The Struggle for State Health Insurance Reconsidering the Role of Saskatchewan Farmers
BY HARLEY D. DICKINSON Studies in Political Economy 41, Summer 1993
The Struggle for State Health Insurance: Reconsidering the Role of Saskatchewan Farmers HARLEY D. DICKINSON he Canadian health care insurance system is in crisis. The two main dimensions of this crisis are rising costs associated with current and projected utilization patterns, and the increasingly apparent inability of the existing health care system to effectively deal with the principal health needs of the population. In some senses the crisis in health care is not new. It was partly the inability of the market-based health care system to satisfy health care needs that led to the establishment of our present taxfinanced and state-administered health care insurance system. An understanding of the current crisis might be enhanced by a re-examination of the historical struggles that resulted in the creation of state-funded health insurance. This paper takes the form of an historical case study of the role of Saskatchewan farmers in the struggle for state involvement in the provision of health care services. I show both the nature and extent of farmer support for state involvement in health care, and how that changed over time and shifted
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between different levels of the state. Through this case study I demonstrate that reductionist theories of the state have obscured our understanding of the social forces that were marshalled both for and against state involvement in the provision of health care services. My analysis leads to the conclusion that relations between the economy, civil society, and the state are dynamic and self-transforming. Political Economy of State Health Care Insurance Those working within a Canadian political economy tradition have paid surprisingly little attention to the origins and form of state involvement in health care delivery. The literature that specifically addresses this topic does so using reductionist and/or instrumentalist theories of the state. Three positions can be identified. Walters provides an example of the first.! She portrays the introduction of state health care insurance as an attempt by the capitalist class and its state to ensure the reproduction of necessary quantities of healthy labour power. By making health care services available and accessible to the working class, the productive potential of labour power could be increased and more fully realized. In addition to this reproduction/accumulation function, state health care insurance also served a legitimation function. By providing universal access to health care services the state obscured class inequalities behind an ideological veil of equal citizenship rights. Despite the instrumentalist and functionalist aspects of her account, Walters draws attention to the fact that the bourgeoisie as a whole was not opposed to the principle of state provided, health care insurance. The main limitation of her analysis is that it is reductionist; it allows no conceptual space for understanding the structural interests of non-class forces in the development of state health care policy. Consequently there is no mention of, hence no attempt to account for, the historical fact that state hospitalization and medical care insurance plans were first introduced in Saskatchewan, where the bulk of the population was involved in agricultural production. In contrast to Walters, Swartz argues that the introduction of state health care insurance is best understood as a concession 134
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won from a frightened capitalist class and its state by a radicalized and militant working class.2 By contributing to the social wage, state health care insurance served a legitimation function and defused working class struggle. Swartz, unlike Walters, recognizes that farmers and farm organizations supported the development and extension of state health care insurance. He discusses the overwhelming evidence that state health care insurance programs of various sorts were pioneered by Saskatchewan farmers to meet their health care needs, but concludes: "None the less, it would appear that in general the needs for the benefits of 'welfare state' programs is less among the petite bourgeoisie.t'J There seems to be no empirical basis for this assertion. One is left with the impression that within Swartz's reductionist model of the state it is not possible to assign a causal role to forces other than the capitalist or working class. Despite the conceptual limitation of his analytical model, Swartz does show how resistance of the organized medical profession resulted in modifications to the health care insurance plan originally proposed by farmers, workers and others, so that the interests of the profession were entrenched and its dominance ensured. The third position, exemplified in the work of Coburn et al, argues, contrary to Swartz, that the introduction of state-funded health insurance marks the beginning of the end of medical dominance.t In explaining the introduction of state hospital and medical care insurance, however, they argue that it is best understood both as a response to working class agitation, and an attempt to satisfy the requirements of the capitalist class for adequate quantities of good quality, that is healthy, labour power. Unlike either of the other two positions, however, they also assign a role to farmers in this process. Specifically, they claim that working class demands for state health care insurance were effective in the postwar period because of the political decline of farmers. During the interwar period, working class demands for health care insurance were ineffective because of the persistent influence of farmers on protest party politics. Their influence
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militated against the adoption of social welfare legislation, which was a concern for working class people, but only of marginal importance to farmers who were more self sufficient by nature of their occupation.e
Under certain conditions and in relation to particular needs, of course, farmers may be more self sufficient than members of the waged working class. There is no reason to suppose, however, that farmers, considered as a class, are more self sufficient than any other class when it comes to medical and hospital services. Were farmers opposed to the introduction of welfare legislation in general, or health care insurance, in particular? If they were, how can the historical fact that universal, comprehensive, compulsory, tax-financed and state-administered hospitalization and medical care insurance were first introduced by a Co-operative Commonwealth Federation (CCF) government in the rural, agrarian, farmer-dominated province of Saskatchewan? Coburn et al simply sidestep the second question by defining the Saskatchewan CCF as "an organized working class party."6 It is true that organized labour was the dominant force in the political alliance that was the national CCF when it transformed itself into the New Democratic Party (NDP) in 1961. Similarly it is true that farmers had greatly declined as a national economic and political force in Canada by that time. This was probably especially true in Ontario. But it was certainly not the case in Saskatchewan. I argue, and will demonstrate below, that the provincial CCF was a farmer party when it gained power in 1944, and remained a farmer party when it introduced state hospitalization in 1947, and when it introduced medical care insurance as the CCFINDP in 1962. Farmers, the State and Health Insurance The political domination of Saskatchewan politics by farmers is indicated in a number of ways. Smith, in his study of the membership of the Saskatchewan legislature between 1905 and 1966, for example, shows that the majority of CCF Members of the Legislative Assembly in the years that the party formed the government were farmers by occupation. Similarly, Eager analyses the political culture of the province, pointing to 136
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the continued power of farmers. In her discussion of the relationship between the provincial CCF and the newly formed national NDP in 1961, she notes: the Saskatchewan party showed considerable concern to preserve the existing provincial structure. Assurances were sought that the provincial CCF would continue as such, and the desire was evident to retain within the Saskatchewan organization its agrarian flavour, with resistance to emphasizing the link to labour."
