Gregory P. Marchildon, Tommy Douglas and the Quest for Medicare in Canada. Toronto: University of Toronto Press, 2024. 728 pages.

Greg Marchildon has written the definitive 700-page book on Tommy Douglas’s political career and the political conflicts surrounding Canada’s “single-payer” health insurance system. If you are inclined to read it, it helps if, first, you know about the Social Gospel tradition (for example, J.S. Woodsworth and Stanley Knowles); second, you are interested in 20th-century Canadian and Saskatchewan politics; and third, you have been engaged in managing a single-payer insurance system and/or multidiscipline community primary care clinics.

I qualify. Long ago, I was a Saskatchewan MLA and briefly served as legislative secretary to the health minister, Walter Smishek, who figures prominently in Marchildon’s book. For three decades I have assumed various board responsibilities for a multidiscipline primary care clinic in East Vancouver.

The rise of Tommy Douglas

Marchildon begins with a detailed biographical account of Tommy’s early years, introducing aspects of his family. He was born in Scotland in 1904 to a devout Protestant family. The family emigrated to Canada in 1912 and settled in Winnipeg. The key to understanding Tommy’s political career is the severe tuberculosis infection he suffered in one of his knees. He received high-quality care, thanks to a young surgeon at the University of Manitoba hospital in Winnipeg. By chance, this surgeon came across Tommy’s case in a general ward and performed, pro bono, a complicated procedure that saved his leg from amputation.

Two decades later, Tommy shifted his career from Baptist preacher to politician as a major leader of the Co-operative Commonwealth Federation (CCF), predecessor of the NDP. In the 1935 federal election, he ran successfully in Weyburn, a town in southeastern Saskatchewan, and was one of seven CCF candidates elected. In 1942 he became leader of the Saskatchewan CCF, and in the June 1944 provincial election the CCF won an overwhelming victory. As Premier, he kept the health portfolio for himself.

Tommy’s political rhetoric was in the populist tradition of both the Canadian Prairies and the Great Plains U.S. states. In small towns or a CCF conference, his typical speech started with a few jokes at the expense of the Canadian Pacific Railway or bank owners in Montreal and Toronto. My favourite among his 1940s-era jokes is based on cream separators. A farmer pours fresh milk into a separator; a worker turns the handle. A banker has his mouth on the cream spout; the farmer sells the skim milk. From time to time, bloated bankers want no more cream. They call for an economic depression: workers are laid off and farm prices collapse. In due course, bankers repeat the cycle. Another standard joke concerns the farmer who buys hammers in the town hardware store. The farmer buys the first hammer for $1.25, goes outside and sells it for $1 to anyone passing. He goes back into the store, buys a second hammer and again sells it for $1. When the hardware employee sees the farmer repeat this money-losing exercise a third time, he asks the farmer why. “It’s better than raising wheat,” the farmer replies. After the jokes, he praises farmers for doing God’s work by raising wheat and feeding the world. Finally, he speaks about socialist solutions – often health insurance – to current problems.

Unlike most rhetorically skilled Prairie politicians – such as John Diefenbaker, who became Prime Minister in the 1950s, and William Aberhart, Social Credit Alberta Premier in the 1930s – Tommy relied on progressive professionals once he became Premier. He made amends for sending Japanese Canadians to internment camps of during World War II by inviting a dozen well-educated Japanese Canadians to live in Regina. The best known among them, Tommy Shoyama, led the provincial economic planning board. After the CCF defeat in 1964, Shoyama moved to Ottawa and finished his career as federal deputy minister of finance. Al Johnson, a farm boy from rural Saskatchewan, served as provincial deputy minister of finance over much of Douglas’s reign and completed a Harvard PhD in public administration. Post-1964, he became assistant deputy federal finance minister, then headed the CBC. He played an important role in composing the 1984 Canada Health Act, which legislated the five principles of Canadian medicare, as well as in expanding equalization transfers to the provinces.

In the middle of World War II, William Beveridge, a U.K. economist, published a postwar welfare state agenda (Social Insurance and Allied Services). Leonard Marsh, a student of Beveridge’s, wrote a Canadian equivalent. Both reports figured in postwar policy debates, and high on the list of goals was universal health insurance. Under Clement Attlee’s postwar Labour government in the U.K., the most important social policy achieved was a universal single-payer medical insurance system with no payments at point of service. Implementation of the National Health System began in 1948. Tommy hoped to implement a similar comprehensive medical insurance program in Canada before his second election, in 1948.

