There’s more fury than sense in the medical care war
Even though it’s not on the agenda officially, the most important issue of the federal election may be the one that’s being fought, as a side-issue, in Saskatchewan. Social and political conflicts that concern the life of every Canadian are involved.
At stake immediately is the province’s Medical Care Insurance Act. Under the Act the 900 doctors of Saskatchewan and their patients will cease to conduct their dealings through a combination of voluntary insurance and private payment. Instead, the doctors will bill the government for 85 percent of their bills to patients, under the schedule of fees set by the College of Physicians and Surgeons. If the patient is solvent the doctor will try to collect the rest from him.
There’s no overwhelming difference between this system and the one in effect already under the widely accepted private, doctor-administered, voluntary prepaid plans. The specialist will get a little less money under the government plan than as a private subscriber to one of the independent plans. But from there on the argument between Saskatchewan and its doctors is over the fine print and seldom in Canada’s history has fine print weighed so much.
Almost to a man the doctors, who constitute one of the most united and disciplined unions in the world, are opposed to the health plan: they say it’s a form of conscription that will lead to what they call bad medicine. The government has said the plan will go into effect on July 1, whether the doctors assent to it or not. The only other thing about this bitter quarrel that can be put in a sentence is that the doctors are threatening to go on strike—some by closing their offices, some by moving out of Saskatchewan for good, some by refusing to attend to any but “emergency” cases.
For now the two positions are fixed as rigidly as permafrost and there seems no chance of any thawing on either side. The people in the middle—the men, women and children of Saskatchewan who need or will need medical treatment and advice-—-haven’t as yet taken any clearly discernible position. In their 1960 provincial election, when the CCF’s Medicare program was the primary issue, the CCF went back into power fairly easily. But the political opposition and the medical opposition can and do point out that the government still got much less than half the popular vote. They point out too that the CCF-NDP was defeated in three recent by-elections.
These arc the rudiments of a situation that’s turned so ugly some are seriously predicting it may lead to bloodshed. The embellishments are more complicated. All of them add to the primary difficulties. To mention only a few:
1. Tommy Douglas, national leader of the New Democratic Party and former premier of Saskatchewan, is fighting for his political life. Douglas is the main architect of the health plan and if it dies, so almost surely will Douglas and the NDP.
2. The Canadian Medical Association and its constituent groups are giving strong support to the Saskatchewan College of Physicians and Surgeons in the fight against Medicare. They all see or profess to see this as a Bunker Hill or a Gettysburg or a Plains of Abraham.
3. One fourth of ail the doctors in Saskatchewan —and this includes some of the best and most influential of them—are from Great Britain. They’re refugees from one state health plan and feel a special anger and despair to find that, having given up their practices, their homes and their country, they are probably going to be drafted into another state plan.
4. If there’s any chance of conciliation it’s not likely to take place before June 18. When he went into federal politics Tommy Douglas handed the health scheme to his protégé and successor as provincial premier, Woodrow' Lloyd. In his loyalty to Douglas and Douglas’ ideas, Lloyd has been backed into a corner. Some of his friends and some of his enemies think he’d like to make a few' genuine concessions to the doctors but that he just can’t do so before election day. If he did he’d be selling his mentor and sponsor, Tommy Douglas, down the river. And Douglas has enough trouble already. So far there’s little evidence that the NDP has caught fire either nationally or in its spiritual home of Saskatchewan. Douglas himself is in the middle of a tough fight for a parliamentary seat against a popular Conservative, Ken More, who had a majority of 12,000 at the last federal election.
It is very hard, even for one accustomed to Saskatchewan, to understand the violence of this struggle. A year ago I went to the Congo, and spent a few months trying to get some glimmer of the feelings of 300 strange tribes with 300 strange dialects. 1 got back thinking I’d found out at least something. When I went this spring to Saskatchewan, where I grew up, I left suspecting that I knew more about the Congo than about my own home. In the Congo you’ve got 300 kinds of hostility all subject to change at any minute. In Saskatchewan there are only four or five kinds of hostility, all well planted and almost impossible to move.
In Saskatchewan, through an old, inviolate, prairiePresbyterian rule, you don’t talk sex or religion. The weather’s highly permissible but has its limits as a conversation piece, and that leaves politics. Everybody talks politics, argues politics, thinks politics, acts politics with a great and gusty passion. In our Saskatchewan town I never saw my father go into the barber .shop or the post office without expecting to see him come out either on a litter or wearing the Marquis of Queensbury belt. There is far more oldfashioned eye-to-eye table-pounding in Saskatchewan than anywhere I know.
