Esyllt W. Jones, James Hanley, and Delia Gavrus, eds., Medicare’s Histories: Origins, Omissions, and Opportunities in Canada (Winnipeg: University of Manitoba Press, 2022)

If one were to take a poll of what stands out as iconically Canadian, many would respond, “medicare.” This collection of 13 essays provides revisionist analyses using the themes of origins or alternative visions, omissions (missed opportunities), and professional opportunities and reactions. As Kathryn McPherson writes in her piece on the role of nurses in pushing for a more cooperative model of nursing care, change is often threatening, and the discussions around a socialized type of care and later hospital insurance consistently conjured up fears of socialism and communism. Indeed, on 2 July 2022 the Globe and Mail revealed from newly released rcmp files that the Canadian state actually spied on those involved in Saskatchewan’s doctors’ strike in 1962, including British doctors recruited by the province; surveillance continued for at least six more months of those health care professionals who supported more cooperative forms of health care, such as community clinics. (Dennis Gruending, “Newly Disclosed Surveillance of Medicare Pioneers Puts the rcmp on the Wrong Side of History”). As Esyllt Jones and Aaron Goss note in their case study of the Saskatchewan Hospital and Medical League (shml), socialized medicine was a movement that envisioned a more socially equitable model of health care, one based on the idea that health equity and social democracy went hand-in-hand. Jones and Goss also note that the shml was the local version of a transnational concept of socialized medicine, the latter a theme developed by J.T.H. Connor writing about the role of Dr. Frederick Mott, an American citizen and graduate of McGill’s medical school. Mott worked in both the US and Canada, first in Roosevelt’s public services and then for US miners and autoworkers, creating union-supported health care services. He migrated to Saskatchewan in 1946 and became deputy minister of health under Tommy Douglas and later a professor at the University of Toronto. He was inspired by the concept of socialized medicine and the Saskatchewan experiment but chose not to accept Premier Tommy Douglas’ invitation to return as Deputy Minister of Health in 1961. Transnational practices also inspired Saskatchewan to look to New Zealand’s program for dental care of children, which proved to be cost-effective, according to Catherine Carstairs’ chapter, which also notes the Hall Commission’s recommendation of public funding for dentistry initially for children, pregnant women, and those on social assistance, and eventually for all. Like many of Hall’s recommendations, it did not come to pass. Foreign doctors seeking employment in Canada in the era of Medicare were more open to collaborative practices in community clinics favoured by supporters of socialized medicine; as noted by Sasha Mullally and David Wright, transient foreign practitioners in Canada’s ‘New North’ often embraced the opportunities for a more varied professional practice in remote locations lacking established medical hierarchies.

Five of the essays discuss “omissions: equity and access,” covering Indigenous health, maternal care, mental health, disability issues, and home care. McCallum and Lux explore the challenges that Indigenous peoples posed to the state, arguing that the medicine chest and treaty rights, not Medicare, ought to govern the relationship between them and the state regarding health care. Treaty 6 (1876), covering the Cree in Saskatchewan and Alberta, contained a clause specifying that each Indian Agent keep such a chest and provide medicines to Indigenous people. Other attempts to codify this practice into written treaties failed according to the authors who trace the contentious history of federal and provincial governments in limiting and narrowly defining Indigenous access to health care. While the federal government assumed more responsibility for Indigenous health care, for example, with the creation of “Indian” hospitals funded at half the cost of provincial institutions, First Nations hoped to close them and integrate care once national hospital insurance was made available in 1957. At the federal, and later provincial levels in subsequent years, support for health care costs was limited to the indigent and sometimes applied only to medicines. Even as late as 1979, new health policy created a Non-insured Health Benefit Program as the payer of last resort while recognizing federal responsibility. This program, according to the authors, remains in place, subject to administrative and cost-saving measures.

Maternal health and childbirth were also impacted by Medicare in that the policies that flowed from it and the introduction of provincial hospital insurance skewed pre- and post-natal care towards physicians (with fee for service payment) and hospitalization, thus displacing midwifery except in remote areas. Even though the 1970s and 1980s witnessed growing criticism of hospital births regarding the lack of safety data and increasing questioning of the evacuation of Indigenous women to southern hospitals, as well as some provinces recognizing and regulating midwifery, the system still centers on doctors and hospitals. Similarly, Erika Dyck finds Medicare’s mental health care policies prioritize hospital care, ignore community care, and provide inadequate funding for treatment in private practice settings.

The focus of Medicare on funding doctors and hospitals has had consequences for the disabled and the elderly as well. As Geoffrey Hudson notes in his Ontario case study of the fight to get assistive devices covered for the disabled, advocacy groups have played a key role in pressuring governments to cover these expenses; he notes that at the time of writing, Ontario’s Assistive Devices Program remains separate from provincial health insurance and does not fully cover the costs. Megan Davies’ chapter on rural seniors and home care in BC examines the recent history of home care on Hornby and Denman islands, which featured the formation of a non-profit society that provided publicly funded care to help seniors stay in their homes though subject to provincial policies. Created in the late 1970s within a social citizenship framework, this type of community-centered health care was subject to neo-liberal cost-cutting measures that undermined available services by the 1980s, despite significant efforts to preserve them. The final section of essays on professional opportunities and reactions includes the essays by Carstairs and Mullally and Wright as previously noted. Additional essays cover Québec’s allied health professionals and politics, physician discontent, and the more recent policies surrounding health promotion and population health. Julien Prud’homme and Antoine Rossignol demonstrate how Medicare shaped professional practices and politics in Québec between 1960 and 1990, noting that many women were encouraged to pursue professional careers, that it shaped a private market for the growing number of allied health professionals, and that the latter not only struggled for self-regulation but also became embroiled in political and linguistic conflicts as more francophones streamed into speech pathology, psychology, social work, and other professions. Jacalyn Duffin reviews physician discontent with Medicare over the years, highlighting strategies to put pressure on governments to increase or maintain physician income—threats to strike, leave the country, or opt out – as well as legal challenges aimed at opening up private clinics. Duffin is critical of those doctors, many of them specialists, whose major focus appears to be personal remuneration, and she blames doctors for being serious obstacles to maintaining and improving Medicare. The final essay by Heather MacDougall documents the battle between efforts to protect Medicare and the move to shift attention to the social and economic determinants of health, which include factors such as income, education level, race, gender, and more. Cost control at the federal level over time, whether through block grants tied to gdp or the Established Programs Financing scheme, both created in the 1970s, and the perceived, persistent need to cut costs – all undermined health promotion programs. The population health paradigm, which emphasized the interconnections between social and economic factors and human health and called for social justice and increased equity, was thwarted by neo-liberal policies of financial restraint in subsequent decades, MacDougall argues.

This thought-provoking collection features a helpful introduction that situates the authors’ contributions in the existing literature and explains how the essays are related. One wishes, however, that some of the authors had paid more attention to explicit discussions of gender, class, and race/ethnicity, among other analytical constructs. Essays by Macpherson, Wood, Jones and Goss, and Davies, for example, note the important but underappreciated roles played by nurses, midwives, and female community workers in providing services and lobbying for clinics, home care, and health insurance, an opportunity missed in other contributions.

Foreign-trained doctors from former British colonies, as discussed by Mullally and Wright, must have faced racism and discrimination in the same way that Indigenous people did. Finally, the editors might have provided a concluding synthetic and thematic reflection on what the essays suggest about the recurring role of political and economic imperatives adopted by various governments over time in the shaping of this imperfect system of Medicare.

Linda Kealey

University of New Brunswick

DOI: https://doi.org/10.52975/llt.2023v91.0018.