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  • Warren Breckman

    Canadian Rules

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    When healthcare reform became a vital issue in the Democratic presidential nomination race in 1992, the Canadian model was essentially swept out of the debate by comments from Senator Paul Tsongas (D-Mass.). Having suffered from non-Hodgkin lymphoma in the early 1980s, Tsongas frequently claimed that in Canada’s single-payer universal system, he would not have survived. Never mind that the bone marrow transplant that saved his life in 1986 was also available in Canada at that time. Indeed, research that led to bone marrow transplants had been pioneered at a Toronto hospital decades earlier. And never mind that, sadly, the lymphoma claimed Tsongas’s life in 1997. His remarks went essentially unchallenged, and the Canadian model was long off the table by the time Bill Clinton attempted to introduce healthcare reform in his first hundred days.

    The Canadian system has come in for even rougher handling in the frequently hysterical, paranoid, and duplicitous campaign against President Obama’s proposed reform of American healthcare. In contrast to some of his Democratic predecessors, Obama has treated the Canadian experience with far greater sensitivity and insight, acknowledging that in many key indicators, Canada’s health system outperforms America’s, while at the same time spending considerably less per capita. Yet even Obama dismissed the relevance of a single-payer system like Canada’s when he remarked, “I’ve said the Canadian model works for Canada. It would not work for the United States, in part simply because we’ve evolved differently. So, we’ve got to develop a uniquely American approach to this problem.” And in fact, none of the Democratic proposals involves a single-payer system.

    What does Obama mean when he speaks of different evolutions? At an obvious level, the two healthcare systems have followed divergent paths. The universal healthcare that was introduced nationwide in Canada some forty years ago has not remained a monolith. It has adapted to new technologies and treatments and evolved through ongoing negotiations among doctors, governments, and citizens. In the U.S., the American Medical Association and the pharmaceutical and insurance industries have defeated efforts at deep reform as far back as the presidencies of Franklin Delano Roosevelt and Harry S. Truman, and the private health business has grown into an enormously complex and powerful giant. Disregarding the historical path that American healthcare has taken would be politically disastrous and self-sabotaging for Americans committed to alleviating the crisis in their country.

    To speak of different Canadian and American evolutions, however, taps into a deeper cliché about the two neighboring nations. That is, Americans are greater individualists who prefer the risks and rewards of the free market to the heavy hand of government, while Canadians are instinctive collectivists who are more willing to accept state intervention for the sake of the common good. From this perspective, the development of a single-payer government healthcare system may look like an inevitable, natural expression of the Canadian character.

    As with so many explanations that rest upon essentialist ideas of national character, though, this one ignores the political inventiveness and sheer political will that allowed the champions of healthcare reform to triumph in Canada. Universal healthcare owes its existence largely to one man, Tommy Douglas, the premier of Saskatchewan from 1944 to 1961, the first federal leader of the New Democratic Party from 1961 to 1971, and, incidentally, the grandfather of the actor Kiefer Sutherland. From the moment Tommy Douglas promised Hospital Insurance in 1944 to the successful introduction of national Medicare in the late 1960s and early 1970s, he faced a storm of protest.

    The battle reached its highest pitch in the two years after Douglas introduced a proposal for universal healthcare in Saskatchewan in December 1959. (The Canadian constitution placed healthcare under provincial, not federal jurisdiction.) Healthcare became the main issue in Saskatchewan’s election of 1960. Douglas’s opponents launched a smear campaign. No one talked of death panels, but other portents of horror circulated, including claims that under a government system, women would be confined to mental asylums for nothing more than menopausal problems. The College of Physicians and Surgeons cautioned that patients would lose freedom of choice and that doctors would leave the province. When Douglas’s party, the Cooperative Commonwealth Federation, won the election with a slightly increased majority, he took this as a mandate to implement his scheme. In 1961, Douglas resigned as premier in order to become the first national leader of the newly formed New Democratic Party. But before he left Saskatchewanian politics, he made a rousing speech in the Legislature defending his legislation from its opponents: “I believe, Mr. Speaker, that if this medical care insurance program is successful, and I think it will be, it will prove to be the forerunner of a national medical care insurance plan. It will become the nucleus around which Canada will ultimately build a comprehensive health insurance program…. I believe such a plan operated by the federal and provincial governments jointly will ultimately come in Canada. But I don’t think it will come unless we lead the way.”

    The real brunt of the battle over healthcare fell to Douglas’s successor as Saskatchewan’s premier, Woodrow Lloyd. The Canadian Medical Association came out aggressively against the legislation, and behind the CMA, the American Medical Association weighed in with its full clout and money. Saskatchewanian doctors launched a strike on July 1, 1962, that withheld all but emergency services for twenty-three days. Doctors and their advocates warned darkly that the province would lose its doctors and that the government would bring in underqualified replacements from abroad. “Keep Our Doctors” (K.O.D.) committees sprang up across the province. These committees had all the appearance of a spontaneous movement of housewives worried about their families’ health. Only subsequently was it discovered that the committees were backed by a large part of Saskatchewan’s business and professional power elite. As a skeptic reported of the K.O.D., “My impression was that an organized attempt was being made to create hysteria among patients, particularly young mothers, and by playing on their emotions, to use them to apply pressure on the government....”