It shouldn’t be too great a surprise then to hear sounds like these:
From Clayton Crosby, one of the most brilliant surgeons in the province and easily one of the most angry, these words about the government and its stand: “Opiates and platitudes of security . . . demagogues . . . socialistic jargon . . . rabble-rousing . . . vote-catching . . . gradual, stealthy intrusion, step by step, by government into our daily lives.”
From another respected doctor: “The destinies of our patients, the privacy, the freedom and calibre of their medical care are being threatened by the cunningly contrived and viciously propagandized, politically motivated state machine.”
From Dr. H. D. Dalgleish, president of the Saskatchewan College of Physicians and Surgeons: “The most vicious type of legislation since the time of King Charles I.”
Another doctor’s description of the government: “Despotic hoodlums.”
The doctors have served notice
From Premier Lloyd: “The issue is whether the people of Saskatchewan shall be governed by a democratically elected legislature or by a small, highly organized group. The people of Saskatchewan have been served notice by this organization. The notice is that until we repeal the Medical Care Insurance Act or unless the group is permitted to ignore this act by a duly constituted government, the people of the province will be punished by curtailment of medical services.”
The dividing line between reason and hysteria has become so thin it’s nearly impossible to guess which is which. One of the first doctors I talked to in Regina
was on the verge of tears within ten minutes. Then he tried to calm himself. “I’m sorry,” he said. “I’ve just insulted you, insulted your magazine, insulted my premier, insulted a lot of my fellow citizens, and I apologize to you each and severally. But I wish you could understand why. I’ve spent all my life getting to be a good doctor and being one—and right now I'm not a good doctor. For a year and a half my mind’s been half filled with this awful fight. An hour from now I have to see a patient. I’ll treat her as well as I can but I should be thinking of her, and her only, right this minute and I should be thinking of her. and her only, every minute I’m with her. Instead ... oh damn it all, why can’t we talk about something else?”
All the questions are loaded
Another eminent surgeon brought home the doctors’ point of view just as startlingly. “You’re a writer,” he said. “Suddenly, without your consent, without even giving you a proper hearing, the government decides you’re working for the government. Now and forever, under conditions set forth by the government. Never mind what the conditions are today—maybe they’re just as good as the ones you have but once you accept the principle your control of them is gone. What would you do?”
The questions are all almost impossibly loaded and so are the answers. The simplest fact, deep as it’s hidden in the underbrush of invective, is that the battle’s not really over prepaid group health but over its administration and supervision. Practically every doctor in Saskatchewan is already enrolled in at least one voluntary health scheme run by doctors. Most citizens are enrolled too, including Premier Lloyd himself and all his cabinet ministers and all the civil service. The toughest point of contention is that under the new blueprints the billing and bookkeeping would be changed. The College of Physicians and Surgeons insists on the right to bill the patient and let the patient then collect from the government. The government wants to be billed directly. Another point in dispute is that the doctors want the government to support existing private plans by paying the fees of indigents.
There’s an incredible amount of pussyfooting on this question of payment. The doctors insist that money is absolutely the last thing they think of and when they do think of it for publication they say their main concern is to save money for the taxpayers. But as the Winnipeg Tribune pointed out not long ago, this is not a very convincing argument or perhaps even a necessary one.
“The doctors . . . have spent a great deal of time talking about doctor-patient relationships, ethics and professionalism. Arguments of this kind may have considerable validity, but the public finds them confusing—particularly when Premier Lloyd pledges that there is no intention of altering in any way doctor-patient relationships, freedom of choice on the part of doctors or patients, or professional standards. Moreover the public finds it difficult to understand why it is state control and socialism when doctors are paid by the treasury for treating persons who are not indigents, but free enterprise when medical men are paid by the public treasury for treating the poor.
“In a way,” the Tribune went on, “this is all beside the.main point that the Saskatchewan health plan would give the government control over the doctors’ incomes. In a free society what right has the state to govern the income of one group? If doctors’ incomes are to be under state control, why not those of lawyers, engineers, farmers, merchants, bowling alley operators? . . . The doctors have been entirely too chary about establishing this point at issue—this is an issue any wage earner can comprehend.”
The lack of candor and straightforward talk is, indeed, one of the chief obstacles to a settlement. The doctors have set up an elaborate public relations organization and the College has decreed that no doctor should speak except through the College and with its approval. This has created the added paradox —one among many there already—that while furiously rejecting dictatorship from without, the doctors accept dictatorship from within. They'll only talk when authorized. The most effective single job of putting their case to the public was done in a television program from Regina in which several first-rate doctors expressed their point of view in a first-rate way. The last words were . . . “This program was brought to you with the approval of the College of Physicians and Surgeons.” No participant would even have dreamed of appearing without approval. When 1 mentioned to the head of the doctors’ PR committee in Regina that I was thinking of going to Saskatoon to see some other doctors he said in the most friendly but pointed way: “You could waste a lot of time unless 1 went with you or phoned ahead.”
