Lessons from Canada in creating a health care commons step-by-step
By David Morris
If health care were more widely recognized as a commons, the idea of a public health care option—or even a single-payer system—would not seem so controversial to Congress members.
It’s relatively easy for Americans to understand that parks, sidewalks, the environment or the Internet are all part of the commons. That’s because no one owns them.
But it’s more of a stretch when it comes to elements of the commons that have traditionally been under private ownership. Access to health care, for instance, rightly belongs to all of us the same as air, water, sunshine or other things we depend upon for life. We are, after all, morally bound to help anyone who needs medical attention. And our tax money funds much of the research that results in new medicines and procedures.
Yet these simple truths are clouded by the fact that in the United States, even after the passage of President Obama’s health care reforms, a large share of health services is operated on a for-profit basis—a unique situation among wealthy nations, which means our health care is more expensive and many people are denied access.
If health care were more widely recognized as a commons, the idea of a public health care option—or even a single-payer system—would not seem so controversial to Congress members. In fact, a look right across the border at the Canadian health care programs shows how well a true health care commons works.
How Canadians Created a Health Commons
The seeds of the current Canadian health system were sown in rural Saskatchewan in the early twentieth century when small cities with no doctors began to subsidize a physician to come and set up practice. Several communities then joined together to open publicly funded hospitals.
In the 1930s, a new Canadian political party, whose name reflected its philosophy, the Cooperative Commonwealth Federation (CCF), came to power in Saskatchewan. In 1946 the province enacted legislation that guaranteed free hospital care. Premier Tommy Douglas had hoped to offer universal health care, but the province lacked the financial resources.
In 1958, building on a decade of success of hospital care in Saskatchewan, the Canadian federal government used the power of the purse to coax other provinces to introduce public hospital insurance. Ottawa promised to pay 50 percent of the cost of provincial programs that satisfied the following rules, which were shaped by the idea of health as a common¬wealth, or commons.
1. Public Administration: The plan must be run by a public authority and be nonprofit.
2. Comprehensiveness: All necessary medical services must be covered.
3. Universality: Every resident of a given province or territory must be entitled to the same level and extent of coverage.
4. Portability: When insured persons travel or move within or outside Canada, their coverage must be maintained.
5. Accessibility: All insured persons must have access to hospital and physician services.
By 1961, all provinces had adopted a hospitalization insurance program.
Taking the Next Step Toward Universal Coverage
Since Saskatchewan had been paying 100 percent of the cost of its program, the 50 percent federal match allowed it to extend public health coverage to physicians’ visits. A promise to do so by Tommy Douglas, who still led the CCF, became the principal issue in the 1960 provincial elections. The CCF won, and on July 1, 1962, the new system went into effect. That day 90 percent of the province’s doctors went on strike.
It was a defining moment in Canada’s health care history. Aided by the American Medical Association, Saskatchewan’s doctors used some of the same rhetoric that has proven so effective in U.S. health care debates: socialized medicine is communistic and would limit a patient’s choice of doctors.
But by 1962 Saskatchewan residents had been served by a commons-based health care system for more than fifteen years. When the doctors called a mass public demonstration against socialized medicine, expecting forty thousand to attend, only 10 percent of that number showed up. The strike ended two weeks later.
In 1964, came further evidence of how deeply rooted the idea of a health commons had become in Saskatchewan. The CCF party lost the elections. The incoming Liberal Party had opposed public insurance for physicians’ services, but it did not try to overturn the 1962 law.
In 1966, Ottawa offered to fund provincial health plans for doctors under the same conditions as it had funded provincial health plans for hospitals. By 1972, every Canadian was covered by the new Medicare insurance.
Thirty years later, a Commission on the Future of Health Care summed up the pro¬cess thus: “The principles of the Canada Health Act began as simple conditions attached to federal funding for medicare. Over time, they became much more than that. . . .The principles have stood the test of time and continue to reflect the values of Canadians.”
Lessons in Defending the Commons
The Canadian experience also shows that the price of defending a commons, as with liberty in general, is eternal vigilance. Once created, a commons will face continuing challenges from two major forces. One is the ingenious ability of individuals and cor¬porations to find loopholes that allow them to maximize their income at the expense of the commons. The other is the tendency of governments during difficult economic times (or when driven by market ideology) to starve the commons, which undermines public support by reducing its effectiveness.
Canada’s health commons has had to defend itself against both forces. The loophole it faced was that Canada’s Medicare legislation permitted doctors and hospitals to charge patients extra for better service. The law required universal access. But it did not specifically prohibit doctors and hospitals from charging additional fees or allowing patients to pay to jump ahead on the waiting lists. In 1984 Canada responded to this threat by passing a new Health Act that effectively eliminated user charges or surcharges on publicly insured services.
More recently, Canada’s health commons has had to deal with shrinking federal support. By the early 2000s, the federal share of the provincial health care budget was down from 50 percent to 20–30 percent. Ever longer waiting lines resulted in ever broader public grumbling and ever more aggressive lobbying by for-profit companies to be allowed to deliver the same health services.
In 2005, the issue came to a head when the Supreme Court of Canada voted 4–3 that Quebec’s prohibition against private health insurance for medically necessary services violated the Quebec Charter of Human Rights and Freedoms. Chief Justice Beverly McLachlin wrote, “Access to a waiting list is not access to health care.”
Quebec responded in two ways. In 2007 it allowed private insurance for the three surgeries that had the longest waiting times: knee and hip replacements and cataract surgery. At the same time, it improved the delivery structure of its health system to reduce waiting times. In March 2009, Quebec’s Health Minister announced that nearly all patients seeking knee and hip replacements in the public system were beginning treatment within three months, down from nine months or more.
At the same time, CBC News reported, “More than two years after Quebec legalized private medical coverage for select surgeries, the insurance industry says it has not sold a single policy.”
In appreciation for their health care systems, Canadians in 2004 voted Tommy Douglas as “the Greatest Canadian” in a national poll sponsored by the Canadian Broadcasting Company.