Marchildon undertook detailed archival research on the disappointing postwar conferences of the prime minister and premiers. Ottawa and most of the premiers balked at the administrative complexity and cost of major welfare state programs, the most costly being universal medical insurance. One reason why Saskatchewan successfully led Canadian health insurance, as opposed to other provinces or the federal government, is the failure of Canadians to elect a CCF government anywhere else.

After World War II, there was a large supply of progressive professionals and limited demand for their ideas. If they wanted to stay in Canada and do something – as opposed to writing articles and books in universities – reform-minded professionals had to leave Toronto, Ottawa or Montreal and move to Regina, a small city with minus-40-degree winters “in the middle of nowhere.” Despite these drawbacks, many accepted Tommy’s invitations.

Tommy tried to persuade Ottawa and the provinces to share the cost of a national single-payer medical insurance scheme. Ottawa and the largest provinces, Ontario and Quebec, flatly refused. Finally, Tommy narrowed his initial goal to a single-payer hospital insurance plan to be in place in Saskatchewan by 1947, well before the second provincial election. Fortunately, Tommy had the backup of a dozen ideologically dedicated physicians and administrators. Marchildon describes their respective roles.

Dr. Mindel Sheps, a young doctor from Winnipeg, and her husband Cecil worked day and night to inspire rural municipal leaders, design necessary regulations and contend with consistent opposition by senior physicians leading the College of Physicians and Surgeons (CPS). From the beginning in the 1940s to the intense conflict in the 1960s, the CPS argued that the majority in the province paid insurance premiums and already had some form of health insurance; all that was needed was a means-tested subsidy for the poor. Despite CPS opposition, the Saskatchewan hospital insurance plan, initiated in January 1947, turned out to be a well-managed program that required no payment at time of service. Successful introduction of hospital insurance was an important factor in the CCF’s second provincial victory.

The introduction of medicare and the doctors’ strike

Sixteen years after 1944, Tommy faced his fifth and what would almost certainly be his last provincial election. He made the 1960 election campaign a referendum on comprehensive medical insurance. After winning the election, he turned to the administrative complexities. He assumed that, as in the earlier hospital insurance conflict, the provincial physicians would ultimately accept a single-payer system, with some compromises. Tommy was naive about the intense opposition of the CPS. In addition, he succumbed to pressure from David Lewis, the foremost advocate for transforming the rural-based CCF into an equivalent of the U.K. Labour Party, to become the first leader of the federal New Democratic Party.

Tommy resigned as premier in late 1961 to take on the federal NDP leadership. The Saskatchewan CCF-NDP selected Woodrow Lloyd as Tommy’s successor. Woodrow was one of nine children in a farm family in southwest Saskatchewan. The family could not afford university; instead, Woodrow became a teacher in Biggar, a small town near Saskatoon. (Passing by the town’s large sign on the highway, drivers read, “New York is big; this is Biggar.”) Tommy realized Woodrow’s political sophistication and insisted he run in the 1944 election. From 1944 until he became Premier, Woodrow served as education minister, and did for rural schools what Tommy did for the provincial health system.

During the first half of 1962, it looked as if comprehensive medical insurance might collapse. With financial support from the Canadian Medical Association, the CPS mounted an effective antisocialist, antimedicare campaign. The Liberal official opposition in the legislature was led by Ross Thatcher, a CCF MP who had become an apostate. Further complicating the conflict, the provincial health minister resigned, crossed the floor to join the provincial Liberals, and supported the CPS campaign. The CPS endorsed Keep Our Doctors, a citizens’ society campaigning for withdrawal of the medicare legislation. KOD organized public meetings around the province, culminating in a large demonstration in front of the provincial legislature in early July.

In the midst of the growing polarization, a federal general election took place on June 18. Tommy ran as the Regina CCF-NDP candidate (the Saskatchewan NDP members were reluctant to drop their “CCF” acronym). In the election, the Conservative MP won reelection, with double Tommy’s vote.