The political dominance of farmers in Saskatchewan stems directly from their economic dominance. In the mid-1950s it was estimated that three quarters of the provincial population were engaged directly in agriculture or were wholly dependant upon it for a living.s Even today agriculture remains a dominant element of the provincial economy, although the relative position of farmers economically and politically has declined. In the 1950s and 1960s when universal, comprehensive, compulsory hospitalization and medical care insurance plans were introduced in Saskatchewan, farming and farmers were undoubtedly the dominant economic and political force in the province. Did they have less of a need for such services as Swartz claims? Or, as Coburn et al assert, were they opposed to the introduction of state hospitalization and/or medical care insurance? Available evidence indicates that farmers and farmer organizations actively supported both the principle and practice of collective provision of health care. Statements of support in principle take the form of resolutions passed by the major farmer organizations. Support in practice refers to the passage of enabling legislation, and the levying of property (land) taxes on themselves to finance the provision of various types of health care services. Agricultural production in Canada in general, and in Saskatchewan in particular, is based on production for the market. It is not primarily organized on a subsistence basis. Consequently farmers' incomes depend upon farmer productivity on the one hand, and relative market strength on the other. Anything that threatens productive capacity, including injury or illness, also threatens the economic well-being and survival of farmers. Because Saskatchewan farmers are both 137
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owners of capital in the form of land and equipment, and dependent on the use of their own and family members unpaid labour to produce crops, they have a direct interest in ensuring the quality and productive capacity of that labour power.? Medical and hospital services, in addition to other illness and injury prevention programs and health care services, are important in this regard. Several characteristics of the provincial wheat economy and the nature and organization of medical care, however, limited the availability and accessibility of medical services. The first was the low population density characteristic of market-oriented grain production. The sparsity of settlement made it difficult for physicians to make a reasonable living. Consequently, doctors tended to establish medical practices in more heavily-populated areas where there was greater demand for and easier access to their services. In 1941 Saskatchewan had fewer doctors per capita than any other province in Canada.l? At about the same time, in 1946, the only province to have fewer rural doctors was New Brunswick, while the urban concentration of doctors in Saskatchewan was greater than in any other province.U This uneven distribution of physicians was further complicated by the erratic nature of farm incomes in Saskatchewan. The boom and bust nature of the wheat economy meant that rural farm families simply did not always have the financial resources available to pay for medical services. Such problems could not be solved at the individual level because they were structurally produced. Farmers organized to use and transform the structures of the state and the institutions of civil society in an attempt to solve their problems. For instance, producer co-operatives were established as part of an attempt to market agricultural products and stabilize prices and incomes. At the same time, various collective efforts were undertaken to eliminate, or at least reduce, the barriers and impediments to available and .affordable health care services. Several authors have looked at the role of farmers in the struggle for health care. 12 Mombourquette, for example, shows that political pressure for the institution and expansion of state involvement in health care delivery came from the 138
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grassroots in the form of populist, social democratic lobbying. With specific reference to various forms of state involvement in the administration and delivery of health care before 1944, that is, before the election of the CCF, he reported that most interventions were "the result of the government reacting to pressures from farm organizations, local governments, professional associations and political parties." 13 Similarly, Lipset noted that "The lack of decent health facilities in the sparsely settled rural regions [of Saskatchewan] made farmers acutely conscious of the need for government provision of such services, and the conventions of farmer's organizations since the First World War have requested state medicine.t'H At the 1916 annual convention of the Saskatchewan Grain Grower's Association (SGGA), for example, it was resolved that "the provincial government should take up the matter of providing adequate nursing and compulsory medical facilities for rural districts at public expense."15 The report of that SGGA annual convention recorded that the Saskatchewan Minister of Public Health, who was present at the meeting, "favoured the resolution as an expression of the opinion of the delegates." It was also recorded that the Minister "thought the government was justified in providing medical assistance in these districts where it was so greatly needed."16 At that same meeting the Minister indicated that he would consider the request to amend the provincial Rural Municipalities Act so as to allow municipal councils to guarantee the salaries of doctors in order to facilitate their recruitment and retention in rural areas.I? The Local State and Health Care As we have seen, the provincial state was generally quite responsive to farmer's demands.Jf This was perhaps especially true with respect to requests for the passage of legislation that would enable farmers to help themselves solve their problems at the local level.I? It was at the local level of government that farmer influence was most direct. It was also at this level of government that most health care services were financed and organized prior to 1946.20 Taylor makes this point in his account of the introduction of state health care insurance in 139
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Saskatchewan, observing that "the institution of local government was used to develop health services to a degree unmatched elsewhere in Canada."21 Local government involvement in this area took several forms,22 the three most well known being the municipal doctor program, the union hospital system, and the municipal hospital care plans. Municipal Doctor Plans The first municipal doctor plan in Saskatchewan was established in the small town of Sarnia in 1914. Fearful of losing its doctor, the municipal officials authorized a retainer of $1500 per year. This was done without provincial government enabling legislation.23 In 1916, as the Minister of Public Health had promised at the SGGA convention, the Rural Municipalities Act was amended to empower rural municipal councils, or rural and village or town municipal councils, to levy taxes for the purpose of securing the full-time or part-time services of a physician on a salaried basis.24 Although there was some variation in conditions of eligibility for medical services, the amount of salary paid and the range of services provided under these plans, they tended to be similar in all important respects.25 Part-time physicians employed under this system received a maximum annual salary of $1500. Part-time physicians generally were required to perform the work of a public health officer, provide medical care to indigents, and provide maternity care at nominal rates. In addition, part-time physicians were permitted to engage in private practice.26 Physicians employed full-time received annual salaries between $3000 and $5000 depending upon the services they were required to provide, their training, and experience. The normal practice was for full-time municipal doctors to provide a range of preventive and therapeutic services to resident ratepayers and their dependants, and usually also to employees of ratepayers, and other legal residents. Doctor's salaries were paid from revenues generated by a local property tax, primarily on farm land. In 1940 it was reported that the tax for this purpose amounted to about $3 or $4 per quarter section (160 acres).27 Most of the municipalities that opted for a municipal doctor plan were more than fifty miles from the three largest cities in the province, 140
