Health Policy in Canada Pols 321 Lecture 3. Outline Pre-20th Century Pre-1945 Post-1945 Summing Up.
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Transcript of Health Policy in Canada Pols 321 Lecture 3. Outline Pre-20th Century Pre-1945 Post-1945 Summing Up.
![Page 1: Health Policy in Canada Pols 321 Lecture 3. Outline Pre-20th Century Pre-1945 Post-1945 Summing Up.](https://reader035.fdocuments.net/reader035/viewer/2022062518/56649ebd5503460f94bc5dba/html5/thumbnails/1.jpg)
Health Policy in Canada
Pols 321
Lecture 3
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Outline
• Pre-20th Century
• Pre-1945
• Post-1945
• Summing Up
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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
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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”)
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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)
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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
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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
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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
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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
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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.
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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
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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
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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
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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
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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
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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
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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
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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)
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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
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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.
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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
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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
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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%)
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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
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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)
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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