Health Policy in Canada

1. Health Policy in Canada Pols 321 Lecture 3

2. Outline • Pre-20th Century • Pre-1945 • Post-1945 • Summing Up

3. 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

4. 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”)

5. 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)

6. 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

7. 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

8. 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

9. 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

10. Professional Self-Government

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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)

19. 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

20. 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.

21. 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

22. 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

23. 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%)

24. 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

25. 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)

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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