In 1948, Paul Martin Sr., in his role as federal minister of national health and welfare for the Mackenzie King government, announced a number of grants that were intended to help the provinces deal with a variety of health care issues, including public and mental health; the treatment of cancer, tuberculosis, and venereal disease; and the prevention of crippling conditions in children. The grants could also be used for training health care professionals, medical research, and the construction of hospitals. Martin, likewise, introduced the Hospital Insurance and Diagnostic Services Act in 1957, which provided money to any province that met certain criteria, to improve health care services for those who lived there, as well as to explore the creation of a health insurance plan in that province.
Before the act could be fully implemented, though, John Diefenbaker’s Progressive Conservative Party surprised just about everyone by winning 112 seats, seven more than Louis St. Laurent’s Liberals, in the election that year, which gave the Saskatchewan native the right to form the next government. The following year, Diefenbaker and his party scored the largest majority in Canadian electoral history, taking 208 of the 265 seats available. Three years later, Prime Minister Diefenbaker called upon his old friend and law school chum Justice Emmett Hall to chair a Royal Commission on Health Services. Justice Hall, who also hailed from Saskatchewan coincidentally, was given the responsibility to “inquire into and report upon the existing facilities and the future need for health services for the people of Canada, the resources required to provide such services, and to recommend such measures, consistent with the constitutional division of legislative powers in Canada, as the Commissioners believe will ensure that the best possible health care is available to all Canadians.” Among other things, the commission was to examine how best to finance Canada’s health care system; what training might be required in the future to properly prepare health care professionals for dealing with patients; what the projected costs of running such a system might be, now and in the future; and what might be done to improve the delivery of health care services.
In addition to Emmett Hall, six others were appointed by the prime minister to serve on the royal commission. These were Alice Girard, a registered nurse; Dr. David M. Baltzan; Professor O.J. Firestone; Dr. C.L. Strachan; Dr. Arthur F. Van Wart; and Wallace McCutcheon (who would leave in 1962 when Prime Minister Diefenbaker appointed him to the Senate). The royal commission — it eventually came to be known as the Hall Commission — would hear from hundreds of Canadians during sixty-seven days of public hearings, which were held in all ten provinces, as well as the Yukon.
Justice Hall himself conducted most of the inquiries, carefully questioning witnesses and experts, in hopes of gaining a better understanding of how Canada’s patchwork quilt of health care services was — and, in many cases, wasn’t — working. The jurist was particularly taken aback by the disparity in the quality of health services he found in different parts of the country, in addition to an alarming lack of access, in some places, to many vital services. Not content with merely hearing from hundreds of individual citizens and delegates representing over four hundred organizations, Justice Hall commissioned twenty-six separate research studies and arranged for his group to visit a number of other countries to study how their health care systems worked. When the Hall Commission released its report in 1964 — it was so comprehensive it was issued in two parts — they recommended Canada adopt a model similar to what Tommy Douglas and the CCF had introduced in Saskatchewan. But Justice Hall took it one step further, proposing that schoolchildren and those on welfare should receive free dental care, and that the disadvantaged and elderly should receive free drugs and prescription glasses. As he told reporters after the report had been released, “The only thing more expensive than good health care is no health care.”
Reading the Hall Commission’s report all these years later provides a fascinating glimpse into what Canada was like back then as our country approached its centennial. Take, for instance, this: “A nation that in 1962 spent $756 million on cigarettes and tobacco and $973 million on alcoholic beverages can afford the programme we recommend which would involve an additional $466 million in 1971.” Or how about this: “The unsatisfactory dental health of the nation and particularly of its children must be attended to as soon as personnel can be trained in one of these crash programmes.” Or this: “We recognize that the well-being and happiness of the society is simply the sum total of well-being and happiness of its individual members. It is clear that the well-being of a proportion of the population at any given time is seriously curtailed because of mental or physical disease or impairment that, strictly by the laws of chance, could strike any one of us.” Or, finally, this: “There is yet another major reason for an expanding public interest in health. It is the growing awareness of the cost to society as a whole of failure to be concerned and to act on behalf of its members. The most dramatic evidence was the rejection rates of armed services recruits in World War II. With the nation in peril, dependent upon its healthy man- and woman-power for survival, the price we were paying for our past lack of adequate health resources and services was glaringly apparent.”
