The Rise of the Modern The Rise of the Modern Welfare StateWelfare State

BritainBritain

CanadaCanada

BritainBritain

National Health Service Act (1946)National Health Service Act (1946) Universal coverage for:Universal coverage for:

– Physician visitsPhysician visits– Hospital staysHospital stays– Public healthPublic health

100 years earlier, no provision for 100 years earlier, no provision for government sponsored health caregovernment sponsored health care

This lecture will examine the forces This lecture will examine the forces that created this dramatic change in that created this dramatic change in the financing of health carethe financing of health care

3 landmark pieces of legislation3 landmark pieces of legislation– 1834 New Poor Law1834 New Poor Law– 1911 National Insurance Act1911 National Insurance Act– 1946 National Health Insurance Act1946 National Health Insurance Act

Have already consideredHave already considered– 1601 Poor Law1601 Poor Law– 1834 Poor Law1834 Poor Law

Have discussed their connections to:Have discussed their connections to:– Medical careMedical care– Rise of health care institutionsRise of health care institutions

Medical care for the sick poor Medical care for the sick poor created another dilemmacreated another dilemma

Fears that the poor laws might be Fears that the poor laws might be creating a disincentive to workcreating a disincentive to work

““The superiority of the condition of the The superiority of the condition of the paupers over that of the independent paupers over that of the independent labourers as regards medical aid labourers as regards medical aid will . . . encourage a resort to the will . . . encourage a resort to the poor-rates for medical relief . . . and poor-rates for medical relief . . . and will thus tempt the industrious into will thus tempt the industrious into pauperism.”pauperism.”

Existing institutions could not keep up Existing institutions could not keep up to demand for hospital/medical careto demand for hospital/medical care– Voluntary hospitalsVoluntary hospitals– Workhouse infirmariesWorkhouse infirmaries

Many patients excluded from Many patients excluded from treatmenttreatment– ChildrenChildren– Terminally illTerminally ill– Chronically illChronically ill– Contagious diseasesContagious diseases

Many sick who had no access to careMany sick who had no access to care

Only resort was the poor lawsOnly resort was the poor laws– Significant stigmaSignificant stigma– Until 1885, anyone using poor law Until 1885, anyone using poor law

medical service lost the right to votemedical service lost the right to vote

First reforms came in 1860sFirst reforms came in 1860s LancetLancet expos exposé of conditions in é of conditions in

workhouse infirmariesworkhouse infirmaries Forced government inquiryForced government inquiry

New poor law (1867)New poor law (1867)– Sick poor should be housed separate Sick poor should be housed separate

from rest of workhouse populationfrom rest of workhouse population

In London, separate facilities builtIn London, separate facilities built Became England’s first state hospitalsBecame England’s first state hospitals

1905 Royal Commission on the Poor 1905 Royal Commission on the Poor LawsLaws

Two reasons for this developmentTwo reasons for this development– More women elected as GuardiansMore women elected as Guardians– More working class people could vote for More working class people could vote for

GuardiansGuardians

Report published 1909Report published 1909 Attributed half the destitution in the Attributed half the destitution in the

nation to sicknessnation to sickness

Majority report:Majority report:– Tinkering with current systemTinkering with current system– Replacement of workhouses with more Replacement of workhouses with more

specialized institutions catering to specialized institutions catering to specific populationsspecific populations

Minority reportMinority report– Dismantle systemDismantle system– Emphasize prevention of destitution Emphasize prevention of destitution

rather than relief of destitutionrather than relief of destitution

Liberal government of the time chose Liberal government of the time chose not to act on either reportnot to act on either report

Still strong indication that the moral Still strong indication that the moral assumptions underlying poor laws assumptions underlying poor laws were collapsingwere collapsing

Consensus that stigma attached to Consensus that stigma attached to medical relief deterred people from medical relief deterred people from seeking legitimate medical aidseeking legitimate medical aid

Reluctance to go of concerns about Reluctance to go of concerns about the character of the poorthe character of the poor

Still focussed on self-sufficiencyStill focussed on self-sufficiency

Poor should provide for themselvesPoor should provide for themselves

Public assistance should be last Public assistance should be last resortresort

Sickness insurance was available at the Sickness insurance was available at the timetime

Very selective as to who they would insureVery selective as to who they would insure

Many conditions excludedMany conditions excluded

Failure to pay premiums resulted in loss of Failure to pay premiums resulted in loss of all accumulated benefitsall accumulated benefits

National Insurance Act (1911)National Insurance Act (1911) Two parts:Two parts:

1. Medical insurance1. Medical insurance– Compulsory medical insurance with Compulsory medical insurance with

contributions from employer, employee contributions from employer, employee & state& state

– Replacement of lost earningsReplacement of lost earnings– Free medical care for insured workerFree medical care for insured worker

