, 28990; Woods Commission, see Royal Commission on Hospital Privileges Women’s Farm Organization, 162 Woodsworth, J. S., 45 Workers’ Education Association Bulletin, 92 worker’s compensation laws and administration, 197, 278; Worker’s Compensation Board (Alberta), 191; Workmen’s Compensation Board (Ontario), 26 Wrinch, Horace A., 189 Zigrosser, Carl, 90; Medicine and the Artist, 90

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