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and those that employed a part-time physician had no hospital or any other residential health facilities.28 These municipal doctor plans were popular both among residents of a municipality that established them, and among the physicians employed by them. From the point of view of rural residents the plans made it possible to have access to basic prophylactic and therapeutic medical services. For doctors the plans provided a guaranteed income, and made medical practice financially feasible in areas that would have been either too sparsely populated or too poor to support a private, fee-for-service medical practice. There were limitations. The level of organization (i.e. municipal) made it difficult to establish or enforce standards and to ensure quality of care. The greatest disadvantages, however, were that the range of available services did not satisfy all health care needs, and the plans themselves only partially covered the health care costs of the people in communities which established them. Thus, even though the plans helped to mitigate the financial burden of injury and illness, by themselves they could not eliminate it.29 Despite these limitations, the number of municipal doctor plans continued to increase, particularly in hard economic times. Between 1916 and 1930, for example, they were instituted in thirty-two localities. In twenty of these physicians were employed full-time, in the other twelve locations they were employed part-time.X' There was also some opposition to the establishment of these plans, particularly from town- and city-based, private practice physicians, and they were never universally established in the province. However, education efforts, such as that undertaken by the United Farmers of Canada (UFC) in 1930,31 combined with economic necessity, contributed to their continued growth. During the 1931 to 1936 period, for instance, when the provincial wheat economy was devastated by the Great Depression and a prolonged drought, the number of full-time physicians employed by municipal doctor plans increased to 68, and the number employed parttime increased to sixty.32 By 1945 there were 170 municipal doctors plans operating in the province: 105 in Rural Municipalities (RMs), 61 in villages, and 4 in towns.33 By 1947, 141
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25 percent of the provincial population received medical care from salaried municipal doctors.H In the post-1945 period municipal doctor plans began to be supplemented by a number of urban doctor-sponsored prepayment plans. Eventually, as Alan Blakeney, Minister of Public Health, pointed out, "people in Saskatchewan had become accustomed to a prepaid and tax-supported health service."35 Thus, in 1962 all the various plans were superseded by the introduction of Medicare, the first provincewide, universal, comprehensive, tax-financed, and publicly-administered system of medical care insurance in Canada. Union Hospital Districts Farmer support for and development of tax-supported, government-administered health care services were not restricted to plans for doctors' services. The union hospital system was also developed in Saskatchewan and adopted in other prairie provinces.36 The union hospital plan was an arrangement by which the residents of adjacent municipalities were empowered by provincial legislation to join together to collect taxes for the construction, operation and maintenance of a hospital. The enabling legislation was passed by the provincial government in 1916. Between 1917 and 1945 twenty-six union hospital districts had been formed. In the eighteen month period between January, 1945 and June 1946, another twenty-two union hospital districts were established. 37 Municipal Hospitalization Insurance In addition to collectively financing hospital construction, residents of rural municipalities also provided a form of hospitalization insurance paid for by land taxes. Under the authority of the 1909 Rural Municipalities Act one of the duties of municipal councils was to pay for hospital services for needy residents. A number of municipalities voluntarily expanded that responsibility to include payment of hospitalization costs for any resident of the municipality.38 In 1919 Saskatchewan passed the "first legislation in Canada to provide for a municipal hospital care plan for all residents of an area."39 In 1927 amendments to the Rural Municipalities and the Union Hospital Acts established the legislative authority for the growing number of rural municipality, hospital care plans that were 142
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being developed by municipal residents in response to local health care needs. Both municipal doctor plans and municipal hospitalization plans were developed through the local state prior to being legalized by provincial legislation. Also in both cases "the sole source of revenue ...was the general land tax."40 There was a growing sentiment among farmers, and other property owners, that despite the advantages of tax-financed medical and hospitalization insurance, restricting the tax base to property owners was inequitable, and limited the range of services it was possible to provide. The solution to this problem was to shift the political locus of effort from the local to a more centralized level. Thus, by 1929 the UFC was actively supporting the expansion of the tax base. In February 1929, a resolution was passed at its annual convention that endorsed the expansion of both provincial and federal government intervention in, and support for, health care: Be it resolved that the Provincial and Federal Governments provide a scheme whereby all our people shall contribute to a fund to provide medical and hospital accommodation to all our people who are unable to pay for same, preferably by a system of contributory insurance, so that our transient and wage-earning population may contribute their share of the cost.41
The land tax remained the only source of revenue for these various health care undertakings until 1934. That year an amendment to the Rural Municipalities Act enabled councils to levy a tax on non-ratepayers for health services. This appears to be the first time that any jurisdiction anywhere in Canada levied a personal tax for health care services.42
It is important to point out that shifting the tax base from land to people does not indicate a lack of farmer support for state intervention in the provision of hospitalization or medical care insurance, or other types of health care services. As the 1929 resolution of the UFC clearly indicates, farmers were calling for an expansion of state involvement in these areas.