2. Employment insurance2. Employment insurance

Provided 15 million working people Provided 15 million working people with medical care & protection from with medical care & protection from earnings lost by sicknessearnings lost by sickness

Rejected idea that poverty was the Rejected idea that poverty was the individual’s faultindividual’s fault

Paid benefits even when worker Paid benefits even when worker might have been at faultmight have been at fault

Rejected the idea that public Rejected the idea that public assistance weakened self-reliance or assistance weakened self-reliance or independenceindependence

Major opposition came from Major opposition came from physiciansphysicians– Insisted that upper income limit be Insisted that upper income limit be

imposedimposed– Middle class continued to rely on private Middle class continued to rely on private

medical caremedical care– Argued with the Lloyd George Argued with the Lloyd George

government over compensation under government over compensation under the planthe plan

– Tried to orchestrate profession-wide Tried to orchestrate profession-wide refusal to accept NIA patientsrefusal to accept NIA patients

– GPs refused to complyGPs refused to comply

Profitable for private insurance Profitable for private insurance companiescompanies– Collected NIA contributionsCollected NIA contributions– Paid out benefits on state-mandated Paid out benefits on state-mandated

scalescale

Served as basis for more Served as basis for more comprehensive program that was comprehensive program that was established after WWIIestablished after WWII

Gaps in NIAGaps in NIA– Did not cover hospitalizationDid not cover hospitalization– Did not cover dependentsDid not cover dependents

1941 opinion poll:1941 opinion poll:– 85% favoured state organized medical 85% favoured state organized medical

serviceservice– 55% favoured nationalizing hospitals 55% favoured nationalizing hospitals

and medical careand medical care

Beveridge Report (1942)Beveridge Report (1942)

Actually concerned with post-war Actually concerned with post-war reconstructionreconstruction

Five great giants on the road to Five great giants on the road to reconstructionreconstruction– WantWant– IgnoranceIgnorance– IdlenessIdleness– DiseaseDisease– squaloursqualour

Included proposals for:Included proposals for:– Social insuranceSocial insurance– Comprehensive publicly funded medical Comprehensive publicly funded medical

insuranceinsurance

Paved way for establishment of Paved way for establishment of National Health Service (1946)National Health Service (1946)

Role of women in the development of Role of women in the development of the welfare statethe welfare state

11stst wave feminism wave feminism Diverse group of women Diverse group of women

– Similar concerns re: women & childrenSimilar concerns re: women & children– Different political agendasDifferent political agendas

Earlier historians referred to this Earlier historians referred to this phenomenon as maternal feminismphenomenon as maternal feminism

Contemporary historians have Contemporary historians have categorized them as:categorized them as:– Sentimental maternalistsSentimental maternalists– Progressive maternalistsProgressive maternalists– FeministsFeminists

What was their impact on the welfare What was their impact on the welfare state?state?

Lobbied for special protection of Lobbied for special protection of women and childrenwomen and children– Child welfare programsChild welfare programs– Mothers allowanceMothers allowance

Lobbied for programs to strengthen Lobbied for programs to strengthen familiesfamilies– TemperanceTemperance– PensionsPensions

Lobbied for programs to support the Lobbied for programs to support the male breadwinnermale breadwinner– Unemployment insuranceUnemployment insurance– Health insuranceHealth insurance

Lobbied for franchise for womenLobbied for franchise for women– This platform tended to set the feminists This platform tended to set the feminists

aside as a distinct groupaside as a distinct group

CanadaCanada

Developments similar to other Developments similar to other countriescountries

Exact details shaped by Canadian Exact details shaped by Canadian form of governmentform of government

Federal rather than unitary Federal rather than unitary

Health a provincial responsibilityHealth a provincial responsibility

In 19In 19thth century, provinces left welfare & century, provinces left welfare & health issues to municipalitieshealth issues to municipalities

Voluntary hospitalsVoluntary hospitals– Municipalities often provided some fundingMunicipalities often provided some funding

Charitable organizationsCharitable organizations

Public funding for care of destitutePublic funding for care of destitute

Aftermath of WWI forced some Aftermath of WWI forced some changes to the systemchanges to the system

Federal program for returned Federal program for returned veteransveterans– Social assistanceSocial assistance– Medical assistanceMedical assistance

Provincial initiatives to improve Provincial initiatives to improve citizens’ livescitizens’ lives– Highway constructionHighway construction– EducationEducation– Mother’s allowanceMother’s allowance– Old age pensionOld age pension

Most significant influence on Most significant influence on development of Canadian welfare development of Canadian welfare state was the Great Depressionstate was the Great Depression

