Early factories, mines and mills were poorly lit, unventilated and unsafe. Work days could stretch to 16 hours a day, six days a week. Working men and women and their families lived in squalid tenement houses - often with two or three families squeezing into a single apartment. With little in the way of sanitation or heating, a subsistence diet and unsanitary public water supplies, outbreaks of diphtheria, cholera and other diseases were rife in working-class neighbourhoods. Family survival depended upon men, women and children seizing every wage and non-wage opportunity that came their way, from working in factories to doing piece work at home to the youngest children scouring the train tracks for pieces of coal for heating.
In the absence of any dependable social safety net (there were no public unemployment insurance, workers' compensation, social assistance or health care programs), loss of work time through sickness or injury had devastating consequences for working people and their families. Workers could depend upon their neighbours and kin to provide what support they could, but loss of even a child's contribution could compromise a family's ability to survive.
With the construction of the railways, the migration of masses of workers in search of jobs meant that people could not even depend upon kin or neighbours to help since workers could well be working far from family and community.
Even with the advent of the workers' compensation system, there was little relief, since workplace accidents were a minor cause of workers' disabilities. There is evidence that up to 91 per cent of all disability was caused by sickness.
Under these conditions, it is easy to understand why access to sickness or disability insurance was a critical benefit for working people. The question was how to get it. Although commercial insurers provided such policies, most workers could not afford the premiums.
The answer, for most workers, was either the early trade union movement, company (employer) societies or fraternal societies like the Independent Orders of Foresters or Odd Fellows.
From a worker's perspective there were serious drawbacks to the employer (company) societies insurance. If you lost your job for any reason, you were cut off from the coverage. And, at least with the early forms of company insurance, most of the fees came from employee dues anyway.
Although the fraternal societies did provide competitive coverage for members, access to fraternal organizations was an issue. The Odd Fellows, for instance, would not accept Catholics, Jews, women or others outside their narrowly defined membership criteria.
Unions found sickness insurance a powerful draw among workers. In the early days of the Western Federation of Miners, who organized hard-rock miners and smelter workers in B.C. and the western U.S., the union reportedly spent more time and resources on providing direct benefits to members than it did on collective bargaining.
Provision of sick benefits became an increasingly important union benefit over time, so that by the end of the 1920s, for example, 46 of 105 American Federation of Labour unions had a sick benefit. Some unions abandoned the direct union provision of sick benefits in favour of collectively bargained disability insurance. However, the instability of union recognition and the fragility of collective agreements prior to World War II made this a risky endeavour.
Beyond Simple Survival: Looking For Health Outcomes
However, finding ways to cope with the immediate disastrous financial consequences of sickness in working-class families only helped them survive sickness monetarily - it did nothing to allow them access to proper medical treatment or to improve their health outcomes.
There were creative efforts to deal with the problem. In the 1880s, unions and coal mine companies in the Glace Bay area of Nova Scotia arranged to deduct mandatory premiums from workers' pay (a check-off) which were then allocated on a per-person basis to one of the local hospitals and doctors (at the worker's choice). The check-off and fees were negotiated between the union, employers and doctors and provided workers and their families with unlimited doctors and hospital visits and procedures.
Similar "check-off" systems became common among mining, lumbering communities and by railway employers. The weakness of the check-off system was that it broke down during industrial conflicts. With workers no longer receiving paycheques, the check-offs ended and workers and their families were left without health care.
Other forms of pre-paid health insurance were also tried. The Medicine Hat General Hospital (1889) in Alberta was the first publicly built hospital in the Northwest Territories (Sask. and Alta.). Any citizen could purchase a "Five-Dollar Ticket" that would guarantee them health services for a year.
Doctors As Public Employees
It is not a huge step from the kind of "voluntary" pubic health insurance practised by local hospitals like Medicine Hat to the idea of a community actually hiring a doctor under contract.
Saskatchewan's "municipal doctor system" began in 1910 when a small rural community paid a doctor $2,500 per year to provide medical services to all resident taxpayers. The government then amended the Rural Municipality Act in 1916, legalising the arrangement. Under this system, rural municipalities, villages and towns hired local doctors, financed from local taxation, to provide medical services to their residents.
They could offer a doctor a salary or fee-for-service payments for general medical care, surgery, maternity care, and public health work. During the 1930s, the municipal doctor scheme was adopted across the province and spread to Manitoba and Alberta. (By 1948, 210 local governments had contracts with doctors under the scheme.)
