If you're poor or working class in America, you know that you can't really afford to get sick.
If you're well-off and you've always been, you may not have considered that some people just can't afford to get sick. But the reality for many Americans, is that health care and dental care are expenses often avoided until a problem too serious to ignore comes along. If you're uninsured or under-insured, getting sick is just too expensive.
But for Canadians, it's different; all Canadians have all their health care expenses covered under a national health plan. Regardless of your needs, or how little income you have, you'll still get access to the best care possible. Have you ever wondered why, two such similar countries would have such radically different approaches to something as important as health care?
0% of Canadians need to choose between an iPhone and healthcare— Stats Canada (@stats_canada) March 7, 2017
Well, to answer that question, you have to go back - back to at least the Second World War, and the development of the modern welfare state. After the war, much of the public on both sides of the border wanted universal health care. But only Canadians got it.
Why are Americans still, the only population in a modern, advanced, democratic society deprived national health insurance? And how did Canadians get so lucky?
Researchers have generally pointed to a couple of explanations: for one, key differences in their political institutions; and two, the influence of organized groups, including the American Medical Association (AMA) in the U.S., and the Cooperative Commonwealth Federation (CCF) in Canada.
On this week's episode of Dossier, we're going to look at why we can't get sick. There are some clear reasons why Americans were deprived a national health plan after the Second World War, and why health care reform remains such a challenge. If we look to Canada, we can better understand the reasons for the situation, how change might be possible, as well as what it might look like.
I: THE CAN-AM (DIS)CONNECTION
The United States takes a free market approach to health care . Canada, on the other hand, has a national health plan, which provides coverage for all . Why do these two countries, who share so much, have such different approaches to health care?
Well, one reason is their very different political institutions. Canada uses a federalist parliamentary system ; America, on the other hand, uses a two-party presidential system . But both countries use single member plurality electoral systems, systems which tend to promote the domination of two main parties, and limit the potential for third parties to gain support . Institutional differences, however, result in third parties having a better shot at influencing political outcomes in Canada. This would be important for health care reform.
One of the most important rules in the Canadian parliamentary system is Party discipline. Party discipline allows a political party to require its members to support their policies. As a result, caucus members in the legislature are required to vote in accordance with the wishes of party leadership. One of the consequences of party discipline is that it results in Canadian political parties being less capable of managing pressures created by critical and opposing factions . Instead of factions being absorbed into existing parties, if they are powerful enough, they can form entirely new parties. Antonia Maioni explains:
In her 1997 article, "Parting at the Crossroads", Maioni explains that the Canadian system is also more welcoming to third parties because of the nature of federalism. Third parties can emerge in response to regional concerns; because provinces can exercise a lot of influence over policy making, the third parties that gain ground at the provincial level are often able to have an impact on policy.
In the United States, the situation is different. Compared to a traditional parliamentary system, the Presidential system in the U.S. is much better oriented to absorb the regional factions and interest groups that emerge on both sides of the political spectrum.
In their article, "It's the Institutions, Stupid!" authors Sven Steinmo and Jon Watts break down their interpretation of the institutional challenges to health care reform in the U.S.:
So because power is fragmented by design and the major political parties represent broad coalitions, capable of absorbing different factions, American political institutions make it difficult for individual groups to arise and establish third-parties . As a result, those fighting for health care reform did so under the banner of the Democratic party; but because the Democratic party was highly diverse, proponents of universal health care had to compromise on the types of reforms that were possible .
Institutional differences are important, but its also important to consider why Truman's initiative aimed at universal coverage failed in the United States after the war.
II: THE DOCTORS DID IT
Understanding health care reform isn't just about understanding institutional bias. To really explain modern health care in the West, you need to go back at least to the early decades of the 20th century. The Great Depression in the 1930's led to a broader movement aimed at progressive social change. But while the origins of the welfare state can be traced to 1930's initiatives to alleviate the effects of the Great Depression, it wasn't until the end of the Second World War that the issue of health care would come to the forefront of political discourse.
In the United States, the first serious attempt at health care reform came in 1945, when President Truman tried to pass his universal health insurance law. Speaking to Congress, Truman declared that the time had come for all Americans to get health care . He argued:
You can imagine sentiments like that resonating with large numbers of Americans. In fact, polls show that after the war, roughly 80 percent of the American public wanted the government to take a more active role in health care. The below graph shows that the lowest level of support for government health care after the war was 61.3 percent, polled in 1978 . This still represents a clear majority of the public. By 1992, public support for government health care had risen to 75 percent .
