7/27/2019 Building the future of health careFinancing only the first stageBy Gregory Marchildon
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Building the future of health care
Financing only the first stage
A version of this commentary appeared in the National Post, Huffington Post and the Hill Times
As premier of Saskatchewan, Tommy Douglas was instrumental
in introducing universal hospital insurance in 1947 followed by
universal medical-care coverage in 1962. Without a doubt, these
two pioneering experiments became the template for what we
now call universal medicare in Canada. But it is essential to
remember that rearranging the financing of the system so that
everyone would have access to medically necessary care was
only the first step for Douglas.
The critical second stage was a fundamental reorganization of
the delivery system to build in more illness prevention and health
promotion, and extend care beyond hospitals and physicians.
This, he recognized, was the more difficult stage, and he always
hoped and expected Canadians to meet that challenge after he
retired from political life.
The fact that we have made only limited progress on the second stage of medicare during the last couple of decade
is hardly his fault. Nor is it the fault of the political leaders who took Douglas’ model in Saskatchewan to build nationa
medicare, from John Diefenbaker (a Conservative) to Lester B. Pearson (a Liberal).
There are at least three aspects of the Douglas model of medicare that should be celebrated, because they provide
the sturdy foundation on which we can build the next stage of medicare. The first is universality, one of the five
principles under the Canada Health Act. For Douglas, universality was the key to his reform.
In contrast, access to private health insurance is based on “ability to pay,” combined with your health risk profile.
While you can avoid or mitigate this through employment-based health insurance, your access then becomes
determined by the type of job you hold.
Douglas replaced this system with a tax-funded approach that allowed coverage to be offered to everyone,
irrespective of job, age or pre-existing medical condition. After Douglas’ momentous reform, access to medical care
became based on “need,” rather than “ability to pay,” or where you happened to be employed.
Although accepted by almost all Canadians today, universality was a contentious change at the time. In this, historyprovides a useful lesson in the outrageous claims made by the powerful anti-medicare coalition during the doctors’
strike in Saskatchewan in 1962. Contrary to what organized medicine, the insurance companies, business groups a
almost every provincial government alleged at that time, medicare actually improved life for the vast majority of
Canadians, including doctors.
The second essential dimension of Canadian medicare is public administration. Contrary to what is often assumed,
this does not mean public delivery. But it does mean that any publicly-financed system of health insurance must be
accountable to those who pay the piper and use the services — i.e., taxpayers and citizens through their elected
representatives.
7/27/2019 Building the future of health careFinancing only the first stageBy Gregory Marchildon
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We call our system “single-payer” to distinguish it from systems where governments own and operate almost all
aspects of the delivery system. In the late 1940s, for example, the government of the United Kingdom took over the
ownership of all hospitals when it introduced the National Health Service (NHS). Far from an ideologue, Douglas
never intended the government to own or control all aspects of delivery as long as there was accountability for publi
funding back to elected legislatures.
This brings me to the third essential dimension, what I will call the Douglas-Diefenbaker-Pearson legacy; and that is
the federal-provincial nature of universal medicare in Canada.
This is a system in which the provinces are responsible for managing their respective system, while the federal
government is responsible for providing the provinces with the incentive to adhere to a few common standards. This
is no micro-management.
Moreover, not one of the five principles of the Canada Health Act prevents the provinces from being more
entrepreneurial in the delivery of higher quality and more timely health services. Even under the current system,
provinces cannot be forced to comply with national principles, such as portability; instead, they are induced to do so
by federal cash transfers and the possibility of their partial withdrawal. But surely this is the minimum we should
expect from the provinces for the billions of dollars they receive in federal health transfers.
Without this minimal federal role, the terms of access to health care will vary from province to province and portabilit
will become a sham. This is precisely what we are in danger of losing, as successive federal governments provide
cash transfers for health care with little or no concern for ensuring the integrity of the principles of the Canada Healt
Act.
On this, more than ever, we need Douglas’ vision, leadership and balanced understanding of our federation more th
ever. Rather than go backwards to a time before medicare, we can focus on the more important business of reformi
the health delivery system so that it will improve the quality of life for all Canadians, not just a privileged few.
Gregory Marchildon is an expert advisor with EvidenceNetwork.ca. He is also a Canada Research Chair and
professor, Johnson-Shoyama Graduate School of Public Policy, University of Regina, and former executive director
the Romanow Commission.