Complex Case

The bare outlines of the story are the mother’s milk of Canadian identity: Tommy Douglas, the plucky premier of Saskatchewan, staring down his province’s combative doctors and establishing a pioneering system where people could get medical care without having to open their wallets.

The tale is true — as far as it goes.

On June 15, 1944, Douglas’s Co-operative Commonwealth Federation won election in the impoverished prairie province, largely on the promise that it would bring primary health care within the financial reach of ordinary people. In office, where he was both premier and health minister, Douglas quickly set up North America’s first single-payer hospitalization insurance scheme. Now patients had only to flash a card to receive treatment in an institution. Later, in 1962, a few months after he left Saskatchewan for Ottawa to lead the New Democratic Party, Douglas’s successors in the CCF government endured a strike by feckless doctors and established the program under which practitioners were paid by the government for the care they provided outside of hospitals. It was this system of medicare that the rest of Canada copied and that so puffs up our hearts whenever we fall into conversation with Americans (including the likes of Bernie Sanders).

Every country needs a hero, and Douglas is ours. But as Esyllt W. Jones shows in Radical Medicine, the hagiography of Saint Tommy, a former Baptist minister, tends to be rather sanitized, and it glosses over the compromises he made along the way. “Rather than a radical re-organization of health and fully socialized provision,” she writes, “Douglas created government health insurance for hospital (and later physician) care.” This is a book about the road not taken and about how Douglas fell far short of his visionary goals. Or, as Jones puts it, “it is in part a story that ends in failure.”

“Failure.” That’s not a word that wins CBC polls about the greatest Canadian or that tends to get your face onto a postage stamp.

Others have pointed out that Douglas compromised on health care. Back in 1950, the American sociologist Seymour Martin Lipset noted the premier’s backsliding in Agrarian Socialism, his classic study of the CCF’s first years. In Private Practice, Public Payment, from 1986, C. David Naylor contended that the Douglas government gave way to the province’s doctors. And Gordon Lawson argued in Making Medicare: New Perspectives on the History of Medicare in Canada, a 2012 collection edited by Gregory P. Marchildon, that the CCF was never committed to the gold standard of placing physicians on salaries, rather than having them bill for their services.

So is Radical Medicine just another book about just another government that made quick promises it soon abandoned? There’s some of that, obviously. But Jones presents a story that’s more involved — and disappointing — because of how much effort went into conceptualizing a truly new plan for health care.

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Attempts to dramatically reshape the health system in Saskatchewan were very much alive even before the CCF came to office. Starting in 1936, an organization with the charmingly dull name of the State Hospital and Medical League mounted an effective grassroots campaign to press for “the socialization of the medical structure.” It issued a blueprint in 1941, when it proposed that all health care workers, including dentists, should receive salaried payment; a fee-for-service structure, it argued, discouraged preventive medicine. (This approach wasn’t as radical as it sounds. By the mid-1930s, more than a third of Saskatchewan doctors were already being paid a salary by municipalities and other institutions to treat tuberculosis and mental illness.)

But, as Jones sees it, the push for medicare, though well founded in prairie cooperative traditions, was also influenced by developments elsewhere: “Local people took ideas with international currency and applied them to their own situations and their own realms of possibility.” In 1944, the league found inspiration in the health care system in the Soviet Union, the only universal scheme in the world at the time. They weren’t the only ones looking: experts in both the United Kingdom and the United States had studied the Soviet system in the 1930s, as had eminent Canadian physicians such as Frederick Banting and Norman Bethune.

The league put together proposals that centred on a so‑called health-centre model, one that would challenge social inequality and the control that doctors had over the system. It would give as much emphasis to preventing health problems as to solving them.

Douglas and his advisers were well aware of the ideas that were percolating, but the league’s sustaining influence on them is somewhat unclear. Despite the league’s loud voice, the CCF was vague in the 1944 campaign about how it promised to transform the medical system, even though it pledged free access to health care. It made no public commitment, for example, to salaried physician payment. Nonetheless, advocates for radical change were heartened after the CCF victory.

Within days of assuming office, Douglas brought in Henry Sigerist, a Swiss-born expert on the Soviet system, and Mindel Cherniack Sheps, a Manitoba physician and activist. He sent them on the road and tasked them with drawing up a blueprint for action. Over three weeks in September 1944, the Sigerist Commission met with robust local groups, with their defined ideas about socialized medicine, and with doctors opposed to those ideas. In its concise report — just ten pages, filed on October 4 — the commission embraced a regionally organized health-centre model.

Initially, it seemed the government would also embrace that model, and there were some quick wins. A new provision provided comprehensive health care for pensioners and widows, for example, and a health services planning commission was established.

But Sigerist returned to Europe after submitting his report, and Sheps’s contract wasn’t renewed. As Jones says, implementing the recommendations they left behind “proved politically and practically challenging” for the CCF, which succumbed to the realities of power, including “a highly decentralized framework of regional authority.” In 1945, Douglas turned his attention to setting up the insurance scheme for institutional costs. Rather than embrace socialized medicine with a measure of community control, the government would ultimately settle for being the paymaster of hospitals and doctors. While the plan Saskatchewan established in 1947 was a significant step forward, it pushed aside a vision of socialized medicine that was more than just insurance.

It took another fourteen years before Saskatchewan felt it could supplement the 1947 plan; it did not revisit the health-centre concept but instead added another layer of insurance to cover doctors’ fees. That too was a noteworthy victory, achieved in the face of a twenty-three-day strike. And by 1971, the Saskatchewan model was being emulated by provinces across Canada. As a result, health outcomes in this country have improved enormously over the past fifty years, as patients no longer have to put off treatment for fear they might not be able to pay their bills.

But as the dust settled, there was no more talk of preventive medicine and community participation. Socialized medicine had come to mean, simply, health insurance that was mandated by the state. Yes, it works well enough, but the story Jones tells — and the complex demands of 2020 — suggest it may be time for another look at “radical medicine.”