Bankrupted municipalitiesBankrupted municipalities

Nearly bankrupted several provincesNearly bankrupted several provinces

Winnipeg doctor’s strikeWinnipeg doctor’s strike Physicians always did some charity Physicians always did some charity

workwork By 1933, believed they were By 1933, believed they were

undertaking unfair burdenundertaking unfair burden Wanted a municipal subsidy Wanted a municipal subsidy Refused to treat non-emergency cases Refused to treat non-emergency cases

who were on reliefwho were on relief Began July 1, 1933Began July 1, 1933

In early 1934, imposed very stringent In early 1934, imposed very stringent definition of emergencydefinition of emergency

City came to agreement with City came to agreement with Winnipeg Medical Society in Feb. Winnipeg Medical Society in Feb. 19341934

Underwrote medical care of the Underwrote medical care of the indigent in Winnipeg until 1960sindigent in Winnipeg until 1960s

Great Depression had similar impact Great Depression had similar impact on other parts of the countryon other parts of the country

Only Ontario provided provincial funds Only Ontario provided provincial funds to defray medical relief coststo defray medical relief costs

All other provinces left it to All other provinces left it to municipalitiesmunicipalities

After depression 4 provinces followed After depression 4 provinces followed Ontario’s exampleOntario’s example

Federal government had limited Federal government had limited capacity to respond to the crisiscapacity to respond to the crisis– BNA Act gave these responsibilities to BNA Act gave these responsibilities to

the provincesthe provinces– Also, sometimes, limited interest in Also, sometimes, limited interest in

doing sodoing so

Royal Commission on Dominion Royal Commission on Dominion Provincial Relations (Rowell-Sirois Provincial Relations (Rowell-Sirois Commission): 1937Commission): 1937

Report tabled 1940Report tabled 1940

Acknowledged that municipal & Acknowledged that municipal & provincial governments had limited provincial governments had limited capacity to provide medical & social capacity to provide medical & social servicesservices

RecommendationsRecommendations– Transfer jurisdiction over taxation to Transfer jurisdiction over taxation to

fedsfeds

– Feds assume responsibility for Feds assume responsibility for unemployment insurance & old age unemployment insurance & old age pensionspensions

– Provinces to retain responsibility for Provinces to retain responsibility for healthhealthBased on assumption that medical care of Based on assumption that medical care of

indigent would continue to be provincial indigent would continue to be provincial responsibilityresponsibility

Many physicians were committed to Many physicians were committed to state sponsored medical insurancestate sponsored medical insurance

Had established physician sponsored Had established physician sponsored health insurance planshealth insurance plans

Endorsed by CMA in 1934Endorsed by CMA in 1934

Private insurance market developedPrivate insurance market developed

Many plans also sponsored by Many plans also sponsored by physiciansphysicians– Ontario, 1938Ontario, 1938– By 1950, all across CanadaBy 1950, all across Canada

In Manitoba, Manitoba Medical In Manitoba, Manitoba Medical InsuranceInsurance

Most were not-for-profitMost were not-for-profit

Pressure continued to be exerted on Pressure continued to be exerted on feds to respond in some wayfeds to respond in some way

Post war reconstruction planningPost war reconstruction planning

Two reports released in 1943Two reports released in 1943

Report on Social Security for Canada Report on Social Security for Canada (Marsh Report)(Marsh Report)– First comprehensive plan for social First comprehensive plan for social

securitysecurity

Report of Advisory Committee on Report of Advisory Committee on Health Insurance (Heagerty Report)Health Insurance (Heagerty Report)– Recommendations for creation of Recommendations for creation of

national health insurance programnational health insurance program

Constitutional changes needed to Constitutional changes needed to implement these initiativesimplement these initiatives

In post-war period, only 6% of In post-war period, only 6% of Canadians had health insuranceCanadians had health insurance

Rose to 50% by 1950sRose to 50% by 1950s

Insurance plans had problemsInsurance plans had problems– Restrictions or caps on coverageRestrictions or caps on coverage– Incomplete coverageIncomplete coverage

By 1960s, pressure began to mount By 1960s, pressure began to mount again for a national solutionagain for a national solution

Insurance companies recognized that Insurance companies recognized that they would never cover everyonethey would never cover everyone– Unemployed/unemployableUnemployed/unemployable

Accepted that these people were Accepted that these people were legitimate responsibility of legitimate responsibility of governmentgovernment

Saskatchewan (as usual) led the waySaskatchewan (as usual) led the way

Developments in this province Developments in this province started in 1920sstarted in 1920s– Municipal doctors plansMunicipal doctors plans– Union hospitalsUnion hospitals

Election of CCF Election of CCF government in government in 19441944

Leader, Tommy Leader, Tommy Douglas (1904-Douglas (1904-1986), committed 1986), committed to medical to medical insuranceinsurance

What does this What does this man have to do man have to do with our “Greatest with our “Greatest Canadian?”Canadian?”

