By Heather MacDougall and Dan Gallacher
CMAJ. 2011 January 11
Making Medicare: The History of Health Care in Canada, 1914–2007 (www.civilization.ca/medicare) is a balanced, visually attractive and informative narrative of the slow process of developing and implementing hospital and medical services insurance programs in Canada.
Launched in April 2010 in both English and French, this is the Canadian Museum of Civilization Social Progress Web Gallery’s most extensive online exhibition to date. Its 300 web pages include numerous archival cartoons, photos and links to educational resources. Each “chapter” focuses on a decade with historical information about the social, political and economic issues of the day, many of which continue to dominate public debate. This information is important to young physicians in particular who are interested in the wider context of Canada’s universal health care programs.
Why did it take so long to create Canadian medicare in comparison to similar programs in Great Britain, Australia, New Zealand, and Western Europe? The opening three chapters demonstrate that Canadians were influenced by external models, but that the federal system and lack of political will at the national level frustrated health insurance advocates. Through the 1920s, rising costs of hospital care, new technology such as x-rays, and the lack of physicians in rural areas led to widespread calls for sickness insurance. In the 1930s, during the Great Depression, the Canadian Medical Association supported contributory health insurance and provinces such as Alberta and British Columbia passed legislation to create programs. However, the lack of federal funding, coupled with opposition from insurance companies and outspoken doctors prevented the implementation of these plans.
Public support for universal, tax-based health insurance grew during World War II according to polls taken in 1942 and 1944. But the division of powers entrenched in the Canadian constitution stymied the first national plan in 1944/5 because the provinces and the federal government could not agree on how to share responsibility for medical, nursing, hospital, pharmaceutical or preventive services. Resolving this conundrum occupied the public, politicians, doctors, nurses and various organizations during the 1950s and 1960s.
Although the general outlines of those early battles to create medicare are well-known, later chapters add depth and context by using contemporary articles, political cartoons and photos to illustrate the passion that hospital and medical services insurance aroused. Other chapters look at the ongoing concerns that make medicare an important political and social issue.
The rising costs of both programs was prompting dismay in Ottawa and all the provincial and territorial capitals in the late 1960s and early 1970s. Day surgery, group practices, capitation, regionalization and introducing electronic records were all solutions suggested by the 1968/9 federal–provincial task forces (electronic records are still a top agenda item today). Health promotion and disease prevention was advocated in A new perspective on health for Canadians back in 1974. The federal government’s unilateral move to block funding through the Established Programs Financing Act (1976) not only unleashed opposition from provinces and the medical profession, but also opened discussion of home care and continuing care as ways to end “bed blocking” and excess hospitalization. This probably sounds very familiar.
From the 1980s to the present, provinces have experimented with a variety of solutions to deeply rooted problems in the health care system. Their efforts have been made more difficult by the rapid pace of technological or scientific advances and rising public expectations. As the various provincial commissions and the Romanow (2002) and Kirby (1999–2002) reports have demonstrated, medicare is a work in progress.
To understand why certain systemic issues continue to limit the choices for change, it is essential to know the history of national proposals for health professional training, drug benefit plans, community nursing, and home care services. Making Medicare includes an Educational Lab, adding to its value as a powerful educational tool worthy of being included in the early training of doctors, nurses, or other health care workers as well as a generally accessible and interesting means of achieving such understanding.