NP1 HEALTH CENTURY

National Post - May 6, 2002
Canada and the health century
Michael Bliss

This is the first in a four-part series on fixing Canada's health-care system adapted from Better Medicine, a new book edited by Dr. David Gratzer, author of the highly acclaimed Code Blue: Reviving Canada's Health Care System. Today, Michael Bliss, author and Professor of History/History of Medicine at the University of Toronto, discusses the history of health care in Canada.

- - -

Health insurance has comparatively shallow roots in the communities that in 1867 came together to found the Dominion of Canada. There was effectively no recognizable form of health insurance in the 19th century. The provision of health care was not a priority of the Fathers of Confederation; unlike education, health care was not discussed at all. The British North America Act, still the governing document of Canada's constitution, does not contain the word "health."

Before the 1920s, the predominant sense was that a young, hard, prosperous North American country was relatively insulated from the worst of Old World problems and did not need Old World policies. The national symbol of Canada at the beginning of the 20th century was tough, sleeves-rolled-up, Johnny Canuck, who was busy logging and making railways and clearing land and playing hockey and getting ready by 1914 to volunteer to fight the Huns in France. The idea of somebody providing unemployment insurance, or pensions, or health insurance for Johnny, or for his good-looking and wholesome little sister, Janey, seemed preposterous. Judging by its real roots, health insurance had something to do with European countries' "identity."

Canadians' desire for access to health care increased steadily as medical diagnosis and treatment became steadily more effective and costly. Canadians wanted to be able to visit doctors, wanted access to the modern hospital. In what has been called "the health century", health care was becoming constantly more important in everyday life. Doctors, the private citizens who had been traditionally expected to provide free health-care services, were among the leaders in discussing health insurance. As an Ontario family doctor put the issue in 1944: "Every day I see patients who are getting inadequate medical service, both diagnostic and curative, because they are unable to pay for it, or if they do pay they are left with insufficient money to provide a decent standard of living. Every such case is a demand, even though usually unexpressed, for some form of health insurance."

The system of universal state medical insurance was created by the Pearson government in the 1960s, an era of maximum Canadian confidence in the competence of government, the possibilities of social engineering, and the feasibility of what was proudly called "socialized medicine." Although extremely popular with ordinary citizens, who suddenly had no more worries about medical and hospital bills, Canadian medicare soon began disintegrating under cost pressure and competition from the private sector. The Trudeau government responded by passing the Canada Health Act in 1983. The public health-insurance system, covering core medical and hospital care, was now guaranteed survival, not on its merits, but through the mechanism of a legislated monopoly.

If the state monopoly had worked, if governments had been able to deliver on the 1964 promise of universal access to health care "without hindrance of any kind," the Canada Health Act system might have been seen by the rest of the world as a distinctive Canadian contribution to health care. The world might have copied Canada. Even the Americans might have copied Canada.

The trouble was, as most students of monopolistic behaviour, planned or command economies, or elementary market economics could have forecast, the Canadian system did not work well in the long run. By the 1980s the whole of the Western world had come to appreciate the flaws of socialist and dirigiste economic management: Remove an industry from market conditions, replace price signalling with administrative fiat, outlaw competition, and you create the classic conditions for inefficiency, declining productivity, and gradually increasing consumer dissatisfaction. Not a single country anywhere copied the flawed Canadian "model." Canadians themselves began to wonder how their system could be sustained as the population aged, its health-care expectations continued to increase, lineups and blockages and shortages increased, and providers became increasingly disgruntled.

The notion that one particular approach to health care was integral to the Canadian identity began to seem increasingly anachronistic. Aside from the weak historical foundation for the argument - medicare was a healthy centrepiece of Canadian policy for only a few years - it was a simple fact that Canada, Canadians' values and Canadians' health-care needs were in constant flux. As Canadian society became more diverse and pluralistic in every respect, the very notion of insistence that Canadianism involved acceptance of a special socio-political agenda, began to seem narrow and stultifying and offensive.

The country had changed. Health care had changed. Canadians had changed. The world had changed. The monopolistic system created by the Canada Health Act, once seen as part of the solution to the problems of public health insurance, had become part of the problem, part of the hindrance citizens faced in trying to develop for themselves and their children the best possible health-care system.

Adapted by the author from an essay in Better Medicine: Reforming Canadian Health Care, edited by Dr. David Gratzer. Published by ECW Press, Toronto and Montreal, 2002.; First of a four-part series.