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The Provincial State and Health Insurance The provincial government was responding to initiatives that had already been taken by farmers at the local level through the municipal structure of government. Health care services, initially an institution of civil society organized on the basis of market principles, came to be part of the state apparatus partly as a result of the political and organizational practices of farmers and farmer organizations. By passing enabling legislation, the provincial government, in many instances, was reacting to developments that had already occurred at the local level. Considered at a higher level of abstraction, these practices and developments can be understood as processes of state formation and transformation of the institutionalized practices of civil society. Of course, the provincial state did not always react in a favourable way to farmers' health care initiatives. An example of this can be seen in relation to the establishment of free consultative clinics which were to facilitate early diagnosis and treatment. Free Consultative Clinics John McNaughton, a member of the UFC, appears to have been the first to suggest the establishment of free consultative clinics in an article published in the Western Producer in April 1927. In May the president of the UFC, John Stoneman, suggested the establishment of such a clinic to the provincial Diamond Jubilee Executive Committee as a "splendid memorial of Confederation." In June the following resolution, put forward by Stoneman, was adopted by the Diamond Jubilee Executive Committee: the Committee endorses the action taken by the United Farmers of Canada, Saskatchewan Section, in urging upon the Provincial Government the establishment of a Free Consultative Clinic as a permanent commemoration of the Diamond Jubilee of Confederation.43
In order to both gauge and garner support for this initiative, the UFC central office solicited opinions from a number of RMs. Over seventy replies were received, all of which were supportive of the idea. A response from the RM of Auvergne, for example, stated: 144
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There is no doubt that the farmers in our district are in favour of an [sic] feasible scheme to alleviate suffering, and reduce the big expense of diagnosis, such as many have been forced to pay in the past, or else forego the benefits of treatment and operative surgery.44
It was anticipated that the medical profession would be opposed to such a plan because successful preventive interventions would reduce the need for medical treatment.45 Discussions with the Saskatoon Medical Association in August 1927, however, generated support in principle, if the proposed clinic were "operated under ideal conditions."46 Ideal conditions, of course, were those that served the profession's interests. As we will see below the position of the medical profession on state health insurance was variable depending on circumstances and their perceived economic and professional interests. With concern over medical resistance to the proposal assuaged, the next step in the struggle to establish a travelling, free consultative clinic was the organization of a conference at the Legislative building in Regina, attended by "representatives of all provincial bodies interested in the issue of Public Health," the Premier, and members of the Cabinet. The Minister of Public Health was the Chair when it was resolved, That a Committee be appointed to consider the question of the feasibility of establishing a permanent Free Travelling Clinic fully equipped with the latest scientific appliances and diagnosticians to periodically visit a large number of points in the province, and when an investigation has been made the Premier of the province be asked to convene a further conference to consider the report.s?
