Completing Tommy's vision

Medicare's future
November 19, 2007

Medicare represents one of our crowning national achievements, a proud reflection of how we see ourselves as a just and caring society.

On this, National Medicare Week, it is important to revisit what medicare is, how it came about, how it is threatened, and how to defend and expand it.

Medicare has come to mean the terms and conditions under which Canadians receive a defined basket of health care services. These are best summarized in the five principles – public administration, universality, accessibility, portability, and comprehensiveness – which underpin the Canada Health Act. More than a public insurance program, medicare is a defined set of services administered and delivered provincially under a national framework. We fund these defined health services through the taxes we pay to our respective provincial governments, as well as the federal government.

Medicare is one of the great achievements of Canada, and Tommy Douglas is rightly seen by Canadians as the Father of Medicare. His idealism, perseverance, and prairie pragmatism are the reason we have medicare today. As Douglas saw it, the first phase of medicare was the removal of financial barriers between those giving the service and those receiving it. But Douglas always saw that the first phase of medicare as just a prelude to a more ambitious second phase. Though more difficult to achieve, Douglas’s vision involved a fundamental restructuring of our health care delivery system, with a much greater focus on illness prevention, health promotion, and the policies required to address the social determinants of health, particularly poverty and inequality.

For Douglas, the ultimate goal of medicare was to keep people well, not just patch them up when they get sick. He also understood that illness prevention and improved health for all Canadians were essential to controlling costs. This second phase remains largely incomplete.

Canadian medicare, built on the pioneering efforts in Saskatchewan, came into being as a national program under the Pearson government in 1967. By the late 1970s, however, the anti-medicare lobby had sufficently recovered from its earlier defeat to lead another charge against the operating principles of medicare. In response to this threat, federal Health Minister Monique Begin, aided by pro-medicare activists throughout the country, mustered the support necessary to pass the Canada Health Act in 1984 to protect what had been achieved in the 1950s and 1960s.

Although temporarily defeated, the small but powerful anti-medicare coalition has sprung back to life, bent on discrediting and undermining medicare. The forces of for-profit medicine are once again challenging the notion of health care as a fundamental right of citizenship. They have sought, with some success, to frame the debate as between defending an untenable status quo or “fixing” medicare by introducing free market “solutions.” They have been emboldened by the recent Supreme Court of Canada’s Chaoulli decision to launch a full scale attack on the principles of public administration and universality as set out in the Canada Health Act. Though they rarely admit it, the real reason they oppose medicare is because medicare is highly redistributional. Every minute of every day, it redistributes resources from wealthier and healthier Canadians to poorer and sicker Canadians.

Claims that medicare is fiscally and economically unsustainable are unfounded, but they are used to persuade a reluctant public that there is no choice but to accept privatized health care. According to Canada’s leading health care economist, Robert Evans, the wolf at the door of the Canadian medicare system is not an economic wolf but rather “a political wolf dressed in phony economic clothing to deceive the sheep.”

Thus, the challenge is to defend medicare against the forces seeking to dismantle it. We can best do this by completing Tommy’s original vision for medicare. Building on the proven administrative efficiencies of the single-payer systems administered by the provinces, we can expand medicare well beyond doctors and hospitals into pharmacare, home care and dental care; to re-orient public health care around primary health care and community care, and tackle head on the social determinants of health.

In some areas change is beginning to happen. There are many examples of successful innovations, which have dramatically reduced wait times, improved access to quality care and reduced costs. Dr. Michael Rachlis, a physician and health policy advisor, has performed an important service for all Canadians by cataloging the most promising innovations in our public system. But missing is the political leadership on the part of provincial and federal governments to ensure the systematic dissemination and application of these solutions throughout the system.

Whether medicare moves forward, or becomes progressively eroded by encroaching privatization will depend on which vision of health care prevails. Will it be one based on the premise that health care is a commodity and that ability to pay should determine who gets what care and how? Or will it be the one actually desired by most Canadians? That is a 21st century medicare, but one still based on the principle that every Canadian should have access to health care on the same terms and conditions.

We believe the time is now to take the offensive and build the broadest possible coalition of Canadians to regain the momentum from the privatizers, and make Tommy Douglas’ vision for medicare a reality.

Greg Marchildon is Canada Research Chair in Public Policy at the University of Regina, and was executive director of the Romanow Commission. Bruce Campbell is the executive director of the Canadian Centre for Policy Alternatives. They are editors of “Medicare: Facts, Myths, Problems and Promise,” published by James Lorimer and Co.