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An estimated 16 percent of the American population under the age of 65 was without any form of public or private health insurance coverage last year alone. Translate those statistics into actual numbers and that amounts to approximately 45 million people nationwide. Contrast that with the entire population covered by the Canadian government that same year and one must ask how these differences in Canadian and American health care systems came to be, and how it is that two countries that share such similar views on medical training and the delivery of medical services came to implement such vastly different health care systems.
Political science professor Antonia Maioni, director of the McGill Institute for the Study of Canada (which celebrates its 10th anniversary this year), strives to answer these questions by comparing Canadian and American politics. She uses comparative historical analysis to understand how countries with similar political systems evolve to produce different social reform policies.
In her book Parting at the Crossroads, Maioni explores health insurance from 1940 to 1965 in Canada and the U.S. She traces their historical divergence of health care methodology to 1944 when the Social Democratic Party — a.k.a., the Co-operative Commonwealth Federation (CCF), which later merged with the Canadian labour movement to become the New Democratic Party (NDP) — took office in Saskatchewan, garnering enough public support in the province to push through a radical new form of health coverage: public medical insurance.
Although the success of Saskatchewan's public health care program demonstrated to the rest of Canada that such an insurance program could be implemented nationwide, the ruling Liberal federal government initially rejected universal health care. The eventual adoption of nationwide health care coverage in 1966 was the result of continued CCF pressure and rising public demand for universal health care coverage, coupled with increased Liberal concerns that rising CCF-NDP support would undermine their voter base.
During this same period, issues of health reform played a central role in American politics, as well. Democratic President Harry Truman endorsed a universal health care system in the mid-'40s and the American public supported this idea. However, divisions in the Democratic Party, coupled with strong opposition from the American Medical Association (AMA), led to limited legislative action on this issue. Comparisons of national health insurance to communist maneuverings soon soured public support for the idea, leading to the eventual adoption of a more limited health program in 1965. Today, a dual-tiered system exists in the U.S., with the Medicare program providing medical coverage to the elderly and the Medicaid program covering the poor, leaving the rest of the population to subscribe to voluntary health insurance.
Reflecting upon health care development in Canada and the U.S., Maioni cites differences in federalism and legislative systems as the predominant agents. Canada is a federation, with an institutional division of powers: the federal government oversees international and inter-provincial matters, while the provincial governments manage internal provincial issues, such as education, social services and health care. This is in stark contrast to the U.S., where the federal government exerts primary control over health care, both by administering federally funded health care programs like Medicare and Medicaid, and by regulating the health care services covered through private health insurance. These differences in American and Canadian federalism mean that "in Canada, provincial governments exert a lot more power over health care than American state governments," Maioni says. This allows provinces to make policy innovations that can affect health care administration in the rest of the nation, as evidence in the initiation of public health reforms in Saskatchewan in the mid-'40s.
Another factor underlying the divergence of the Canadian and American health care systems is the phenomenon of party discipline. In Canada, party members are expected to vote along party lines, allowing the political party in power to effectively control the House of Commons. In the U.S., while many issues are voted along party lines, party discipline is "not a functional requirement," making it harder for the ruling political party to exert full control over decisions made in Congress. Maioni argues that the force of party discipline was a major factor in establishing universal medical coverage in Canada. Once Prime Minister Lester Pearson supported nationwide health coverage in the mid-'60s, the bill was sure to pass, as cabinet ministers were expected to vote along the party line. In the U.S., members of Congress were not obliged to do so, resulting in enough opposition within the Democratic Party to limit the bill, despite strong support from the president.
While Maioni established that differences in federalism and political culture existed between these two countries at the time of their health reform divergence, she argues that "nothing predestined Canada to be different from the U.S. in the '30s to '60s". Nothing differed fundamentally between the values or morals of Canadians and Americans that would warrant such a divergence in their social reform policies, but diverge they did, and this divergence has had implications on who we are as Canadians. According to Maioni, "this program has deeply affected Canadian identity and Canadians view of themselves," and will probably continue to do so in the future.
Interested in learning more about Canada and its role in a global context? If so, register for the "Canada in the World" conference, sponsored by the McGill Institute for the Study of Canada. The conference will be held at the Omni Mont-Royal Hotel in Montreal from Feb. 16-18, 2005. For more info, see Around campus, or visit www.misc-iecm.mcgill.ca.
WARM-SPARK (Writing About Research at McGill-Students Promoting Awareness of Research Knowledge) is a program sponsored by the Faculty of Science, the Offices of the Vice-Principal (Research) and University Relations, NSERC, the Faculty of Engineering and the Faculty of Agriculture & Environmental Sciences. See www.spark.mcgill.ca for more information and articles.