Despite support for Truman's initiative in 1945, it was eventually defeated, not only due to the institutional bias described, but thanks in part to organized efforts by groups like the American Medical Association . Private doctors all over the United States played an important role in driving opposition to Truman's health care reform initiative, and they've opposed other attempts at reform. In fact, some researchers argue that the primary reason Americans are still deprived universal coverage is the collective professional and economic power of American doctors . Author and researcher Jill Quadagno notes:
In direct response to Truman's proposed law, the AMA launched a "National Education Campaign". The goal of the campaign was to paint universal healthcare as socialized medicine, as well as promote the idea that Americans should buy private health insurance . At the time, it was the most expensive lobbying campaign in American history . They were not subtle in their attacks, calling Truman White House staff, "followers of the Moscow party line" . The AMA did a good job painting Truman's national health plan as a stone's throw from Communism, and capitalizing on public fear at the time proved effective.
The structural make up of the AMA as an organization helped make sure that opponents of health care were able to get their message out . The AMA is basically setup as a hierarchy: at the lowest level is the county medical society. All doctors need to belong to a country medical society. The next level up is the state medical society, which is made up of county medical societies. Above this is the AMA's House of Delegates, which draws delegates from the different state medical societies . This structure ensured that the AMA's members were organized and could mobilize members to carry out their public influence campaign. And mobilize they did: in 1949, the AMA and its members were responsible for distributing more than 50 million pieces of mail as part of their campaign; in the following year, they sent out another 43 million .
Still, authors like Antonia Maioni, as well as Steinmo and Watts argue that while the presence of powerful interest groups can help explain why individual reform initiatives failed, these explanations cannot account for the consistent failure of health care reform . In discounting explanations that focus entirely on interest groups, Steinmo and Watts argue:
So, clearly, American doctors fought hard to prevent Truman's national health plan from becoming a reality. But how do the differences between American and Canadian institutions explain why Americans have never got a national health plan?
To answer that question, we have to look at exactly how health care reform took shape in Canada following the war.
III: A COMMUNITY FREED
Prior to World War II, the Canadian government spent little time or effort on health care reform. Questions about jurisdiction and provincial sovereignty limited any kind of progress that could be made . In the wake of the war, however, just like in the U.S., there was growing support for health care reform. The idea that government had a critical role to play in safeguarding a basic level of social welfare led to notions that government-funded healthcare was the next logical step. Despite growing support for universal coverage, however, the Liberal government in power in Canada at the time was divided on how to address the issue. It wasn't really until they faced the prospect of a serious political threat from the presence of a third party, that they adopted universal health care as part of their official platform .
To understand how exactly their hand was forced, you have to go back a few years. The Cooperative Commonwealth Federation, or CCF, was originally established in 1932 as a consortium of labour leaders, farm and labour organizations, and elements of the country's socialist movement . Throughout the 1930's, the group fought to establish what they termed a "cooperative commonwealth" in Canada . A cooperative commonwealth was defined by the group as:
Lofty goals, perhaps, but it motivated the group to set about fighting for a robust social safety net. Officially, the party advocated a platform of social reform, which included universal health insurance for all Canadians . The postwar public was very responsive to the plan; the idea of national health insurance resonated with Canadians from across the political spectrum. And this broad, public support soon led the CCF to become a real political force; by 1944, they won the popular vote in British Columbia, had risen to the status of official opposition in Ontario, and won office in Saskatchewan, all thanks to public support for universal health care .
As you might imagine, the rise of the CCF in Canadian politics caused the Liberals to panic. By the end of 1942, public opinion polls showed the CCF on par with the Conservative and Liberal parties, and an overwhelming 75 percent of the Canadian public supported the creation of a national health plan . The Liberals recognized that they needed to do something, or risk losing a large segment of their voters to the CCF. This ultimately led to Mackenzie King, then Prime Minister, to setup a Special Committee on Social Security in 1943 .
Leonard Marsh, a social scientist from McGill University was tapped by the government to produce a report which would set forth the minimum standard for social security in Canada . While many of the recommendations put forth by Marsh would be implemented in later years, the government at the time continued to stall.