The provincial medical insurance program came into effect on July 1, 1962. The same day, the CPS triggered a doctors’ strike. Woodrow Lloyd was one of the major actors in the 1962 drama – as was Allan Blakeney, who became health minister in mid-1962 (and Premier in 1971). More than a hundred U.K. doctors were invited to Saskatchewan to provide at least minimum primary care. Woodrow invited Lord Taylor, a Labour member of the House of Lords, to serve as mediator during the strike. After ten days of shuttle diplomacy between the cabinet and the CPS offices, Taylor successfully negotiated a workable compromise that maintained the single-payer principle. (Taylor refused payment for his task – except for a government-paid week fishing in northern Saskatchewan lakes.)

Woodrow lacked Tommy’s rhetorical skills and lost the 1964 election to Ross Thatcher. Fortunately, both Lloyd and Blakeney were exceptionally competent administrators. They introduced the complex insurance plan in the midst of political polarization and a doctors’ strike. Two years after introduction, public opinion in Saskatchewan had switched. Universal medicare was too popular for Ross Thatcher to cancel.

In 1964, I was a naive young summer employee in the provincial planning board. Thatcher, the new Premier, shook hands with us. The new cabinet mistrusted civil servants, some of whom were using government cars for personal use. I wrote the memo to cabinet with the solution: all government cars would henceforth have a licence plate number preceded by “G,” which would shame civil servants tempted to abuse use government cars.

In 1968, I came to know Woodrow Lloyd as a friend. He was concerned about the Saskatchewan CCF-NDP. Would there be a generational renewal? Would the party collapse, as was the fate of most populist parties in the U.S. plains and Canadian Prairies? That summer, Woodrow trekked to Chicago to attend the conflict-ridden Democratic convention. He empathized with Hubert Humphrey’s Farmer-Labour party and wanted to discuss with Humphrey why he was willing to lead the Democrats in pursuing the French colonial Vietnam war.

Woodrow wanted me to enter politics. I did so. Sandy Nicholson, one of the last Social Gospel CCF-NDP members of the legislature, held a Saskatoon riding. He retired in 1970, and I won the nomination to succeed him. One day, Sandy took me to northeast Saskatchewan where he had campaigned in the 1930s. He recalled his youth, campaigning in winter by horse-drawn cabins on sleighs. My wife was not impressed. I was a one-term MLA: elected in 1971, defeated in 1975.

Marchildon devotes the last third of his book to post-1963 politics in Ottawa and other provinces. During Lester Pearson’s reign as Prime Minister, 1963 to 1968, he and his cabinet colleagues introduced major programs: the Canada/Quebec Pension Plan, the Guaranteed Income Supplement and a national copy of Saskatchewan’s single-payer medical insurance. Al Johnson and Tommy Shoyama had their fingerprints on all the program designs and funding. Not surprisingly, cabinet ministers disagreed – and the CMA lobbied against a single-payer system.

Tommy resigned his NDP leadership in 1971 and was succeeded by David Lewis. Douglas remained an MP until the 1979 election. In his final decade, he consistently pressured the government to entrench principles for medicare. He died in 1986, having lived to see enacted the five principles of the Canada Health Act.

Bilateral monopoly

 A theme throughout Marchildon’s history is physicians’ organized opposition to single-payer medical insurance – from Saskatchewan hospital insurance in the 1940s through the 1962 doctors’ strike to the Canadian Medical Association’s adoption of “extra billing” until enactment of the 1984 Canada Health Act.

Marchildon documents in great detail examples of “bilateral monopoly” (economists’ jargon). If the suppliers of a good or service have the ability to limit market supply and sell at high prices, and agents of the purchasers are similarly well organized to limit their collective willingness to pay, the outcome is unpredictable.

Individually, physicians are largely well-intentioned suppliers of quality health care. Collectively, they exercise a monopoly: they organize themselves into very powerful associations at the provincial and national levels. Provincial governments have monopsony power: the ability to control the number of practising physicians. They have taxpayers’ money with which to hire health care providers and determine their number and remuneration.