Discontent with the inequities Discontent with the inequities between the provincesbetween the provinces

““Canada is like an old cow. The West Canada is like an old cow. The West feeds it. Ontario and Quebec milk it. feeds it. Ontario and Quebec milk it. And you can well imagine what it's And you can well imagine what it's doing in the Maritimes.”doing in the Maritimes.”

Douglas’s 1Douglas’s 1stst act was to guarantee act was to guarantee medical coverage to destitutemedical coverage to destitute

Established survey of province’s Established survey of province’s health conditionshealth conditions– Headed by Henry Sigerist (1917-1957)Headed by Henry Sigerist (1917-1957)– Physician & medical historian at Johns Physician & medical historian at Johns

Hopkins UniversityHopkins University

Recommended expansion of Recommended expansion of provincial health programsprovincial health programs

Federal/provincial negotiations Federal/provincial negotiations stalematedstalemated

Saskatchewan decided to go it aloneSaskatchewan decided to go it alone

Hospital Services Act (1946)Hospital Services Act (1946)– 11stst compulsory tax supported hospital compulsory tax supported hospital

insurance program in North Americainsurance program in North America

Created tremendous pressure on Created tremendous pressure on other provinces and federal other provinces and federal governmentgovernment

Hospital Insurance & Diagnostic Act Hospital Insurance & Diagnostic Act (1957)(1957)– Federal legislationFederal legislation– 50/50 cost sharing of hospital costs50/50 cost sharing of hospital costs

By 1961, all provinces had hospital By 1961, all provinces had hospital insurance plansinsurance plans

Medical fees still not coveredMedical fees still not covered

Saskatchewan again led the waySaskatchewan again led the way

CCF won 1960 election on promise it CCF won 1960 election on promise it would create tax funded medical would create tax funded medical insuranceinsurance

SMA/CMA opposed this measureSMA/CMA opposed this measure

Saskatchewan Medical Insurance Bill Saskatchewan Medical Insurance Bill passed passed

To come into effect April 1, 1962; To come into effect April 1, 1962; physician opposition pushed date physician opposition pushed date back to July 1, 1962back to July 1, 1962

Precipitated most famous physician Precipitated most famous physician strike in Canadastrike in Canada

Withdrew Withdrew allall medical services (not medical services (not just to the poor)just to the poor)

Supported by other physician groups Supported by other physician groups across the continentacross the continent

Seemed to ignore political will of the Seemed to ignore political will of the peoplepeople

SK government recruited foreign SK government recruited foreign physicians to substitutephysicians to substitute

Furious public relations campaign on Furious public relations campaign on both sides of the issueboth sides of the issue

Anti-medicare lobby led by coalition Anti-medicare lobby led by coalition of Liberal supportedof Liberal supported

Organized mass rally where 30,000 – Organized mass rally where 30,000 – 40,000 were predicted to attend40,000 were predicted to attend

On July 11, only 5000 showed upOn July 11, only 5000 showed up

Clear that the strike was overClear that the strike was over

Public opinion clearly favoured medical Public opinion clearly favoured medical insuranceinsurance

Ironically the plan worked well for Ironically the plan worked well for physiciansphysicians

Guaranteed payment for services Guaranteed payment for services renderedrendered

Within 1 year, SK physicians were Within 1 year, SK physicians were highest paid in Canadahighest paid in Canada

Created tremendous pressure on Created tremendous pressure on federal governmentfederal government

Royal Commission on Health Services Royal Commission on Health Services (Hall Commission)(Hall Commission)

Established 1961, reported 1964Established 1961, reported 1964

Endorsed national health insuranceEndorsed national health insurance

Five principlesFive principles– ComprehensiveComprehensive– UniversalUniversal– PortablePortable– Publicly fundedPublicly funded– Publicly administeredPublicly administered

Medical Care Act passed in 1966 by Medical Care Act passed in 1966 by Liberal minority government under Liberal minority government under Lester PearsonLester Pearson

Implementation was very difficultImplementation was very difficult

Start date changed from July 1, 1967 Start date changed from July 1, 1967 – July 1, 1968– July 1, 1968

Initially, only 2 provinces qualified Initially, only 2 provinces qualified under the planunder the plan

By 1972, all 10 provinces and 2 By 1972, all 10 provinces and 2 territories were participatingterritories were participating

Short-lived physician strike in Short-lived physician strike in Quebec (1970)Quebec (1970)

This program was never a sure thingThis program was never a sure thing– Powerful Liberals opposed itPowerful Liberals opposed it– Created during an era of unusual Created during an era of unusual

prosperityprosperity

Impact on physiciansImpact on physicians– Incomes increased 31% relative to Incomes increased 31% relative to

increases attained by other Canadiansincreases attained by other Canadians

Many bumps along the road since Many bumps along the road since thenthen– Extra billingExtra billing– Threat of user feesThreat of user fees– Decrease in federal fundingDecrease in federal funding– GlobalizationGlobalization

WTOWTO