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 govt 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, Queens, 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, womens, labour
  and veterans groups (1919)
• established a commission of inquiry on public
  insurance schemes
• mothers 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
• coveragemedical, hospital, dental
• commission employers, medical profession,
  municipalities

16
Impact of Depression and War

• physicians incomes dropped radically
• municipalities became insolvent
• seven month doctors 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 Govt (cont.)

• Heagerty Committee (1942)
• formal Cabinet Advisory Committee on Health
  Insurance
• national health insurance plan (provincially
  administered), including health
  regionsprovincial 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 Govt (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 Govt (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