In Canada, the most dramatic illustration of bilateral monopoly was the 1960–62 conflict in Saskatchewan. The outcome of that battle enabled Canada to develop a single-payer insurance system. Despite Canadian Medical Association lobbying, Lester Pearson’s cabinet in the late 1960s extended the Saskatchewan system to all provinces.

By the 1990s, I was neither a naive summer employee in Regina nor a radical graduate student. Saskatchewan is a small province, and I was part of the CCF-NDP provincial “family.” In the 1991 election, NDP leader Roy Romanow defeated Grant Devine, the academic economist who had become Conservative Premier in the 1980s. To the shame of academic economists, Devine sold Saskatchewan crown corporations and created the largest debt relative to provincial GDP. By 1991, Allan Blakeney was in retirement, but he exercised considerable influence behind the scenes. I recall his conclusion that Romanow might well be a one-term premier because his first obligation was to “clean up the Devine financial mess.” Blakeney was wrong: Romanow remained Premier into the new century.

In the mid-1990s, after two decades of continuous deficits at both provincial and federal levels, Canada had a debt/GDP ratio above 100 per cent. It is ironic that the first province to balance its budget in the 1990s was Saskatchewan under the fiscally prudent CCF-NDP. Romanow increased taxes and cut spending. The province exercised its monopsony power by closing more than 50 small rural hospitals.

The federal Liberals under Jean Chrétien were a shoo-in to win the 1993 election. They prepared a “Red Book” campaign document which promised to continue expansion of federal spending. Chrétien’s senior Finance Department officials warned that, if Ottawa honoured the Red Book promises, the Canadian dollar would collapse as had the Mexican peso. Chrétien threw away the Red Book. The 1995 federal budget reduced transfers to provinces, trimmed employment insurance benefits, doubled Canada/Quebec Pension “contributions” and increased federal income tax rates. The premiers, obliged to cut spending and increase provincial taxes, blamed Ottawa. There followed a round of bilateral monopoly conflicts. On one side, physicians’ associations, nurses’ unions and public sector unions damned their respective provincial governments, three of them led by the NDP. On the other side were provincial finance departments.

Not surprisingly, given fiscal conflicts in the 1990s, provincial governments are avoiding further bilateral monopoly conflicts this decade. In the health sector, provinces have allowed physicians’ associations a too-expansive role. I have abandoned radical rhetoric and wound up using policy wonk prose on behalf of preserving single-payer health insurance. For anyone interested, I have recently written a C.D. Howe Institute critique of physicians’ policy dominance. Here are several pieces of circumstantial evidence that link the power of physicians’ associations to the present political crisis of lack of adequate primary care providers:

• Canadian physicians have reduced average weekly hours of work since 1990. Legitimately, young physicians want a better work/family ratio than the physicians they are replacing. Their associations have been able nonetheless to maintain stable inflation-adjusted remuneration.
• Normalized, Canadian general practitioners (GPs) in 2021 are at the 70th per cent rank among family physicians in OECD member countries; specialist physicians are at the 79th per cent rank.
• Canada’s ratio of practising physicians per thousand population is low. The OECD average in 2021 was 3.6 per thousand; Canada’s ratio, at 2.8 per thousand, was well below the average.
• In all countries, the ratio of physicians per thousand population is higher in urban than in rural regions. The Canadian urban/rural ratio is much higher than the OECD average, an indication of inadequate provision of rural health care.

The inadequate supply of primary care provision came to a boil during the COVID-19 pandemic. Every two years, the OECD surveys national respondents’ satisfaction with availability of quality health care. In 2019, 78 per cent of Canadians responded that they were satisfied with access to quality care, well above the OECD average. In the same survey conducted in 2021, the Canadian score was 56 per cent, a decline of 22 percentage points; the OECD average fell only four percentage points in the same period, from 71 to 67 per cent.

The major proposals of physicians’ associations are to train more GPs, build new medical colleges and, to some extent, certify more foreign-trained doctors. To date, the provinces have acquiesced. A partial solution to give governments more ability to challenge physicians’ associations is a massive expansion of nurse practitioners. All rigorous evaluations undertaken over the last quarter-century have concluded that nurse practitioners deliver ambulatory primary care as well as do family physicians. Provincial limited scope of practice is not the problem. Scope for nurse practitioners is nearly as broad as it is for general-practice physicians.