Patients on gurneys line the hallway due to an over-capacity at the Humber River Hospital emergency department in Toronto on Jan. 25, 2022 during the COVID-19 pandemic. PHOTO BY NATHAN DENETTE / THE CANADIAN PRESS
Much of medicare’s dysfunction comes from compromises made to win votes in moments of political weakness
A few weeks ago, I was chatting with a popular talk-radio host about the 177-to-2 vote on the Medicare Care Act, 1966. He said, “Who were the two who voted against it?”
This sparked a short trip into parliamentary records to uncover events around the “unanimous” and “near-unanimous” votes that gave us medicare.
As always, the details reveal a different story. The article is on the National Post site.
Enjoy!
Politics trumps patient care when governments are failing
Policies that are not necessarily the best for the long term, including those affecting health care, are often implemented by weak governments only concerned about votes, writes Shawn Whatley.(from the photo caption)
Medicare emerged during failing and minority governments, much like the time we find ourselves in now. Three pillars of medicare legislation passed with near unanimous support during periods when the opposition could not risk debate.
The first pillar of medicare, the Hospital Insurance and Diagnostic Services Act (HIDSA), passed unanimously in 1957. The majority Liberals had been in power since 1935. HIDSA introduced dollar-for-dollar cost sharing between the federal government and the provinces. The Diefenbaker Progressive Conservatives offered unanimous support, and months later won an upset minority. In 1958, Diefenbaker won again — the largest majority in Canadian history, up to that point.
By 1963, voter sentiment had reversed, and voters had tired of Diefenbaker. The minority Liberals tabled the Medical Care Act. The MCA promised to expand Parliament’s 50:50 funding to include doctors’ services. Provinces needed to nationalize medical insurance and create publicly-funded, single-payer provincial insurance plans to qualify for federal funds. Parliament passed the Medical Care Act in 1966 by a vote of 177 to two. The two “nays” came from Social Credit MPs: Robert N. Thompson, from Alberta, and Howard Earl Johnston, British Columbia. The Liberals, Progressive Conservatives and NDP offered unanimous support. Pierre Elliott Trudeau won a majority in June 1968, and the MCA took effect weeks later on July 1.
The last pillar of medicare, the Canada Health Act, came when Pierre Trudeau faced historically low voter support, much like his son does now. The Canada Health Act, 1984, leveraged public fury over hospital user fees and physician “extra billing,” even though extra billing accounted for only 1.3 per cent of total physician billings under medicare. An amendment to the MCA could have fixed the issue, but new legislation presented a perfect wedge.
Mulroney saw through the trick. He ignored the bait and whipped the vote. The CHA passed unanimously, and the PCs went on to redefine “landslide election” victory that fall. It remains the largest majority government in Canadian history.
Much of medicare’s permanent dysfunction comes from compromises politicians made to win votes in moments of political weakness. Medicare escaped meaningful debate.
Remember, the Diefenbaker PCs supported social programs and even appointed the first Hall Commission on universal medical insurance, 1961-1964. But they abandoned program design to left-leaning visions in a failed quest to regain voter support. Again, political survival became the only concern and compromise knew no limit.
As Carson Jerema, National Post’s Comment Editor, recently put it, “All governments debase themselves for partisan advantage, but it isn’t clear that (the current Liberal) government is capable of doing anything else. Every policy, every action, every pronouncement is designed, not to achieve a particular goal, but to wedge the Conservatives, or appease the NDP.”
Wedge-and-bait politics creates serious risk for Canadians. Radical ideas escape debate and run unopposed. Weak governments do not worry about long-term impact. They only worry about how to make the opposition look bad. The opposition also ignores long-term impact, while fretting about whether critique could weaken voter support. For example, Conservative Leader Pierre Poilievre held back criticism of the capital gains tax until days before the vote in Parliament, no doubt to lessen time for the left to foment negative press.
All politicians face a fundamental dilemma: stick to principles or pursue popular support? Stand up for what you believe, and never get elected, or compromise to get into power?
Minority governments generally require compromise. But compromise leaves voters shackled with ideas we can never adjust or abandon, especially when passed with “unanimous” or “near-unanimous” support.
Polling shows Conservatives have strong support in Canada right now. Let’s hope Poilievre feels strong enough to oppose the inevitable wedge-and-bait politics we can expect this fall.
Over the last year, I served as President of Civitas Canada. Civitas started in 1996 and revolves around an annual conference.