A committee was constituted with four representatives from the UFC, four from the Saskatchewan Medical Association, and two each from the Saskatchewan Association of Rural Municipalities, the Saskatchewan Association of Urban Municipalities, and the Saskatchewan Hospitals Association.48 This committee conducted preliminary research into the establishment of free consultative clinics, and reported its findings to a conference in August 1928. At that time, another 145
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committee was struck "to interview the government," and to request the establishment of "a small representative committee to fully investigate all factors concomitant to the proposal to establish" such a clinic.49 The Minister of Public Health refused to agree, giving two reasons: first, that several other commissions had recently been established in relation to other issues and it was inadvisable to establish too many at once; and second, consideration was being given to the establishment of health districts throughout the province.50 The health districts were conceived as an alternative and superior solution to the problem of health care services from both the medical and political points of view. Despite this resistance from the provincial government a further resolution in support of the establishment of the requested committee was passed and a new committee was struck "to wait upon the government to present this request."51 In March 1929 the UFC Executive Board appointed yet another committee consisting of the UFC President, the Secretary, and the Director of the Publicity and Research Department. That committee was "to press the matter of the Consultative Clinic. "52 The government, however, did not change its position. Even though the provincial state resisted that particular farmer initiative, it generally remained responsive to their demands. In 1939, for example, the government passed further legislation that expanded the tax base for financing health care services as the UFC had requested. The Municipal Medical and Hospital Services Act empowered municipalities, or groups of municipalities, villages or towns, to levy either a land tax, a personal tax, or a combination of the two, to provide medical or hospital services to residents. 53That year, eighty-six RMs, or parts of RMs, provided residents with medical services, and fifty-seven provided hospital care services. In addition, fifty-six towns and villages provided residents with medical care services, and seven towns and villages provided hospital care services. Five towns and villages, and twenty-four RMs, provided both medical and hospital care to residents. Of the 115,013 people (12.1 percent of the provincial population) covered by municipal hospital services plans that year, 110,731 lived in RMs.54 146
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The broadened tax base allowed for continued expansion of this form of state involvement in the provision of health care services. By 1942 eighty-eight municipalities provided hospital services to residents at municipal expense. In twelve of those, services were financed by a personal tax levied under the authority of the 1939 Municipal Medical and Hospital Services Act. Most of the municipalities that established such provisions, however, provided coverage under the authority of the Rural Municipalities Act. Services provided under that act were more limited because it only authorized revenue to be raised from a property tax.55 By 1945 hospitalization schemes were operative in one hundred and seven RMs, twenty-three villages, and six towns.56 The municipality, however, was about to be superseded as the tax base and administrative unit for the organization and financing of health care services in the province. The first step was the move to regionalize service delivery and financing, this was followed by the move to a province-wide basis, first for hospital services and later for physician services. Health Regions We have seen that farmers were interested in shifting the tax burden for health care from the property base to the individual/family unit. Political and fiscal pressure for this change mounted as a result of the transformation of the conditions of agricultural production, namely, the trend towards a decreased number of larger farms. By 1946 the number of farms in Saskatchewan had shrunk to pre-1931 levels. With their numbers declining, farmers were unwilling, possibly even unable, to be the sole source of financial support for state-provided health care services. The tax base had to be broadened and, as a consequence, the organizational framework for service delivery also had to expand. Upon assuming office in 1944, the CCF moved quickly. The Saskatchewan Health Services Survey Commission (the Sigerist Commission) was established. The Commission report recommended the establishment of a Health Services Planning Commission (HSPC), and the division of the province into health regions for planning and health service provision
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purposes.J? Both recommendations were accepted and implemented. A plan was devised to divide the province into fourteen Health Regions. It was deemed necessary that each region have a population of approximately fifty thousand for both health program delivery and fiscal reasons. The health regions had two primary functions. First. they were to provide an administrative base for full-time public health services. Once a health region was established this function was compulsory. Second. they were to provide a base for the provision of therapeutic treatment services. This function was voluntary. 58 Part of the reason why the second function was voluntary was that the newly elected CCF. firmly rooted at the time in a tradition of agrarian. democratic populism. was concerned not to usurp traditional local prerogatives and control over the provision of health care services. Although municipal ratepayers were keen to expand the tax base. they were not as eager to give up control over the form and content of health care services. The principle of local control was institutionalized in the procedures for establishing a health region.59 The initiative for establishment of a health region resided with local governing authorities. or other local organizations. Provincial government officials would meet with local representatives to discuss the organization of services only if invited to do so. Following these initial discussions. the Health Services Planning Commission (HSPC) worked out a more detailed plan taking into consideration existing health services, general economic circumstances and demographic characteristics of the population. The draft plan was then discussed with local officials and representatives. The next step in establishing a health region also required local (municipal) governments to take the initiative by petitioning the Minister of Health. Only after ten petitions were received from a potential region would the provincial government act. This action took the form of publication of a ministerial order in The Saskatchewan Gazette giving notice of intention to establish a health region. At the end of sixty
