Health Policy in Canada

Pols 321

Lecture 3

Outline

• Pre-20th Century

• Pre-1945

• Post-1945

• Summing Up

Historical Overview

• European Developments– state-sponsored schemes: Austria (1883),

Hungary (1891), Luxembourg (1901), Norway (1909), Serbia (1910)

– Britain - many G.P.s bid for contracts with consumer collectives (fraternal orders) and were paid on capitation

– 1912- British Government introduces national sickness insurance plan for wage earners

Canada

• Health provided primarily by non-profit religious orders and municipalities

• Physicians were independent fee-for-service practitioners based on price discrimination according to ability to pay (“robin hood”)

Nurses in the New World

• first nurses were male attendant at a “sick bay” at the French garrison in Port Royal at Acadia (1629)

• First laywoman was Marie Rollet Hebert (c. 1617) - husband had “apothecary skills”

• Several orders on nuns followed: hospital nuns, Ursuline nuns, Grey Nuns (1736)

The Medical Profession

• Humble Beginnings– in 18th C. Europe medicine was little more

than a loose collection of practitioners of various “medical” arts (barber-surgeons, barber apothecaries, self-taught healers,surgeons

– education provided through guild academies, apprenticeships, proprietary schools, univers.

– division between those who served upper class and those serving the masses

Medical Profession (cont.)

• Early Development in Canada– state regulation of the medical market place

was requested of the profession• 1710 - barber-surgeons and surgeons

apothecaries persuaded gov’t to issue an edict• 1750 - warning about the evils of underqualified/

credentialization established• 1788 - b-surgeons/b-apothecaries relegated to

second class in favour of British surgeons

Medical Profession (cont.)

• 1795 - weak licensure procedure started in Upper Canada

• 1818 - first licensing board appointed in Upper Canada

• pressure for formal self-regulation to replace licensure boards led to the establishment of the College of Physicians and Surgeons in 1839

• Quebec - College established to deal with Thomasonian Herbalists, Homeopaths and Eclectics

Medical Profession (cont.)

• Ontario - less successful at warding off the “irregulars”

– petitions for self-regulation (1845), (1849), (1859), (1860)– scepticism of mainstream medicine– homeopaths and eclectics were given the right to self-

regulation before main stream practitioners

• Ontario and Quebec - local medical socieities preceded provincial Colleges

– eventually coalesced into provincial societies

Professional Self-Government

Province/Territory Inaugural DateQuebec 1847Ontario 1869Nova Scotia 1872Manitoba 1877New Brunswick 1881British Columbia 1886PEI 1890NYT 1888-1905Alberta 1906Saskatchewan 1906

sakatchewan

source: C.D. Naylor, Private Practice, public payment, , p.20.

Medical Profession (cont.)

• Ascendance of Medical Science – enhanced the status of the profession– formal medical education began in the 1820s – matriculation requirement were stiffened– by 1910 schools were established at McGill,

Toronto, Laval, Queen’s, Western, Dalhousie and Manitoba

– provincial medical associations everywhere

Medical Profession (cont.)

– homeopaths declined in numbers– osteopaths and chiropractors were esp.

despised– 1925 Drugless Practitioners Act relegated

osteopaths to spinal manipulation alone– nurses began to challenge doctors

• midwives officially barred from practice in 1865

Early Role of Public Health

• Debate Over Public Health Insurance was spearheaded by public health doctors (1910-1920)– already government employees– Charles Hastings T.O. medical officer of health– more predisposed to social engineering and

collectivism– W.W.I tended to reinforce this growing

sentiment

British Columbia

• mounting pressure from Church, women’s, labour and veteran’s groups (1919)

• established a commission of inquiry on public insurance schemes

• mother’s pension was introduced in 1921, but not health insurance

• legislation was passed in 1936

The B.C. Plan

• compulsory health insurance for all lower income wage earners

• funded by employer-employee-state contributions

• coverage:medical, hospital, dental

• commission: employers, medical profession, municipalities

Impact of Depression and War

• physician’s incomes dropped radically

• municipalities became insolvent

• seven month doctor’s work- action strike in Winnipeg in 1933

• 1934 CMA policy statement: public health insurance; ffs payment, contributory plans

Enter The Federal Government

• Rowell-Sirois Commission (1940)

• Committee of Seven (1941)– Dr. J.J. Heagerty (DM) suggested the the

CMA set up a committee to work with him to develop legislation

– supported physician preference for method of payment; pension plan; full medical control; plan administered by independent commission

Federal Gov’t (cont.)