The Liberals were successful in the next election, but the CCF had demonstrated their ability to keep the health care issue front and centre. In Saskatchewan, 1947 saw the ruling CCF, led by Tommy Douglas, set about implementing North America's first ever universal public hospital insurance plan . At the time, Saskatchewan, a primarily rural and then low-income province, was experiencing a shortfall in terms of hospital beds, as well as doctors; the plan worked to create a regional system of hospitals in the province for serving patients with different needs . After other provinces felt political pressure to follow suit, the federal Liberals couldn't ignore the issue any longer .
In 1956, the federal government enacted the Hospital and Diagnostics Services Act, which set the stage for federal public hospital insurance . By 1957, there was federal public hospital insurance in Canada, and by 1962, Saskatchewan's CCF implemented provincial Medicare, a true universal health insurance program . This marked a tipping point in the struggle, and by the end of the 1960's, a federal Medicare program was in place.
But what about the impact of doctors in Canada?
Clearly, many physicians opposed universal health insurance, for many of the same reasons doctors to the south opposed health care reform. Doctors on both sides of the border saw government intrusion in health care as a threat to their professional sovereignty. The Royal College of Physicians released a statement in 1959 which stated that Canadian doctors officially opposed the introduction of a national health plan, and most doctors had literature in their offices that was designed to dissuade the public from supporting reforms . But physicians in Canada weren't organized to the same extent as those in the United States. Moreover, there was division in their ranks; while most doctors in Canada opposed the idea of government health insurance, others actively supported reform. The Saskatchewan College of Physicians mounted an opposition campaign, but the Canadian Medical Association released contradictory statements .
There was also an important generational divide. Younger doctors tended to be more idealistic, as well as more left-leaning, while specialists tended to be older, and more conservative . Younger doctors actively supported universal health insurance, along with rural doctors, while older and more conservative doctors tended to oppose reform . So doctors in Canada weren't a monolithic force fighting against health care reform. Some even worked to help realize universal coverage.
So, besides the fundamental institutional differences, the nature of interest-party opposition in Canada was different following World War II. Ultimately, progressives in both countries favoured national health insurance as part of a social safety net. But it was only the CCF that was able to create the political pressure needed to effect change, thanks to the different institutional environments in both countries. At the same time, a more fractured response from doctors in Canada meant that interest group opposition was of a different nature and character.
In the U.S., more fragmented power has made it harder for third parties to emerge and pressure one of the major parties to adopt national health insurance as a policy goal. As a result, reformers have had to operate with much more constraint, within the bounds of the Democratic party . As a result, there has been no concerted effort toward universal health care. At the same time, when Truman floated universal health care, opponents drew on key cultural norms to minimize support.
IV: A DIFFERENT CULTURE
To be sure, difference in culture is also an important factor to consider. The United States traditionally has a unique and anti-statist culture that's not really found in other modern liberal democracies. Anti-statist and anti-government values can make it hard to sell government health care. Canada has never really had the same anti-statist or anti-government sentiment, at least not on the same level.
Anti-communist sentiments definitely played a role in the defeat of Truman's proposed health plan. At the time, fear over communism in the U.S. was out of control, thanks in part to deliberate propaganda campaigns. While paranoia about communism has declined over time, there is still strong anti-Marxist and anti-communist sentiment ingrained in U.S. culture.
Later attempts at reform also may have failed because they were simply too ambitious. Author Jonathan Oberlander argues that the Clinton 1993 reform initiative failed because reformers tried to do too much at once . Besides wanting universal coverage, the reform sought to change the delivery system and introduce an employer mandate .
By necessity, Clinton's plan was a compromise, and the constraints placed on the plan preventing greater government involvement ultimately led to its demise .
A variety of different groups have opposed initiatives aimed at universal health care. Critics charge that it leads to low quality health care and patients denied the services they need. The failure of such reforms is seen as a good thing, as the free market can best allocate resources.
So let's briefly compare the two systems.
Some quality of care indicators show the U.S. system to provide exceptional quality service, particularly in areas of cancer survival and screening. For example, the U.S. has the highest five-year survival rates for both breast and colorectal cancers . At the same time, the U.S. has low levels of immunization and shows poor performance in areas such as asthma care . Patient satisfaction surveys show that Americans, by and large, are less satisfied with their healthcare options than patients in other countries .
