11. The politics of reform: conflict and accommodation in Canadian health policy

Phases of Capitalism, Welfare States, Medical Dominance, and Health Care in Ontario

“…Regarding health care, the use of state power to ameliorate the Depression or to advance the war effort, in combination with the burgeoning role of labor and working-class movements generally, led to a hugely increased role for the state in Canada, including an increase in welfare state measures. Universal medical insurance, provided through government auspices, was one of the last welfare state measures enacted across Canada by 1971-an implementation highly influenced by the Saskatchewan example, by the rise of labor power, and by the electoral "threat" of socialism at the federal level at the end of the war (12,13). The CCF government of Saskatchewan had enacted insurance for physicians' services in 1962.…”

“…(But note that this was a national insurance plan only, in which doctors still practiced on a fee-for-service basis, not a national health service as in Great Britain.) But a more general explanation is needed, because medicare can be viewed, not in isolation, but as part of the enactment in Canada of the "Keynesian welfare state," in however an attenuated form (35,36), and as part of a long historical process of struggle for access to care by working-class parties and movements (13).…”

“…Paralleling the discussion of medical dominance we encounter somewhat similar arguments about a major characteristic of health care in Canada: payment for health services through a national health insurance scheme. That is, there are contrary tendencies toward a focus on endogenous factors versus an emphasis on health care matters within contextual changes as explanations for the implementation of health insurance or for some current perceived "problems" with the same system (11)(12)(13).…”

“…Class theorists, or structuralists generally, are more likely than are pluralists to point to what they view as basic structural factors within the capitalist mode of production as explaining how, why, and when health insurance was implemented in Canada. Swartz (13), for example, thinks health insurance only came about because of a prolonged working-class struggle for access to health care services. Today, with the welfare state in Canada under attack (17,18), the changing economic context of recession and international competition are often given as explanations for the contemporary "restructuring" or "downsizing" of health care or for threats to the principles of medicare from forces pushing for privatization.…”

“…But, the application of the "stages of capitalism" thesis of Ross and Trachte also raises empirical and theoretical questions, particularly regarding its application to the Canadian case, which I briefly mention in the final discussion. The notion of variants of capitalism also, incidentally, helps resolve an apparent conflict between two alternative class-based explanations for the implementation of health insurance in Canada: that by Swartz (13), who emphasizes class struggle, and that by Walters (21), who provides a more "functional for capital" argument.…”