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days the minister was empowered to establish the health region. Once a health region was established, a regional health board would be set up. Members were appointed to the board by municipal councils so as to ensure maximum local control over the form and content of the health services to be provided, as well as the form of taxation to be used. As we have seen, by that time it was possible to finance health services by a per capita tax, a general land tax, or a combination of the two. The HSPC was empowered to approve all agreements entered into by local governments for the provision of health care, and acted independently of the provincial government. The first health region, Health Region Number One, was established in the southwestcomer of the province and centred around the small city of Swift Current. On July 1, 1946 it became the first jurisdiction in North America to provide a universal, comprehensive system of hospitalization and medical care insurance financed by a per capita tax of $5.50 with a family maximum of $30 and a land tax of one and a half mills. Here again it is clear that farmers not only supported the principle of state provision of hospitalization and medical services, they voted to doubly tax themselves, as individuals/family members and as land owners, in order to make such services universally available within a circumscribed geographic and administrative region. The regional provision of hospital and medical care, as outlined, was well accepted by the local population and the medical profession. Although there were some disagreements between doctors and the Regional Health Council over fee schedules, overall it was enthusiastically supported by doctors. An indicator of this is the fact that in the decade following the introduction of the plan the number of doctors in the region doubled. This was a greater increase than in any other rural section of the province. Part of the reason for the popularity among doctors was the fact that assured payment of bills resulted in physician incomes in the region being higher than the provincial average. It was not only physicians practising within the region who were satisfied, the population generally supported the arrangement as was 149
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"reaffirmed each year with virtually unanimous votes by the elected Regional Council, which ...[imposed] the annual tax."60 The regional base for organizing and financing hospital services was transformed in 1947 with the introduction of a province-wide, universal hospitalization insurance plan. This plan was the model for the introduction of the national system of hospitalization insurance in 1958. Similarly the introduction of universal, comprehensive, portable, tax-financed and state-administered medical care insurance in 1962 in Saskatchewan was the model for a national program introduced in 1966 by the federal government.s! Both developments were supported by farmers and their various organizations. A 1989 submission to the Saskatchewan Royal Commission on Future Directions in Health Care (the Murray Commission) by the National Farmer's Union Region Six (Saskatchewan) reaffirmed farmer support for the principles of a national health care insurance system with costs shared by both provincial and federal levels of govemment.62 Conclusions It is important to note that, historically, support for state involvement in health care has been broadly based. By focusing on the role and support of Saskatchewan farmers I do not mean to suggest that other class and non-class groupings did not support the principle of state involvement in health care service provision. Nor do I mean to imply that there was no opposition or disagreement over the nature and extent of state involvement. Opposition to the introduction of state health care primarily focused on the form it would take. Numerous plans were advocated. These covered the range from a plan for a complete system of socialized health care provided by salaried physicians as proposed in the 1933 Regina Manifesto, to the more modest proposals for state health care insurance provided only to those who were needy and who did not have private coverage, proposed by the organized medical profession, the insurance industry and their political and ideological allies. The final form assumed by Medicare was the result of a compromise between various positions advocated by different interests, and as such it is characterized by a number 150
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of contradictions.63 Although it is not a central focus of this paper it is worth pointing out that the vigorous opposition of the organized medical profession and their political allies to the introduction of Medicare by the Saskatchewan CCFINDP in 1962 exerted a considerable conservative effect on the nature of the plan that was eventually implemented. In fact, Medicare as we know it is primarily a system for paying doctors' bills. It does not substantially affect the form and content of private medical practice, and has, therefore, contributed little to overcoming the many wellknown limitations of the dominant medical model. 64 It has had the effect, however, of removing direct financial barriers to those seeking medical care. Whether this has contributed to improved health status is open to question. There is general agreement, however, that the establishment of state-funded health care has led to increased utilization and costs, and therefore, contributes to the current crisis in health care. Saskatchewan farmers were clearly not indifferent to, nor did they oppose, state involvement in the provision of health care insurance. The evidence clearly. shows that farmers pioneered health service innovations at the local level through the municipal state, and actively solicited provincial and federal government intervention in the provision, and financing of those services. Prior to the various initiatives undertaken by farmers in this regard, health care was largely a private affair,conducted within the context of market relationships. After several decades of struggle and innovation, Saskatchewan farmers had transformed the provision of key aspects of health care delivery into part of the state. This structuraltransformation,of course, had profoundconjunctural consequences for the political balance of power and the alignment of political forces, and in this way ushered in federal legislation that established national hospitalization and medical care insurance plans. My analysis suggests that relations between the economy, civil society and the state are dynamic and self-transforming. It was through various associations, unions and political parties that public opinion was formed and people mobilized in an attempt to secure the establishment of various forms of state intervention in the health care arena. Organizations 151
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such as the Saskatchewan Grain Growers Association, the United Farmers of Canada, the National Farmers Union, or political parties like the Co-operative Commonwealth Federation are not best understood as being part of the state, or as constituting the economic base of society considered as a mode of production. Such organizations exist outside both the state and the economy and cannot properly be reduced to either, but are rather part of the sphere of civil society. At a more abstract level of analysis I have also tried to show that the boundaries between civil society, the state and the economy are permeable. And that law, in the form of enabling legislation, was the medium by which the boundaries between civil society and the state were permeated and the institutions of both transformed. There is no theoreticalor historical reason to suppose, however, that the processes run one way or are irreversible. That is, if the organization and financing of health care delivery can become part of the state under particular circumstances there is no reason to believe that it cannot be transferred back to the realm of market relations, either in whole or in part, at another point in history and under altered material circumstances. Notes I would like to thank Peter Li and B. Singh Bolaria for helpful comments on an early draft of this paper. I would also like to thank SPE editors and reviewers, particularly Jeanne Laux for her clear, concise and extremely valuable suggestions. I would also like to thank Scott Dresler for his research assistance. l.
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V. Walters, "State, Capital and Labour: The Introduction of FederalProvincial Insurance for Physician Care in Canada," Canadian Review of Sociology and Anthropology 19/2 (1982), pp. 157-72. D. Swartz, "The Politics of Reform: Conflict and Accommodation in Canadian Health Policy," in L. Panitch (ed.), The Canadian State: Political Economy and Political Power (Toronto and Buffalo: University of Toronto Press, 1977), pp. 311-43. Swartz, "The Politics of Reform ...," see footnote 22 p. 338. David Coburn, George M. Torrance, and Joseph M. Kaufert, "Medical Dominance in Canada in Historical Perspective: The Rise and Fall of Medicine?" International Journal of Health Services 13/3 (1983), pp.407-32.
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5.
6.
7.
8.
9.