    The Cold War rhetoric that had turned the opposition to Harry Truman’s proposal for universal healthcare into an ideological battle against Communism abounded in the province. A Catholic priest fulminated at a large K.O.D. rally, “Tell those bloody Commies to go to hell when it comes to Canada. I loathe the welfare state and I love the free-swinging freedom.” A death-threat sent to Premier Lloyd anticipated the confused ideological slurs that we have seen in the opponents of President Obama, whereby he can be labeled both fascist and communist: “Postpone the Medical Care Plan if you want to live, you Hitlerite.” The supporters of Medicare waged a quieter campaign. Even Premier Lloyd adopted a “strategy of silence” that he defended years later because, as he recalled, “I was as near to knowing how close we were to violence and how ready many people were to act in a violent way as anyone. Believe me, the margin was a small one.”

    Lloyd, Douglas, and the supporters of Medicare persevered, despite virulent attacks and electoral setbacks. True to Douglas’s prediction, the Saskatchewanian model served as the template for the universal system that became truly nationwide when Quebec, the last province to ratify the plan, signed on in 1970. Forty years later, the Canadian health system undoubtedly faces challenges, as does every medical system in the world. Yet the great majority of Canadian doctors support this system and Canadian citizens report a very high level of satisfaction. Indeed, universal medical care is one of the strongest sources of Canadian pride and across a very wide political spectrum, it is seen as a fundament of Canadian citizenship. As for Tommy Douglas, who died in 1986, a nationwide contest in 2004 named him the “Greatest Canadian.”

    There was nothing easy or inevitable about the introduction of universal healthcare in Canada. To be sure, there was considerable support among the citizenry, but the forces that now stand arrayed against healthcare reform in the United States were present and powerful in Canada in the 1950s and 1960s. It may well be that these forces are now too strong to overcome in the U.S. It may even be true that the evolution of American healthcare and society itself rules out a single-payer, universal system. But Americans should not be too quick to ignore the Canadian story. Whatever else it may offer to Americans now in the throes of this desperate challenge, it provides a stirring example of visionary leadership, clear ideas, firm conviction, and strength in the face of seemingly insurmountable opposition.

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  • I'm a Canadian author who returned home to Canada last Friday from a weeklong book tour, in and around New York City. I was supposed to be talking about Henry Hudson, but I was constantly asked about public health care. I told my American friends and audiences that for a Canadian, the virulent U.S. health care debate has been like watching a married couple next door engage in a nasty domestic dispute, in which every now and then one of them points over the fence at me and either declares me a beacon of the collective good or a poster boy for socialist insanity. Good luck sorting this one out, and thank-you to Mr. Breckman for explaing how difficult and venal (and suspiciously familiar) the struggle was on this side of the border to introduce public health care.

    Posted by Douglas Hunter on Tue 22 Sep 2009

  • Thanks for this excellent piece of history. I owe my wife's life to the Canadian medical system. As a graduate student in Illinois in the late 90s, she was unable to get the medical attention she needed from the doctors we consulted in the Champaign area. None were able (or willing) to commit the time, effort, and expenses necessary to figure out the cause of a mysterious set of symptoms that afflicted her on a regular basis. It wasn't until we moved to the province of Quebec a couple of years later (I got a postdoctoral fellowship at Laval University) and started to receive treatment by doctors there that we met a physician with enough curiosity and perseverance to identify the cause of her illness. He sent us to a number of different specialists, and thanks to his persistence, he was able to determine the source of the symptoms. Without that doctor and an accompanying team of experts, it's probable that my wife's symptoms would have worsened to the point of death. Hats off to the pluck of the Canadian medical system and its tireless team of physicians, nurses, and technicians!

    Posted by Edmund Searles on Tue 22 Sep 2009

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Warren Breckman teaches modern European intellectual history at the University of Pennsylvania. He is the author of Marx, the Young Hegelians & the Origins of Radical Social Theory, European Romanticism, and the forthcoming Adventures of the Symbolic: Postmarxism and Democratic Theory. He is the co-executive editor of Journal of the History of Ideas, a founding member of Zeitschrift für Ideengeschichte, and a member of the editorial board of Lapham’s Quarterly. Born and raised in Winnipeg, Canada, he has lived, studied, and worked in Berkeley, London, Toronto, Paris, New York, Philadelphia, and Berlin. In 2008-2009, he is the academic director of the Berlin Consortium for German Studies at the Free University of Berlin.
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