On the other hand, Canadians appear reasonably appreciative of their healthcare system. The Canadian Broadcasting Corporation (CBC) conducted a poll in 2004 to determine "the greatest Canadian of all time". Results showed an overwhelming majority picked Tommy Douglas, considered the chief architect of universal health care .
Around the same time, a Gallup poll found that 16 percent of Canadians were "very satisfied" with their health care system, compared to just 6 percent of Americans . The same poll showed that 41 percent of Canadians were "somewhat satisfied" with their health care, compared to just 19 percent of Americans. Perhaps most telling, the poll found that only 17 percent of Canadians were "very dissatisfied" with their health care system, compared to a stark 44 percent of Americans .
Besides the difference in overall satisfaction, an astonishing difference relates to the difference in costs between both. Author Dan Zuberi explains:
So not only do all Canadians have access to health care, they spend substantially less for a system they are largely satisfied with, all without sacrificing quality of care.
That's not to say that Canada's health care system is perfect - there is much needs to be improved.
If you're a patient in Canada and need a medically-necessary surgery, the average wait-time is 20 weeks . This represents the longest wait-time since wait-times started being recorded in 1993; that year, the average wait-time to see a specialist was 9.3 weeks . The dramatic increase over time suggests that Canadians have their own concerns to address when it comes to health care.
According to the WHO, Canada's health care system ranks #30 in the world; the United States, ranks #37 . So there isn't a huge margin of difference between the two systems. But for the uninsured and under-insured in the U.S., costs can be prohibitive, and act as a barrier to treatment.
But a lack of health care can also lead to diminished social mobility.
According to a recent article published in Canada's Maclean's magazine, the American Dream is alive and well - just not in the United States. According to the author of the article, Scott Gilmore, however you define the American dream, it seems to be much more accessible in Canada. In a recent interview with CNN's Fareed Zakaria, Gilmore cited universal health care as one of the reasons why Canadians seem to be doing better than their neighbours to the south .
Gilmore makes a fundamental point. A basic measure of coverage for all citizens ensures that inevitable medical issues do not become crippling financial ones. Ultimately, the basic and fundamental protection afforded by universal access to health care makes the experience of being a working class person radically different in each country. And one of the consequences of this is that poor Canadians are better equipped to move up the social hierarchy. If you're poor in Canada, you have better chances of getting an education and moving into a higher income bracket than you do if you're a poor person in the United States. One of the factors that can account for this is Canada's system of universal coverage.
So given the very different institutional environments that exist in Canada and the U.S., how can progressive-minded Americans create the political pressure needed to finally implement a national health plan?
The lesson of the CCF shows that forcing the hand of one of the major parties to prevent an existential political threat can lead to real change, especially if there's broad support for the proposed initiative. It is unlikely that the Democratic party will adopt a position of universal health care, unless they are forced to do so.
The challenge for those in favour of national health care relates to the many barriers to organizing and then rising up as a legitimate third party with broad based support. A "National Health Party" however, could potentially help a number of different groups to coalesce under a single banner in order to force one of the parties to adopt universal health care as a matter of political pragmatism.
But that's obviously easier said than done.
As I've been putting this show together, angry town halls have been going on, all over the United States . One of the major issues is public concern over the loss of the ACA and affordable access to health insurance .
Republicans have recently announced their plan to replace the ACA, the American Health Care Act, or AHCA . The plan has been opposed by the AMA, the American Hospital Association, and other interest groups . But it's also faced opposition from some House and Senate Republicans; Rand Paul recently called it "Obamacare Lite" and assured it was a non-starter .
Whether or not the AHCA passes, health care reform will likely continue to be a hot topic in American politics. Americans from both sides of the spectrum will likely continue to debate what, exactly, the government's role in health care should be.
For Canadians, however, the matter appears settled.
 Benjamin Mason Meier and Dhrubajyoti Bhattacharya, "Health Care As A Human Right", in Debates On U.S. Health Care, (Thousand Oaks and London: Sage Publications, 2012), 32-47. 46. https://us.sagepub.com/en-us/nam/debates-on-us-health-care/book235908
 Dan Zuberi, Differences That Matter: Social Policy And The Working Poor In The United States And Canada, 1st ed. (Ithaca: ILR Press/Cornell University Press, 2006). 70. http://www.cornellpress.cornell.edu/book/?GCOI=80140100762850
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