Wednesday, July 20, 2011

The Struggle to Implement Medicare

Witnesses to Medicare in Saskatchewan: Medicare Workshop at the University of Saskatchewan — Wednesday, 20 May 2007
Allan Blakeney reminisces on the public relations battle launched by the Saskatchewan College of Physicians and Surgeons, and fuelled by most local media, when the Co-operative Commonwealth Federation (CCF) government passed legislation in 1961 to deliver on their election promise of a province-wide single-payer medical care insurance plan, the provincial forerunner of Medicare in Canada. Blakeney details the major events leading to the doctors’ strike and recalls the role of some major players on both sides of the conflict. Blakeney highlights strategies conceived by the CCF to cope with the potential and realized eventualities of the doctors’ strike.

The Saskatchewan provincial election of 1960 was fought on the issue of introduction of a single-payer type of medical care insurance in Saskatchewan. It was a bitterly fought campaign, the most bitter that I have experienced in my eight campaigns, and in three or four other election campaigns when I was not a candidate, but which I followed with interest. What made it so hotly contested was the intervention of the organized medical profession. Operating under the name of the College of Physicians and Surgeons, they spent more money on electronic and print media than any political party. Their campaign was aimed against the Co-operative Commonwealth Federation (CCF) government of Saskatchewan.

Following the election victory of the CCF in 1960 and the report by the Thompson Committee appointed to examine the proposal, the Medical Care Insurance Act was introduced and passed in 1961 and implemented in 1962. The opposition voted in favour of the bill on second reading— the decision in principle. The Act provided for the plan to be administered by a Medical Care Insurance Commission (MCIC). We were unclear how the medical profession would react to the legislation. I felt that the election had been fought on virtually a single issue. The electoral system had elected a government. The government had done what it had said it would do. And that the profession should be willing to accept the will of the voters and not take the position that the law did not apply to their profession, however distinguished. I was clearly naïve.

The first sign of trouble was that the College of Physicians and Surgeons [the College] declared that it would not appoint any members to the Commission. Appearing before the federal royal commission—the Hall Commission—the College said that their members would not practise under the plan but would continue to serve their patients.

I will not try to deal with all the twists and turns during the first few months of 1962.

I’m not sure we fully understand the College’s strategy. One possibility was that they would continue to practise, send bills to patients and urge them to send the bills to the government. This would mean that either the government would pay any amount physicians billed or alternatively that the patients would receive only partial recovery depending upon the amount billed. Either result would have destroyed any single-payer concept of Medicare. To counter this strategy, we enacted legislation in April to give the Medical Care Insurance Commission the power to negotiate with members of the College on behalf of patients on the value of the services rendered. This is perfectly standard practice. If your car is involved in a collision, you take the car to an auto body shop and, at least in Saskatchewan, SGI (Saskatchewan Government Insurance)—the insurer—does the bargaining with the auto body shop. If a workman is injured, he goes to a doctor and the Workers Compensation Board—the insurer—does the bargaining with the doctor about his fees. The same was true for medical services provided to medical indigents. The legislation made clear that the same rules would apply to the Medical Care Insurance Commission in its role as an insurer.

The College responded with a mass rally timed to coincide with the resignation of one of our cabinet colleagues—Walter Erb. It was a pep rally to solidify support for a doctors’ strike. This was in early May.

Alarm was growing among the public fed by an unbelievable scare campaign run by the media, particularly the Regina Leader Post, the Saskatoon Star Phoenix and most of the weeklies.1 We began to prepare in earnest for a strike. The Cabinet divided its duties. Premier Woodrow Lloyd was leading the team; Minister of Health Bill Davies and the MCIC were planning to maintain medical services. My job was to help Woodrow meet the countless delegations, later to take the many press conferences, and to devise strategies to ward off possible legal attack. Other cabinet ministers had other duties. Maintaining medical services included lining up as many British doctors as we could who would come to Saskatchewan if there was a strike.

A fair number signed up in response to our ads in the British medical journal Lancet, and were interviewed by the Saskatchewan Agent General in London—Graham Spry—an under-appreciated great Canadian in many ways. A Saskatoon alderman, the late George Taylor, in his capacity as a member of the MCIC, went to London and helped with this work. The reason for the push for British doctors was that, in theory at least, they had a legal right to practices in Saskatchewan on showing simply that they were qualified to practise in Britain, whereas, in the case of US doctors, the College had the right to check their training and credentials.

We felt that if we had recruited senior doctors from the Mayo clinic in Rochester, Minnesota or from Johns Hopkins in Baltimore, it would have taken the College many weeks to determine that they were qualified to practice in Saskatchewan. Nonetheless, we had a Plan B. If there was a near complete walkout, we lined up doctors from the Auto Workers medical plan in Detroit and the Steel Workers plan in Pittsburgh who would come. If there was a total break down, we felt that nobody would be quibbling about whether the College had found them to be qualified. Fortunately, that did not prove to be necessary.