Conference magic cannot be planned. It comes as a surprise. Audience and speakers connect, questions delight, and responses enlighten. Each party comes away encouraged and grateful, not just informed.
The speakers, sponsors, audience, and organizers created something extraordinary at the Vancouver Civitas conference. Better than we could have imagined. I’m so grateful to everyone involved.
Here are my opening remarks (with a few edits). I review ground rules and then try to encourage conversation outside the ordinary.
If want to learn more about Civitas, feel free to write to see if it might be a fit for you.
Welcome to the 28th Annual Civitas Conference. My name is Shawn Whatley, and I’m your president this year.
It is really great to see you all. None of this would be possible without our sponsors. Please join me in a round of applause for our sponsors.
You know, I was very skeptical about a conference in Vancouver…
When I became president, as per tradition, I announced, at a board meeting, that the 2024 conference would be in Vancouver.
The board just stared in silence.
Finally, one person said, “That … is a REALLY bad idea. We will never fill a room … let alone pay for the conference.”
He made the whole planning committee panic.
Thankfully, panic sparked furious activity. And here we are at a SOLD OUT conference!
Thank you so much for coming and being part of this event.
Terms of Engagement
I need to say three things about Civitas — lay the ground rules, as it were.
Our purpose statement says that Civitas exists:
“to promote and deepen understanding through the exchange of a wide range of political, economic, social, religious, cultural, and philosophical ideas concerning the principles and traditions of a free and ordered society.”
Very briefly … let’s unpack three points.
ONE: We are here to learn.
Our purpose statement says, promote and deepen understanding. This means we need to be open, curious, and receptive.
TWO: We are here to be challenged through the exchange of a wide range of ideas.
The broader conservative movement includes a wide mix of ideas. You may be sitting between an anarcho-capitalist, on one side, and a monarchist on the other! This is a fantastic opportunity – don’t let it go to waste.
THREE: We follow the Chatham House Rule.
The identities of the participants are private and all discussions are not to be recorded, reported, attributed, or disseminated in any fashion.
All members and guests are asked to respect this rule.
Without this rule, we could only have conversations that were safe … and superficial. We want to go deep … so we need privacy.
Alright, that sets out our terms of engagement. What do we want to accomplish over the next 1 ½ days?
Goals
I’m hoping we can do two things [this weekend], and avoid one pitfall.
I am a physician and much of my time, over the last 25 years, has been spent in leadership and medical politics.
My work has focussed on improving service for patients, while improving the work experience for doctors and nurses.
Improvement means change. For example, you cannot improve wait times, without changing how people work.
But how can you change behaviour? Many of us can’t make our own children behave. How can we make 200 of our colleagues act differently?
Ideas and policy and strategy will not work to change behaviour.
They are not enough.
As Peter Drucker said,
“Culture eats strategy for breakfast.”
We need something more.
In my experience, we need to do two things.
First, we must find a wedge.
Consider emergency medicine. A robust clinical culture shapes care in the emergency department.
Culture is just a set of norms and behaviours. Culture rests on a conceptual apparatus – a whole clinical worldview.
We need to address that worldview and find cracks in it.
The best way to do that is by pointing out bits of reality that do not fit. Think Sesame Street: “One of these things is not like the others…”
For example, we would often say to the doctors and nurses in our emergency department, “Isn’t it interesting how we break all sorts of rules to get timely care for our friends and family? They never wait in the waiting room.”
Then let that comment float; let them ponder it. It takes many similar comments to crack the status quo.
Second, we need to tap people’s internal motivation.
Not just emotion. We need to connect with their internal drive.
For example, we would ask nurses about their experience at triage. They are the wardens of the waiting room. We would ask them to talk about their experience managing a packed waiting room.
It usually took several questions, but they would soon start to tell about people vomiting in buckets for hours or women miscarrying in the waiting room bathroom.
We would just listen.
Eventually, we would ask, “Is this why you went into nursing?”
They would say, “No!”
That is the moment everything changes. Now they want change and are willing to try something new – something better.
In all of this – identifying a wedge, tapping internal motivation – we are attempting to bridge the philosophical gap between theory and practice.
Ideas need to infect people. They need to come alive to shape how people think and see the world.
Our job this weekend is to reflect on each panel and ask: Where is the wedge? And, how can we inspire?
Can we crack open the conceptual apparatus that exists around each issue? What bit of reality does not fit? Think: Sesame Street or cognitive dissonance.
And second, where is the ‘nursing’ question? [“Is this why you went into nursing?”] We must touch the fundamental aspects of human experience.