The report continues: “We seem, in a sense, to have become ‘insurance minded’ in that we now believe that an individual family should not have to bear alone the full cost of risks that could happen to any one of us. Accordingly, if the resources of the whole can be used to strengthen the ability of families and individuals to manage and plan for themselves, then they should be so used.” Here, we see the beginning of the “social safety net” — or at least the thinking that would lead to it.
Justice Hall and his fellow commissioners took it one step further, though, coming up with a Health Charter for Canadians. The charter proclaimed:
“The achievement of the highest possible health standards for all our people must become a primary objective of national policy and a cohesive factor contributing to national unity, involving individual and community responsibilities and actions. This objective can best be achieved through a comprehensive, universal Health Services Programme for the Canadian people, IMPLEMENTED in accordance with Canada’s evolving constitutional arrangements; BASED upon freedom of choice, and upon free and self-governing professions and institutions; FINANCED through prepayment arrangements; ACCOMPLISHED through the full co-operation of the general public, the health professions, voluntary agencies, all political parties, and governments, federal, provincial and municipal; DIRECTED towards the most effective use of the nation’s health resources to attain the highest possible levels of physical and mental well-being.”
Did you catch that bit about “national unity”? This is the poison pill, the seed planted all the way back in 1964 that would produce a tree with many limbs and deep roots. The hysteria those two words have led to over the years, when we’re talking about medicare, can’t be overstated. As someone who has fought long and hard for a new and better made-in-Canada health care system, one that is truly innovative and modern and addresses the fiscal realities every person in this country must deal with, now and in the future, I’m frankly appalled at those who continually wrap themselves in the flag and claim to be the only true patriots in Canada. All because they, unlike me, support the status quo when it comes to health care.
The last paragraph of the Hall Commission’s report is both instructive and frightening. Entitled, simply enough, “The Future,” the section sums up rather eloquently why medicare was doomed from the start to turn into Canada’s most costly social program, one that, if we don’t soon act, will bankrupt the country by 2030. Here’s how the commission’s report concludes:
“It is obvious, even if no new programmes are adopted, that gross expenditures on health services will increase very substantially by 1971 … The population will be 22.6 million by then, an increase of 24 percent over 1961. Over the same period hospitalization costs alone will have increased by over 1.3 billion, or by 145 percent, and Canada is committed to the hospital programme. No one has suggested curtailing or abandoning it. The sum total of all our proposals is to add to the hospital programme and to the existing services the personal health services needed to round out the concept of comprehensive and universal coverage. These additional services will, if implemented, cost an extra $466 million in 1971. That is the price tag which must be affixed to our proposals. We are fully aware that it is a substantial sum. But we are equally aware that the benefits which will flow from such a comprehensive universal health service will be more than worth the price in terms of good health and human happiness.”
By the time the commission made its report, Canadians had been forced to suffer through two rather lengthy and divisive election campaigns — the first election taking place on June 18, 1962, the second on April 8, 1963. In 1962, the Progressive Conservatives were able to hold on to power, but less than a year later John Diefenbaker’s minority government fell and Lester B. Pearson found himself occupying the prime minister’s office, albeit with a still-wobbly minority. Because of the Pearson government’s tenuous situation, and because the party was so deeply divided on the issue of health care, it took a while to decide what to do about Justice Hall’s report. With the country’s doctors still not completely onside, individual MPs were worried that supporting a plan so similar to the one in Saskatchewan might set off protests and doctor strikes nationwide.
Eventually, cooler heads prevailed and the Medical Care Act was introduced by Allan MacEachen, the minister of national health and welfare, on July 12, 1966. The legislation extended the federal government’s original cost-sharing agreements, which had been hammered out in the 1940s and 1950s during the Mackenzie King and Diefenbaker years, so that now medical insurance plans covering physician services would be included. Even then, the Liberals got cold feet, delaying implementation of the new law until July 1, 1968.
Eleven years later, in 1979, Emmett Hall was appointed by Prime Minister Pierre Trudeau to once again examine Canada’s health care system, as a sort of follow-up to his earlier work in the 1960s. When Justice Hall submitted his completed report in September of 1980, he recommended eliminating extra-billing and opting-out, as he felt that those things, along with user fees, had the potential to seriously affect equal access to health care services for many Canadians. His findings would lead to the introduction, in 1983, of the Canada Health Act, a piece of legislation that would, in effect, prohibit those practices by financially penalizing any province that allowed them to continue.
