Canadian Doctors Fought Reform : Health care: They even resorted to a strike. But politics, the insurance setup and the culture led to fairly popular system.

Canadian physicians are not too different from their U.S. counterparts. Back in the early 1960s, when legislators began to put together the pieces of what would evolve into this country’s broad, single-payer health insurance plan, doctors fought the reformers with all they had.

The doctors lost the battle, of course, and today most would say that is a good thing. Even though Canada’s health care system is now under financial pressure, one survey after another has shown that most doctors are glad the government took over health insurance.

Which raises a question: If American detractors insist that a single-payer health program is politically impossible in the United States, then how did Canada--a country similar to America in so many respects--manage to put one in place?

The answer lies in the way Canada’s insurance industry was structured in the 1960s, in the interplay of political parties and governments in Canada and in the subtle cultural differences between the two North American countries.

“We (Canadians) have a different attitude,” said Malcolm Taylor, author of a history of health insurance in Canada. “Your emphasis is on individualism, whereas here we have a sense of collective responsibility. Here, the government may be seen as ineffective and inefficient, but it isn’t considered the enemy.”

In Canada, the first government health insurance plan opened for business in the province of Saskatchewan, a realm of small farm towns and vast empty spaces north of Montana. Saskatchewan had fared poorly during the Depression and consequently was fertile ground for populist, even bluntly statist economic ideas.

In 1944, its voters elected a social democratic government, which promised sweeping economic reforms--including the creation of a public health care system.

The social democrats started by introducing a government hospital insurance plan immediately after World War II. Much later, in 1960, they decided to expand government insurance to cover all forms of medical care.

There were elections in Saskatchewan that year, and health care became the hot-button issue.

“The election was all but a referendum on health insurance,” Taylor recalled. When the voters returned the social democrats to power, the government saw its victory as a clear mandate to set up its state-run program.

Before long, the plan was working its way through the Legislature. It was to be financed with modest tax hikes and premiums.

An artifact of Canadian political life helped the bill move swiftly to passage: In Canadian legislatures, the members operate on a system of strict party discipline.

The upshot is that American-style legislative gridlock is not a deal-breaker here. The party in power almost always gets its legislation onto the books--and the social democrats controlled Saskatchewan at the time.

Still, Saskatchewan’s new health insurance program did not pop up overnight. There was still a nasty fight with the doctors of the province. Through their professional society, they voted not to practice once the program was law.

In their doomed opposition is found another important difference between Saskatchewan circa 1960 and the United States today: Although the province’s doctors were militant and well-organized, they had virtually no help from the private insurance industry. Saskatchewan then, as now, was overwhelmingly rural and a full third of its small towns and villages had their doctors on municipal payrolls--not on a private insurance reimbursement system.

That is not to say that the doctors were ineffective or isolated. As the implementation date--July 1, 1962--approached, fear swept the province that the doctors would move en masse to the United States.

“It was fiery indeed,” said Meyer Brownstone, a political scientist who was a deputy minister for municipalities at the time. “We’re talking about a rural environment, which is normally pretty placid. . . . But the doctors invaded the legislative buildings. They burned the premier in effigy. There were threatening phone calls, dirty words and so on.”

And on July 1, the doctors struck. The Canadian Medical Assn. backed them up, calling on the federal government to investigate the events in Saskatchewan, in hopes of keeping the single-payer movement from spreading.

But the doctors lost in Saskatchewan and at the national level.

In Saskatchewan, a determined Premier Woodrow S. Lloyd refused to negotiate with the strikers, instead recruiting strike-breaking doctors from Britain.

At the national level, the Canadian Medical Assn. got the inquiry it wanted, but the investigating panel came to the conclusion that a Saskatchewan-style program of universal, government-funded coverage was cheaper than a system in which the government subsidized only the poor.

The persuasive force of that finding, combined with widespread public interest in the events in Saskatchewan, led to the federal government’s passage in 1966 of a bill creating Canada’s nationwide single-payer program.

Canada’s health insurance system has evolved since then, and doctors have opposed many of the changes. In recent waves of cost controls, coverage for certain drugs and procedures has been dropped, and some provincial governments have limited the ways doctors can practice medicine.

All the same, a Canadian magazine, the Medical Post, recently surveyed Canadian doctors and found that nine out of 10 believe that the Canadian system is better than that in the United States.

Does It Work? Doctors Say Yes

A survey by the Medical Post, a Canadian magazine, found Canadian doctors satisfied with current conditions but leery of the future. Nine out of ten say they believe the Canadian system, in which the government pays all medical cost, takes better care of patients than the U.S. system.

Percentages of doctors who ranked Canadian health care as: Excellent: 15% Very good: 68% Fair: 15% Poor: 1% *

Percentages of doctors who think health care will: Improve in the future: 10% Deteriorate: 66% Stay the same: 23% *

A majority of Canadian doctors say they are happy with: Career choice (90%) Quality of health care (83%) Medical education (81%) Practice income (71%) Equality of health care (59%) *

A majority of Canadian doctors are unhappy with: Cost constraints (81%) Federal contributions (80%) Rules that cap incomes (69%) Pharmacists’ altering of prescriptions (61%) Some categories do not add up to 100% because of rounding

Source: The Medical Post, based on surveys by Angus Reid Group of 3,387 doctors. Margin of error is plus or minus 1.7 percentage points.