Example 1 — Finding the wedge
Here’s a quick example of finding a wedge. It’s meant to be fun. Don’t be stressed, if you don’t agree with it.
We opened the conference with applause for our sponsors.
What is applause?
Applause is a public endorsement.
Notice: applause is not transactional.
With applause, we declare that this [sponsorship] is good; not just that it makes us feel good.
It is agathos.
It is part of the True, the Good, and the Beautiful.
But hang on. How can we declare something to be intrinsically Good, in a secular, liberal democracy?
Philosophers across the political spectrum agree that modern liberalism avoids public endorsement of any preconceived Good.
In case you don’t believe me, consider three philosophers.
Starting on the radical left, Slovoj Žižek wrote that,
“[Liberalism] considers any attempt directly to impose a positive Good as the ultimate source of all evil.”
Irving Kristol, godfather of neoconservatism, wrote that
“a keystone of modern liberal secular society” is the impossibility of knowing “what constitutes happiness [the Good] for other people.”
Francis Fukuyama, great defender of liberalism, wrote that now,
“Personal autonomy [includes] the ability to choose the [moral] framework itself,” not just the particulars.
In other words, liberalism seems to say we must not declare anything Good – or at least we must not expect to be taken seriously, if we do.
And yet here we are applauding something we see to be Good.
Perhaps, we misunderstood the nature of applause?
Or we misunderstand the nature of modern liberalism?
Or maybe we misjudged modern society?
Or maybe, society isn’t so liberalised after-all?
Now, this is just an example – something fun. I’m sure you can come up with better ones.
Example 2 — Finding inspiration
Our second task this weekend is much harder. How can we inspire and tap into Canadians’ internal motivation?
Wordsworth tackled this with poetry, during the industrial revolution. He wrote,
“The world is too much with us; late and soon
Getting and spending, we lay waste our powers:
Little we see in Nature that is ours;
We have given our hearts away, a sordid boon!”
And later in the poem, he writes, “We are out of tune.”
Wordsworth is saying there is more to life than work and money and spending. We waste our talents and become out of touch – out of tune – with those around us: friends, colleagues, family, even with our own bodies.
We need to draw attention to fundamental aspects of the human experience, if we hope to inspire true change.
Aristotle did this by calling us to human excellence: wisdom, courage, self-control, justice. Christian thinkers added faith, hope, charity. We could add generosity, magnanimity, or the Roman liberalitas.
People hunger for these things. They need to hear it in our language.
One pitfall to avoid
Finally, we need to avoid a common pitfall for the right. Roger Scruton called it Hegel’s “labour of the negative”.
The labour of the negative refers to Hegel’s dialectical thought. It is the act of negation repeated relentlessly. Or as Karl Marx put it, “the ruthless critique of everything existing.”
Augusto del Noce, Italian philosopher and specialist on Marx, explains that Marx taught we cannot be free, if we accept anything created by anyone other than ourselves. If we accept anything as a given – even our own biology – we can never be truly free.
We on the right must be careful of adopting a ruthless critique of everything existing. When the left appears to be in control of everything – media, academia, culture – we risk becoming circumspect. As one speaker said at a conference in the US, “They are coming for everything.”
Now this may be true. In fact, it is what we might expect from the Hegelian left. And there is a time to diagnose and identify the negative. But then we need to turn our minds to treatment.
Scruton said it is hard to shift from a labour of the negative to positive, constructive work.
Conclusion
So in summary …
Our job is to find the cracks in the conceptual apparatus that sustains current opinion in each topic area …
… and find ways to inspire change by tapping into people’s internal motivation: “Is this why you went into nursing?”
We need to do these two things while avoiding Hegel’s labour of the negative.
I pitched a piece arguing that Conservatives don’t actually believe in freedom, free enterprise, or limited government, when it comes to medicare. I was pleased that the editors tuned up the article and published it, March 20th (Here’s the piece on The Hub). Enjoy!
Canadian conservatives—particularly these days under Pierre Poilievre’s federal leadership—say they embrace freedom, free enterprise, and limited government. But too often conservatives at the federal and provincial levels have abandoned these intellectual commitments in office. Their past and ongoing support for central planning in health care is a good example.
Canada’s health-care system is marked by a government monopoly on certain types of insurance and similar top-down restrictions on the delivery of health care itself. Conservative governments across the provinces have been unwilling to liberate Canadians from this dirigiste model.
