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The Romanow report observed, “Canadians embrace medicare as a public good, a national symbol and a defining aspect of their citizenship.” Medicare, as the national single-payer Health Care system is called, began in Saskatchewan on July 1, 1962, but operated without federal funding until July 1, 1968. Other provinces and territories joined over the following four years. The steps leading up to the adoption of medicare go back a long way: the idea of national health insurance was discussed as long ago as 1919, when it was a plank in the Liberal Party platform of that year. Because the Canadian Constitution assigns responsibility for health to the provinces, negotiations with the provinces about some kind of joint funding were unsuccessful until 1957, when the Hospital Insurance and Diagnostic Services Act was passed in Ottawa. This brought substantial federal funding to help pay for the hospitalization program in Saskatchewan, which had come into effect on January 1, 1947.

The seeds were sown for publicly funded hospital and medical care in the province with the Union Hospital Act of 1916, which was broadened in 1917 to enable municipalities to come together to build a union hospital and to levy taxes to finance its operation. About the same time, the Rural Municipalities Act was amended to give rural municipal councils authority to levy taxes to finance the Municipal Doctor System, enabling them to offer doctors an annual retainer fee in order to encourage them to practice in a given community. With the onset of the Depression in 1929, accompanied on the Prairies by a devastating Drought, money was extremely scarce, and little progress was made. However, in 1939, at the instigation of Matt Anderson of RM McKillop, the Municipal and Medical Hospital Services Act was passed, permitting municipalities to levy either a land tax or a personal tax to finance hospital and medical services. When the CCF government came to power in 1944, their platform called for comprehensive health insurance. The Hospital Insurance Act came into effect on January 1, 1947, guaranteeing every citizen of the province hospital care without a fee. No other jurisdiction on the continent could boast such a sweeping reform. T.C. Douglas insisted on a small annual premium to help finance this insurance. The introduction of hospital insurance in Saskatchewan, and its wide acceptance by the physicians of the province, paved the way for the introduction of medical insurance.

The Saskatchewan Medical Care Insurance Act was passed on November 17, 1961, and after two delays became effective on July 1, 1962. Meanwhile, Douglas resigned as Premier to head up the newly created federal NDP, leaving Woodrow Lloyd, who had become Premier, to oversee the introduction of medical insurance. On July 1, 1962, almost all Saskatchewan doctors went on a three-week strike. Only those who lived through those fear-ridden days, when doctors abandoned their offices, can appreciate the pressure that Lloyd came under to capitulate and withdraw the insurance scheme. The Regina Leader-Post was vicious in its attacks; while doctors, with the moral support of the American Medical Association, were merciless, warning their patients that most doctors would be leaving the province if “socialized” medicine were introduced. Patients in turn appealed to their elected members. The Opposition Liberal Party promised to bring in their own scheme, which if it had seen the light of day would have left patients in much the same situation as patients in the USA find themselves today. If Woodrow Lloyd had withdrawn the legislation, the story of national medicare might never have been written. Through the mediation of Lord Taylor, a physician whom the government had brought from England, the strike came to an end after twenty-three days, and things returned more or less to normal.

In 1964 the Royal Commission on Health Services, chaired by Justice Emmett Hall of Saskatoon, recommended that Canada should adopt national medical insurance; Hall stated later that the demonstrable success of Saskatchewan's medical insurance system played a role in this decision. When the federal Medical Care Act of 1966 came into effect on July 1, 1968, with the four principles of public administration, universality, portability and comprehensiveness, Saskatchewan began immediately to enjoy joint funding. The formula in effect meant that the costs of medicare would be split approximately 50-50 between the federal and provincial governments. Eventually, however, the federal government became disillusioned with a scheme that continually cost more, while they had nothing to say about how the money was spent. The provinces also found that constraints in the formula prevented them from bringing in needed reforms. In 1977 a new system was agreed upon, called Established Program Financing (EPF). The effect was that the federal government provided support on a block-funding basis, enabling the provinces to use the federal money to finance health initiatives, in addition to hospital and medical services. Unfortunately, annual increases to the federal contribution were tied to the rate of growth in Gross National Product (GNP); since health costs tended to grow faster than the GNP, the result was a gradual decrease in federal support. Later on this system was revised, enabling the federal government to cut support even more drastically. Thus, in the 1990s, as Ottawa cut back in an attempt to eliminate the deficit, the provinces came under severe fiscal strain and the Saskatchewan government in turn began cutting its support for health, introducing the concept of wellness as its rationale.