• Heagerty Committee (1942)– formal Cabinet Advisory Committee on Health

Insurance– national health insurance plan (provincially

administered), including health regions;provincial commissions, physician lists, HCs

– physicians would occupy key roles at all levels of the system (joint prof.-lay commissions)

Report on Social Security for Canada (Marsh Report -1943)

• National employment and investment program to maintain full employment

• Expanded system of social insurance protection federally administered to protect workers from risks of income interruption

• Social insurance program to protect employed from ‘universal risks’, old age, permanent disability, death

• Comprehensive health insurance including medical, dental, pharmaceuticals, optometrists, jointly financed and contributory

• Universal family allowances

Federal Gov’t (cont.)

• Special House Committee on Social Security– struck after concerns expressed by the

Finance Department about economic implications

– Committee of Seven began lobbying doctor MPS (27) - nine were appointed

– majority of physicians on the committee considered themselves to represent the prof.

Federal Gov’t (cont.)

• Special Committee (1944)– continuing criticisms over the financial

implications led to further revisions of the legislation

• changes to the premium scale• provincial discretion to administer the plan

Federal Government (cont.)

• CMA changes– RCAMC members pressured for federal

control of the scheme; compulsory coverage of everyone; and abandonment of the medical control principle

– CMA responded by calling for an independent commission without majority control; dropped the complete control principle; provinces to decie on who should be included

Role of Labour

• Canadian Federation of Agriculture– 350,000 rural residents– wanted a lay-controlled, preventive-oriented,

universal access, no premiums, and CHCs

• CCF– became the official opposition in Ontario in

1943– elected in Saskatchewan in 1943 (nat. 29%)

1945 Green Book Proposal

• King worried about threat from the left and costs– organized labour and CCF membership X2,

• 1945 federal proposal for national health insurance– planning and organization grant (to provide

administrative personnel);health insurance (50%); health grants; hospital construction

Green Book Proposal (cont.)

• 1945 failure– provinces balked because of the federal

request for the transfer of exclusive jurisdiction over personal income, corporation income, and succession taxes (a major problem for the wealthy provinces)

Changing Medical Position

• failure of the two levels of government to establish a role in the health care market led to a shift in the official position of organized medicine to state involvement

• called for a residual approach to health insurance, physician and hospital-sponsored plans

Growth of Selected Non-Profit Medical Care Plans, 1951-9

Plan 1951 1955 1959

MSA-BC 190,415 297,658 467,939

MSI (Alberta) 31,833 116,127 427,207

MS(S)1 48,893 122,191 211,514

MMS 118,210 219,243 346,046

PSI 218,147 584,043 1,246,221

QHSA - 588,414 680,895

MMC 44,622 64,272 128,990

Total persons in

TCMP plans* 775,165 2,403,351 4,023,216

Percent of Canadian

population covered 5.5 15.2 22.7

Composition of Boards of Directors of Doctor-Sponsored Medical Care Plans

Total Non-

Plan Members Medical Medical

Maritime Medical Care 9 6 3

PSI (Ontario) 10 7 3

Windsor Medical

Services 10 7 3

Manitoba Medical

Services 21 14 7

MS(S)1 20 10 10

GMS (Regina) 14 7 7

MSI (Alberta) 5 1 4

MSA-BC 8 2 6

Saskatchewan Innovates

• Progressive history on health policy– Rural Municipalities Act (1909)– Rural Municipality Act (1916)– Municipal Medical and Hospital Services Act

(1939)– one-third of province- union hospital districts– launched the first provincial hospital insurance

scheme in 1947

Federal Hospital Insurance

• Planning and Organizing, and Hospital Construction Grants (1949, election year)

• Hospital Insurance and Diagnostic Act passed in 1957– major issue in 1953 election– forced on the agenda by the provinces at the

fed-prov. conference in 1955

Hospital Insurance and Diagnostic Services Act (1957)

• 50-50 cost -shared

• formula based on: 25 % average national per capita costs; 25 % average provincial per capita costs X # of insured individuals

• benefits: all inpatient and most outpatient services

Saskatchewan does it again ...

• With an election again pending, the CCF announced that it intended to introduce universal medical care– universal and compulsory– administered by a commission– premiums– resulted in a bitter doctors strike

The Feds do it again !

• Pearson government was rocked by scandal and in a minority position in 1964

• 1965 Speech to the Throne

• provinces in favour

• Universal Medicare introduced in 1968 with almost unanimous consent - principles and cost sharing

National Medical Insurance Act (1966)

• 50-50 cost shared based on national per capita costs

• benefits: comprehensive coverage of all medically necessary services

• universality, portability, public administered, comprehensiveness

Canada Health Act

• Ottawa introduces the Canada Health Act – retains the five principles– consolidates the two previous pieces of

legislation– penalizes the provinces for allowing extra-

billing by reducing EPF payments– came before an election