Similarly, the Union Hospital and municipal hospital care plans pioneered in Saskatchewan (later spreading to Alberta and Manitoba) allowed rural municipalities, villages and towns to pool their limited resources to establish and maintain hospitals. Municipal hospital-care plans provided payment for the hospital services from general revenues.
Meanwhile, the public demand for a comprehensive system of health insurance continued to grow. In 1932, a B.C. Royal Commission on Health Insurance reported "an overwhelming desire on the part of the public for the introduction of state health insurance..." The Commission recommended a plan that would cover all doctors' services, hospitalization and drugs. However, when the province attempted to introduce a watered down version in 1936 (it didn't include coverage for the unemployed), it was ultimately scuttled by a coalition of business organizations and the medical establishment. Similarly, the UFA government in Alberta drafted a health insurance act that they used as a major platform in the 1935 election. When the UFA lost the election to the Social Credit Party of William Aberhart, the plan was discarded.
Prior to 1945, most existing health programs were run by nonprofit insurance cooperatives made up of local groups of workers, churches, employers and farmers. These consumer insurance cooperatives made both hospital coverage and treatment by doctors affordable to their members.
After World War II, the for-profit insurance industry began to enter the health insurance field. However, there were still large portions of the population without access to such cooperative schemes.
Tommy Douglas, The CCF And The Birth Of Medicare
One of the priorities of Premier Tommy Douglas when the Cooperative Commonwealth Federation (CCF - forerunner of the New Democratic Party) came to power for the first time in Saskatchewan in 1944 was public health care.
By 1947, the CCF had developed and implemented the Hospital Insurance Plan which charged individuals $5 per year and families $10 per year for access to free basic hospital services. The government also initiated free mental and cancer care.
However, Douglas had a far more ambitious program in mind - ultimately he thought to use Saskatchewan's program to become "the nucleus around which Canada will ultimately build a comprehensive health insurance program which will cover all health services - not just hospital and medical care - but eventually dental care, optometric care, drugs and all other health services which people require" (Speech to Sask. Legislature, 1961).
Douglas, from the beginning, had been counting upon financial support from the federal Liberals who had been promising a national health care program since 1919. Without federal support, the province could not afford to expand the Hospital Insurance Plan.
However, it was the newly elected Diefenbaker Conservatives who first enacted federal cost-sharing of Saskatchewan's hospital plan - thus enabling Douglas to announce the introduction of Medicare in 1959. (Curiously, it was also the Conservatives who launched the Royal Commission on Health Services chaired by Emmet Hall whose report mapped out the national Medicare program eventually adopted by the Pearson Liberals.)
When Douglas launched Medicare in Saskatchewan in 1961, just slightly more than half (53%) of all Canadians had any coverage in either a hospital insurance or medical services insurance scheme - equally split between profit and non-profit plans. The problems with for-profit insurance plans, as the American have found out to their dismay, are legion. First, deductibles actually pass on huge costs to the individual. Insurance companies place arbitrary limits on what procedures are covered, and, unlike governments who do that, the companies are not accountable to the public. Insurers typically penalize or refuse coverage to people who claim too many times (that is, people with serious health issues). Finally, even the most affordable plans are often too expensive for workers unless their employer pays part of the premium costs.
Despite the flaws in the private insurance schemes, business organizations, the private insurance industry, the Canadian and American Medical Associations and the media in Saskatchewan all viscously attacked Medicare, culminating in a 23-day doctors' strike in July 1962. Despite the furore over Saskatchewan's social health care, the program was so popular that even when the Liberals won the 1964 election in Saskatchewan, they left the system intact.
From Saskatchewan To All Of Canada
And, as Emmet Hall, dubbed by some as the father of Medicare, wrote later to Douglas, "I think your greatest and enduring accomplishment was the introduction and putting into effect Medicare in Saskatchewan. If the scheme had not been successful in Saskatchewan, it wouldn't have become nation-wide."
In 1965, at the urging of the federal New Democrats who held the balance of power in Parliament, the minority Liberal government under Lester Pearson passed the Medical Care Insurance Act and Canadian workers finally got a national Medicare system.
There is still a long way to go. There is no universal program for optometric care or prescription drug care. Provincial governments continually try to control costs by reducing coverage or providing inadequate facilities and personnel. Many medical services are uncovered. Doctors, paid on a fee-for-service basis rather than on salary and uncontrolled drug costs are huge drains on health care funds.
However, working people no longer have to check their wallets before getting a doctor to check their pulse.
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