In 1984, the federal legislation enabling joint federal-provincial funding for hospital and medical services was consolidated under the Canada Health Act. This added a fifth criterion to the Medical Care Act of 1966: services had to be accessible to be eligible for federal funding, and providers would not be allowed to make additional charges (extra billing). By the end of the 20th century, questions were being raised about the need to amend the Canada Health Act, which dealt mainly with hospital and physician services, in order to produce a more seamless health care system, from the nursing home and Home Care to the Intensive Care Unit. Meanwhile, the right-wing press harped on the question of the sustainability of medicare. Because of these two factors, plus the phenomenon of ever-increasing waiting lists, Prime Minister Chrétien appointed Roy G. Romanow, QC, on April 3, 2001, to head up a Royal Commission. It was “to recommend policies and measures respectful of the jurisdictions and powers in Canada required to ensure over the long term the sustainability of a universally accessible, publicly funded health system that offers quality services to Canadians and strikes an appropriate balance between investments in prevention and health maintenance and those directed to care and treatment.”

The Romanow Report, published in November 2002, contained forty-seven recommendations which, taken together, presented a roadmap “for a collective journey by Canadians to reform and renew their health care system.” Three of these recommendations, in particular, held out revolutionary possibilities for the sustainability of a reformed system. The first put forward something new, a Canadian Health Covenant establishing governments' commitment “to a universally accessible, publicly funded health care system.” The second recommended “a Health Council of Canada … to facilitate co-operation and provide national leadership in achieving the best health outcomes in the world.” This one was accepted immediately by the federal government and several provinces; but when the Council was established it was virtually a toothless old lion - a far cry from what was intended - due to differences of opinion among some provinces, particularly Alberta, BC, and Quebec. The third recommendation concerned the dire need to institute Primary Health Care; this idea was also strongly recommended by the Senate findings, known as the Kirby Report, which was published in the fall of 2002. The Kirby Report suggested that properly established Primary Care units could form the foundation required to make the whole system much better organized, bringing seamless health care within reach.

The advent of medicare represents perhaps the greatest test of participatory democracy Canada has ever known. In 1962, Community Clinics sprang up in many districts - the Swift Current Health Region, which began functioning on July 1, 1946, showing the way. Regina, Saskatoon and Prince Albert still have successful functioning community health clinics. Within such organizations, grassroots decision-making results from community ownership of the system, giving individuals a feeling of empowerment that makes for volunteering services and explains why these agencies work effectively. Primary Health Care is a movement to generalize that kind of decentralized decision-making. At the outset of Saskatchewan medicare in 1962, there were those who believed that centralized control was necessary to guarantee the success of the innovation; whatever the reason, grass-roots community clinics were not encouraged, which set participatory democracy back for more than a generation. The advent of Primary Health Care may well solve the dilemma of how to achieve systematic central control, yet gain the dynamism inherent in local decision-making.

In 1995 a district health board structure was put into place, with the hope of making the administration more democratic and, one suspects, to deflect criticism away from the Department of Health. Thirty-two health districts were created, plus the Athabasca Health Authority in the far north. Two-thirds of the members of the boards were elected, and the rest were appointed to ensure a better balance concerning gender and minorities. Preliminary results suggest that the devolution increased local control; however, the Fyke Report (2001) recommended that the health districts be reduced in number, with appointed, instead of elected, boards. How to organize the administration of health services remains worrisome. Also worrisome is the increasing share of the provincial budget being taken up with public health, including medicare. The fear is that health costs will continue to rise faster than the growth of the economy, and that other services will be crowded out. One solution is to have the federal government accept a growing responsibility for financing medicare, and the other is for provinces to increase revenues; but a combination of both would seem the most likely outcome. The problem is that the federal government and the provinces suffer from insufficient revenue because of the pressure to cut taxes: under these circumstances it remains exceedingly difficult to increase revenues sufficiently to meet the demands of health care and leave enough funding for other essential services such as education, roads, and the environment. With drug costs increasing (cancer drug costs in Saskatchewan go up 22% each year), all governments are faced with some tough decisions. It has been suggested that one way around the dilemma is to raise taxes without appearing to do so, by means of an increase in the provincial income tax devoted to health.

Medicare has come a long way. The steps often have been faltering and there have been stubbed toes, but a system of health services has taken shape that is the envy of many. As it continues to evolve to meet emerging needs, how the system will change or should change in the future will depend on the studies that are continuously commissioned and on the adoption of their key recommendations.

John A. Boan

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