The paradoxical relationship between Canadian conservatives’ notional commitment to freedom and their practical affirmation of central planning in health care is best demonstrated by Ontario Premier Mike Harris’s health-care restructuring in the late 1990s.
Premier Mike Harris: the best central planner in Canadian history?
Will Falk, a former management consultant, recently wrote a detailed review, analysis, and scorecard of the Harris government’s health-care agenda in a new anthology about the premier’s record entitled, The Harris Legacy. Falk’s focus is the government’s Health Services Restructuring Commission (HSRC) and its effects on the province’s overall system and patient outcomes. He writes:
The Harris health program represents exceptionally well-done central planning. This is striking and ironic because a true ‘revolutionary’ of the ‘common sense’ school should not believe in central planning at all…Mike Harris ended up being among the best health care central planners in Canada’s history.
As Falk observes, though the Harris Conservatives were generally quite committed free marketeers (he notes for instance that many young staffers were acolytes of the Nobel Prize-winning and libertarian economist Friedrich Hayek), the government’s health-care policy preached freedom but actually practiced coercion. He explains:
As neoconservative revolutionaries, the CSR’ers ‘should’ have chosen an allocative method that would allow for freedom of choice…Instead, in 1995, the Harris government imposed a highly coercive, expert regime. The HRSC central planners closed over forty beloved institutions. More than 20,000 workers had their jobs disrupted.
Falk leaves no doubt in his conclusion: “It is ironic that Mike Harris is accused of being a free market advocate in health care while overseeing one of the best central planning processes in Canadian history.”
Two sides of Keynes
Reading Falk’s description of the Harris government’s health-care reforms got me thinking about the two forms of Keynesian thinking that came to influence post-World War II public policy and remain with us today.
The first form is John Maynard Keynes’ economic thinking which included the rather banal idea that governments can help to smooth the ups and downs of the business cycle in a market economy. One can argue for instance that the Harper government’s fiscal stimulus in response to the 2008 global financial crisis broadly followed Keynes’s counter-cyclical prescription.
The second is from Keynes, the philosopher, whose technocratic ideas became something of a “generalized theory”—particularly after his death. What sometimes describes as “bastardized Keynesianism” became a justification for all types of state intervention in the economy and society. His views about business cycles, which were contingent and narrow, were moulded and shaped into a scientific socialism that was subjected to virtually no constraints.
We came to abandon parts of economic Keynesianism in the post-stagflation era in the 1970s. But the “bastardized” parts remain prevalent in public policy thinking and practice, including in parts of Canadian health care.
Poilievre, freedom, and conservatives opting out
Free enterprise offers the best way out of a socialist slough. It worked well in the era of Reagan and Thatcher. It should work for Poilievre if he’s elected prime minister.
But will conservatives affirm freedom in health care and abandon the bastardized Keynesianism that still prevails today?
One possible answer can be found in a recent interview with Hub contributor Ginny Roth in which she said:
When Conservatives are losing, sometimes it’s tempting to opt out of the policy conversations that we think we are losing on. Provincially, this always happens: ‘Don’t talk about health care and education. Conservatives lose when we talk about health care and education.’
This instinct to “opt out” may be viewed by political strategists and the politicians they advise as good short-term politics. But the long-term result is to effectively abdicate public policy to their political opponents. What’s the point of winning if you’re simply going to implement the other side’s priorities?
If conservatives are genuinely committed to freedom and free enterprise, then they should propose legislative and policy changes to the health-care system that foster more freedom (including competition and choice) and reject the central-planning instinct inherent in Keynesianism.
Put differently: conservatives have only two realistic options. They can opt out of the health-care discussion and cede the terrain to progressives, or they can apply their principles to a much-needed reform agenda. They must, in the interests of Canadians and their well-being, choose the latter.
One key area for policy reform is to insist on greater provincial autonomy and in turn interprovincial competition and experimentation. This requires clarity on federal-provincial health-care mandates and a circumscribed federal spending power—including even something as bold as a possible constitutional amendment to limit it on a permanent basis.
Regardless of what approach they take, the federal Conservatives face a wide-open field in calling for market-friendly universal health care. No other party will steal their platform. They should resist therefore the temptation to match the Liberals on boutique health policies and instead fight for policy freedom in Canada’s most heavily regulated industry. At its core, this means granting clinicians and patients freedom to build their own solutions safe from regulators and planners.
Poilievre has offered three cheers for freedom. He doesn’t sound like a Keynesian planner. Let’s hope he expresses the same enthusiasm for freedom in health policy.