Ibid.• p, 429. As Coburn et al indicate. the quote is taken from Reg Whitaker. "Images of the State in Canada." in Panitch, The Canadian State. p. 56. Coburn et al, "Medical Dominance." p. 429. Reducing the Saskatchewan CCFINDP to a party of the organized working class makes sense only if Prairie farmers are conceptualized as a sub-category of the industrial working class. Coburn et al, however. do not do this. In their analysis farmers clearly are classified as petit bourgeois. This is generally accepted as a correct classification. See for example. James N. McCrorie. "Change and Paradox in Agrarian Social Movements: The Case of Saskatchewan." in Richard J. Ossenberg (ed.), Canadian Society: Pluralism, Change and Conflict (Scarborough: Prentice Hall, 1971). pp. 36-52; and P. Ghorayshi, "Canadian Agriculture: Capitalist or Petite Bourgeois?" Canadian Review of Sociology and Anthropology 24/3 (1987). pp. 358-73. Evelyn Eager. "The Conservatism of the Saskatchewan Electorate." in Norman Ward and Duff Spafford (eds.), Politics in Saskatchewan (Don Mills: Longmans Canada Ltd .• 1968). pp. 1-19; David E. Smith. "The Membership of the Saskatchewan Legislative Assembly. 19051966," in Ward and Spafford. Politics in Saskatchewan. Robert Brym, "Canada's Regions and Agrarian Radicalism," in James Curtis and Lome Tepperrnan (eds.), Images of Canada: The Sociological Tradition (Scarborough; Prentice Hall. 1990). pp. 121-32. also presents data which show that farmers were the largest occupational group making up CCF MLAs in 1944. Eager. "The Conservatism ...••• p. 3; . F. B. Roth and R. D. Defries. "The Saskatchewan Department of Public Health," Canadian Journal of Public Health 49/5 (1958). p. 276. P. Ghorayshi, "Canadian Agriculture ... ," p. 369 concludes that petite bourgeois wheat producers (with 99.6 percent of farms and 99.4 percent of wheat sales in 1981) show no sign of being replaced by capitalist farm units. She also demonstrates the extent and effect of wives' work for family farms in P. Ghorayshi, "The indispensable nature of wives' work for the farm family enterprise" CRSA 26/4 (1989). F. D. Mott, "Recent Developments in the Provision of Medical Services in Saskatchewan," The Canadian Medical Association Journal 58 (1958). p. 3. Ibid. S. M. Lipset, Agrarian Socialism: The Cooperative Commonwealth Federation in Saskatchewan. A Study in Political Sociology, Revised Edition (Berkeley: University of California Press. 1971). p. 290; R. Badgley and S. Wolfe. Doctors' Strike: Medical Care and Conflict in Saskatchewan. (Toronto: MacMillan. 1967); J. Feather. ''From Concept to Reality: Formation of the Swift Current Health Region." Prairie Forum 16/2 (1991) pp. 59-80;and J. Feather. "Impact of the Swift Current Health Region: Experiment or Model?" Prairie Forum 16/2 (1991) pp. 225-248; D. Mombourquette. "'An Inalienable Right': The CCF and Rapid Health Care Reform," Saskatchewan History XLIII/3 (1991). p. 110. Mombourquette. ". An Inalienable Right' ...••• p. 110. Lipset, Agrarian Socialism. p. 290. n
10.
II.
12.
13. 14.
153
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15. 16. 17. 18.
19.
20.
21.
22.
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Saskatchewan Archives Board (SAB), Saskatchewan Grain Growers Association, Annual Convention Report, 1916. B2 I, 3., p. 17. Ibid. Ibid. Carl A. Dawson and Eva R. Younge, Pioneering in the Prairie Provinces: The Social Side of the Settlement Process. (Toronto: The MacMillan Press of Canada, 1940). Saskatchewan is divided into Rural Municipalities of about 18 square miles in area and, in 1946, having a population of between 1500 and 2000 people. SAB, T. C. Douglas R 33.1, XIV 580 (14-31), T. C. Douglas, "Saskatchewan Plans for Health," Health (1946) (reprint), p. 2. There were several health and health care services organized and financed at the provincial level. In 1917, for example, a program to distribute, without charge, essential serums and vaccines was introduced. The following year free drugs were provided to doctors for the treatment of indigents with venereal diseases. In 1920 the VD control program was expanded to include free treatment in four full-time clinics and four part-time clinics. In 1929 a tax -supported system of tuberculosis treatment was initiated. The following year the cancer diagnosis and treatment was provided under the authority of the Cancer Commission Act. In 1944, free diagnosis, treatment and hospitalization for all cancer patients was provided. And in 1946 free treatment for mental disorders was provided. For a more complete listing of provincial health care services see Roth and Defries, "The Saskatchewan Department of Public Health," pp. 276-85. Malcolm G. Taylor, Health Insurance and Canadian Public Policy: The Seven Decisions that Created the Canadian Health Insurance System (Montreal: McGill-Queen's University Press, 1978), p. 7. There were several attempts to provide collective solutions to the problems of health care delivery in rural Saskatchewan. Some of these were adaptations of initiatives undertaken elsewhere, and some were "made in Saskatchewan" solutions. A plan to provide nursing services to rural areas is a case in point. The Report of the Women's Section of the 1916 Annual Convention of the SGGA, for example, pointed out that nursing services were unavailable to many. Mrs. Ames, who made the report to the SGGA Convention, described the "Lady Grey district nursing scheme" in which a house was provided in rural districts 20 miles square, which could accomodate two Victorian Order Nurses, and two emergency cases. A provincial government grant to cover part of the cost was given to each district establishing such a facility, and another "part of the expense was born by those in the community who could afford to pay something for the services of a nurse." Mrs. Ames herself felt that dividing the province into hospital districts with a doctor at the head of each, and then sub-dividing each hospital district into nursing districts "supported by a direct tax on land" would be preferable as a scheme. SAB. SGGA Annual Convention Report, 1916, B2 I, 3., p. 36. Yet another experiment was the "rural health unit." One was established in Saskatchewan on a three-year basis. Modeled on plans previously developed in Eastern Canada, the rural health unit attempted to provide rural areas of about 20 thousand people with the
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23.