Now, I realize hindsight is 20/20 and that it’s not fair to pass judgment on those who came before us, especially those honourable men and women who sat, alongside Justice Hall, on that royal commission half a century ago and who tried their best to come up with a solution to our health care challenges. But the problem is … they were working on the wrong problem. By focusing chiefly on things that were acting as impediments to Canadians’ being able to afford health care, Justice Hall and his commissioners inadvertently ensured that we ended up with an insurance scheme instead of a health care system. Not only that, but by ignoring things like nutrition, wellness, and prevention, our so-called health care system is, in reality, little more than a sickness system. Imagine that instead of taking your car in for regular maintenance, doing things like changing the oil, rotating the tires, and replacing worn-out wipers and spark plugs, you simply waited until something broke down and your car had to be towed to the shop for repairs. That’s the kind of health care system we’ve ended up with. A system where cost is paramount, where we ration care not by the size of your wallet, as they do in the United States, but by the length of a wait-list. A system that is broken and unsustainable because it wasn’t built right in the first place. This, unfortunately, is the legacy of Emmett Hall and his royal commission — a good man who asked the wrong questions and ultimately came up with the wrong solutions. (You might be interested to know, by the way, that even his own son, Dr. John Hall, a distinguished pediatric orthopaedic surgeon in Toronto, Ontario, wanted no part of his father’s plan, leaving the Hospital for Sick Children, and thereby escaping socialized medicine, in 1971 to become chief of orthopaedic surgery at Boston Children’s Hospital.)
As a consultant and political strategist, I see this all the time. Failing to properly identify the problem first inevitably leads to wrong turns and dead ends. Making matters worse, even when a problem is correctly identified, human beings often try to find quick and easy solutions because we feel we don’t have the luxury of time to dig deeper and test out our assumptions. Ironically, taking shortcuts only adds to the length of the journey because so much time is wasted having to backtrack after going down blind alleys. Had Justice Hall and his commissioners been able to take a little more time during their deliberations, I believe they likely would have discovered they’d misidentified the problem. Quality health care is expensive and can cost an individual a great deal of money — there’s no argument there. But to focus solely on finding ways to keep Canadians from having to declare bankruptcy or lose their homes should they fall ill was a mistake. Even worse, not allowing Canadians to contribute financially to their health care, while it might have been popular politically back in the day, was a recipe for disaster. No wonder so many people think health care is free. Right from the beginning, medicare was designed in such a way to avoid speaking truth to that lie.
Granted, Canadians no longer lose everything just because they get sick or need an operation, but, and it’s a big but, nobody is minding the store. Like teenagers in possession of a credit card with no spending limit, people today don’t worry about what health care costs or who’s footing the bill. As far as most are concerned, socialized medicine means everything is taken care of by the government. Little do they stop to think about who funds all government activities — the taxpayer. So, naturally, the “health care is free” mindset continues to grow, causing problems for provincial treasuries and finance ministers. By insisting upon going down this road, the federal government is bankrupting the provinces. In the province of Ontario, for instance, close to half the annual budget goes to pay for health care services. Close to half. That’s ludicrous. As former premier Dalton McGuinty once said, “There will come a time when the Ministry of Health is the only ministry we can afford to have, and we still won’t be able to afford the Ministry of Health.”
For those defenders of the faith who passionately believe the status quo is the only way, and that we mustn’t allow innovation or outside-the-box thinking to intrude upon our government-run, state-monopoly, one-tier health care system, I have but one question: “Are you willing to privatize our education system and turn every road into a toll road?” Because the reality is, if we don’t soon do something and drastically overhaul medicare, then, as Dalton McGuinty suggested, we won’t have any money left to pay for anything else. “The rent is due.” “It’s time to pay the piper.” “You can’t cover the cheque you’ve written on that account.” No matter how you say it, the day of reckoning for our health care system is close at hand.
Stephen Skyvington’s book, This May Hurt A Bit: Reinventing Canada’s Health Care System, was published February 2019 by Dundurn Press. Follow him on Twitter @SSkyvington.