We tried to plan for the eventuality of the Lieutenant Governor dismissing the government and calling an election on his own. That would have been completely unconstitutional but we were not sure that the Lieutenant Governor knew his constitutional role. This was the same Lieutenant Governor who in 1962 would not sign a bill because he didn’t like its contents—he felt it was unfair to oil companies. And without any instructions from Ottawa, he reserved it for consideration by the federal Cabinet. This had never been done in any province in Canada before or since. Even with instruction from Ottawa, it had not been done for decades.

We tried to plan for what would happen if an application was made to a court to have the Medical Insurance Act declared unconstitutional. There were absolutely no grounds for this, but with one or two of the judges, that might not have mattered. It would have taken us weeks to overturn a rogue decision. I devised a plan where we would pass an order-incouncil under other existing legislation to provide another legal basis for the plan. That approach might have been open to legal question but it would have taken time to attack and the strategy would have bought us time.

Meanwhile, we were losing the war of public opinion. As a measure of this, I cite that when T. C. Douglas ran in the federal election of June 1962 in Regina city, which was a C.C.F. stronghold, he received just 29%
of the vote. This was certainly not encouraging. July 1 dawned bright and clear. And most doctors’ offices were closed.

They stayed closed. Public concern mounted. It was clear that we had a full-blown strike on our hands with a skeletal emergency service in a few major hospitals involving about 125 of the 1000 or so doctors who normally served patients. The provincial press began publishing horror stories.

It was a very tough few days. But then, British doctors began to come in—a good trickle of them. A nice problem for the College. They dragged their feet a little. But with the papers predicting doom, it was not easy to delay the licensing of these professionally and legally qualified doctors for long.

In order to give the British doctors a venue for practice, community clinics were organized in Prince Albert—that is a story of its own—in Saskatoon, in Regina, and in other locations. Several survive today.

And another thing happened. Reporters streamed in from all over the world. A doctor’s strike was news. There were reporters from the Canadian dailies, from the New York Times, the Washington Post, the London Times and many other papers. And about a week into the strike they began reporting on the two strikes that were going on—the one that the reporters were seeing and reporting on, and the other strike which was being reported by the Leader Post and the Star Phoenix. The Winnipeg Tribune, bless them, about a week into the strike, ran an editorial on how badly the Leader and the Star were reporting the strike. The Leader responded that these reporters from outside didn’t understand the issues and therefore couldn’t do a good job of reporting. For the Regina Leader-Post—hardly a world leader in journalism, then or now—to opine that the specialized health reporters of the New York Times, or the London Times or the Washington Post could not do a proper job on reporting was not a promising line of argument. Under the withering scrutiny of the world press, the Leader-Post and the Saskatoon Star-Phoenix had to amend their reporting and give at least some regard for the facts as observed by some of the world’s best medical reporters.

Premier Lloyd had two press conferences a day with 50—60—70 reporters at each—more than I’ve ever seen before or since at a provincial  press conference. Woodrow also had other things to do—he was out of the province for over two days without the press finding out— that’s a great little story. I took many of the press conferences in my role as the government’s legal joe-boy. It was fun. The tone of reporting began to shift from the day-to-day events to the propriety, or otherwise, of doctors going on strike. Gradually the tide began to turn. I feel that the tipping point was the rally organized by the Keep Our Doctors Committee—
the KOD—in front of the legislature building on 11 July. It drew 4500-5000 people—not the predicted 20,000. The rally speakers were using a public address system hooked to the legislative building and operated by the Wascana Centre Authority. If necessary we could have cut off the PA system.

Just before the KOD rally, Father Athol Murray had given one of his fiery and intemperate speeches in Saskatoon to a large audience. It was widely reported. The line that got lots of electronic coverage went something like this: “If the government doesn’t withdraw this Act—the Medical Care Insurance Act—there will be blood running in the streets—and God help us if it doesn’t.” Now this is pretty strong stuff from a clergyman at a public meeting in tense times. And I think it was too strong for many of the opponents of the Act. And I think it affected the turnout at the KOD rally. I felt we should have sent Father Murray a Friends of Medicare Medal.

You know the rest. Rural doctors began to trickle back to their offices and serving patients. The community clinics were thriving—and on 17 July—the College, as I term it, sued for peace.

Enter Stephen, Lord Taylor, who appointed himself as mediator and hammered out a compromise—the Saskatoon Agreement. It was certainly not what the College wanted. They conceded the key point—single-payer medical care insurance. It did not contain everything the government would have wanted—easier methods of transition to other modes of practice. But it brought peace. It brought relief to a stressed population and it brought Medicare to Saskatchewan and soon to Canada. It’s our job to take the next steps forward.

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