24. 25. 26. 27. 28. 29. 30.
31. 32. 33. 34.
35. 36. 37. 38. 39. 40.
41. 42. 43. 44. 45. 46.
47. 48. 49.
same public health services then available in urban areas. The unit established in Saskatchewan was financed through a cost-sharing arrangement wherein the provincial government paid 50 percent of the costs. the local area 25 percent. and the Rockefeller Foundation the remaining 25 percent. At the end of the initial three year period the Rockefeller money was withdrawn. and the local area was required to pay 50 percent of the costs. This financial burden was unbearable and the unit was dissolved. Dawson and Younge. Pioneering in the Prairie Provinces. pp. 276-77. Badgely and Wolfe. Doctors' Strike ...• p. 8. These authors point out that three different dates are found in the background literature concerning the date of establishment of the Sarnia Municipal Doctors Plan. They chose 1914 as the most accurate. Dawson and Younge. Pioneering in the Prairie Provinces. p. 261. Rufus C. Rorem, The Municipal Doctor System in Rural Saskatchewan (Chicago: University of Chicago Press. 1932). Dawson and Younge. Pioneering in the Prairie Provinces. p. 261. Ibid .• p. 262. Ibid. Rorem, The Municipal Doctor System. pp. 41-43. Ibid., p. 14. SAB. UFC. Health: Municipal Doctors. 1930. B2 IX. 134.• Returned questionnaire from RM of Prairie Rose. February 20. 1930. Dawson and Younge. Pioneering in the Prairie Provinces. p. 264. Douglas. "Saskatchewan Plans for Health." p. 2. Alan E. Blakeney. "The Saskatchewan Experience." prepared for publication in the Forensic Quarterly of the Committee on Discussion and Debate of the National University Extension Association (U.S.A.) at the invitation of the editor. n.d .• p. 1. SAB. Department of Public Health. PH4. Ibid. Dawson and Younge. Pioneering in the Prairie Provinces. pp. 264-5. Douglas. "Saskatchewan Plans for Health." pp. 1-2. Taylor. Health Insurance ...• p. 72. Ibid. Ibid. SAB. UFC. B2 IX 139. Resolution passed at convention of the U.F.C .• Regina. Feb. 1929. Taylor. Health Insurance ...• p. 72. SAB. B2 IX 41.. Clinics: Research. 1927-1930. Free Consultative Clinic: History of the Idea, p. 1. SAB. UFC. B2 IX 42 .• Letter from the Secretary Treasurer of the RM of Auvergne, No. 76. to Secretary. UFC. December 22. 1927. SAB. Clinics: Research. p. 4. Ibid .• p. 1. Again it is noteworthy that support for state health insurance was widespread. Most of the debate was over the specific form such involvement should take. not whether it should take place or not. Ibid .• p. 2. Ibid. Ibid.
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50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60.
61. 62.
63.
64.
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Ibid .• p. 3. Ibid. Ibid. Taylor. Health Insurance ...• p. 71. Saskatchewan. Annual Report of the Department of Public Health. 1939 (Regina: King's Printer. 1940). Taylor. Health Insurance ...• p, 72. Douglas. "Saskatchewan Plans for Health." p. 3. Saskatchewan. Saskatchewan Health Services Survey Commission (Sigerist Commission) (Regina: King's Printer. 1944). Douglas, "Saskatchewan Plans for Health." p. 3. Ibid .• the following description of the establishment of Health Regions was taken from this source. Milton I. Roemer. '''sOcialized' Health Services in Saskatchewan." Social Research 1958 p. 91. See also A.D. Kelly. "The Swift Current Experiment." The Canadian Medical Association Journal 58 (1948) pp. 506-11. Taylor. Health Insurance ... National Farmers Union. Region No.6. Submission to the Saskatchewan Commission on Directions in Health Care. Saskatoon. (28 March 1989). See Badgley and Wolfe. Doctors' Strike; Walters. "State, Capital and Labour ...;" Swartz, "The Politics of Reform ... ;" and S. Rands, "The CCF in Saskatchewan: Recollections." in Don C. Kerr (ed.), Western Canadian Politics: The Radical Tradition. (Edmonton: Newest Press 1981); and Robert S. Bothwell and John Englis, ''Pragmatic Physicians: Canadian Medicine and Health Care Insurance. 1910-1945." in S.E.D. Shortt (ed.), Medicine in Canadian History: Historical Perspectives. (Montreal: McGill-Queen's University Press 1981) for a discussion of the nature and consequences of the political compromise over the form of state involvement in health care. D. Naylor. Private Practice, Public Payment: Canadian Medicine and the Politics of Health Insurance. 1911-1966. (Kingston and Montreal: McGill-Queen's University Press. 1986).