Parts of the patchy and far from finished story might have been written by George Orwell. The doctors are spying on the government and the government is spying on the doctors. After their negotiations had dissolved in nothingness, the premier asked the College if he could address its emergency meeting last
spring and explain his willingness to carry on the negotiations. The 600 members present gave him a hostile reception. At one stage they jeered and hooted him. But Lloyd went on because he'd known what was coming anyway. Two hours before the meeting began a friend called him—having read the premier's written speech and somehow learned that some of the premier’s enemies had read it too—and told him exactly where in his speech he'd get silence, where faint applause, where cries of derision.
These local aggravations have been further aggravated by the hearings of a national Royal Commission on health plans generally. There are perhaps just as deep and lasting implications in the United States, where the American Medical Association is fighting the same fight. There have been many rumors that AMA has been pouring money secretly into Saskatchewan in the hope of finding there and winning a test case. No one’s produced a shred of evidence to support the rumor.
“It's pretty tough.” Walter Erb. the former minister of health, said recently. “If you’re not being smeared from one direction you’re being smeared from the other.” Erb created a sensation a few weeks ago by resigning from the cabinet in protest against the way his heaíth plan had been hurried through. “I get accused of all sorts of motives,” he said as we ate some of his wife’s excellent cooking. “In fact there
are only two. First. Mr. Douglas said any health plan had to be acceptable to the doctors as well as to the public. 1 endorsed that and guaranteed it. Then, when the doctors wouldn't agree, Mr. Lloyd said the plan was going ahead anyway. There was another point too. 1 used to be an opera singer in Chicago and then l used to be a schoolteacher, but I’m really a farmer. From the start 1 was worried about the labor unions moving in on the CCF and I'm still worried. The unions were running Mr. Douglas and Mr. Douglas was running Mr. Lloyd and Mr. Lloyd was running me and 1 was helping to run Saskatchewan and I decided to get back to running myself.”
More defections on the way?
Erb, like another celebrated CCF apostate, Hazen Argue, may conceivably go over to the Liberals in time, but says he has no present intention of doing so. He says he still likes almost everything about the health plan except the way it’s been handled.
A third CCF renegade. Ross Thatcher, leader of the provincial Liberals and of the provincial opposition. is said to have remarked in private that at least a dozen other prominent CCFers would gladly defect to the Liberals. “I hope they stay where they are.” Thatcher is reported to have said. “We’ve got them licked anyway but if too many of them join us we may end up tarred with their brush.”
The ebullient Thatcher has done an impressive job of rebuilding the Saskatchewan Liberals after the collapse of the old machine of Jimmy Gardiner. He knows it and doesn't hesitate to boast about it. His records show 15,000 donations from individuals. “Right now.” he says, “we’re getting two or three thousand dollars a month more than we're spending and the big thing is that it’s coming in ones, twos and fives. The CCF is a spent force and that goes for the NDP. Tommy (Douglas) may get elected in Regina on something like 32 or 34 percent of the vote because it’s a four-way fight. But I can’t see them doing much else.”
On the health scheme itself. Thatcher is. as usual, outspoken. “We're absolutely opposed to state med -cine as a medium to look after a sliver, a boil or a hangover. We’d bring in a prepaid plan of medical insurance with some deductible feature—maybe a hundred dollars, maybe seventy dollars. The economists we’ve consulted tell us the first three quarters of the costs of state medicine are in the first few dollars. The plan we’d favor would stop its frivolous use and still stop the risk of catastrophic costs.”
Premier Lloyd admits frankly: "They’ve touched a few soft spots in our position.” and he's repeatedly said he'd like to explore the possibility of some further compromise. Until after the election there seems no real hope of this. Between the election and July 1, the date when the Act is due to go into elfect. there may be a great need of it. One of the events that normally sober people are predicting is that some old lady will die during the full or partial doctors’ strike and be thought to have died because of a lack of proper care. From then on matters could get worse, and they’re bad enough right now.
It was a pure coincidence that in the middle of the debate the Regina Leader-Post printed a photograph of a curious, sad-faced quadruped, discovered in a routine shipment to the Regina stockyards. The caption under the photograph read: IMPOSSIBLE ANIMAL. The caption went on to explain that although biologists had hitherto considered such a hybrid utterly out of the question, they thought this one might be a cross between a deer and a domestic cow. “Agricultural experts arc continuing their investigation,” the item concluded.
Whether a productive marriage between the Saskatchewan College of Physicians and Surgeons and the government is possible will be decided within the next few months. Pessimists on both sides say that right now. the only conceivable progeny would be another impossible animal. Meanwhile the debate continues. Which — the government or the College — is the adventurous soaring deer? Which — the College or the government — is the fat grazing cow? ^