Brown on Jones and Hanley and Gavrus, 'Medicare's Histories: Origins, Omissions, and Opportunities in Canada'

Esyllt W. Jones, James Hanley, Delia Gavrus, eds. Medicare's Histories: Origins, Omissions, and Opportunities in Canada. Winnipeg: University of Manitoba Press, 2022. 392 pp. $31.95 (paper), ISBN 978-0-88755-280-9; $70.00 (cloth), ISBN 978-0-88755-286-1. 

Reviewed by Hayley Brown (London School of Hygiene and Tropical Medicine) Published on H-Sci-Med-Tech (March, 2023) Commissioned by Penelope K. Hardy (University of Wisconsin-La Crosse)

Printable Version: https://www.h-net.org/reviews/showpdf.php?id=58107

This edited collection emerged from a symposium organized to reflect on the fiftieth anniversary of Medicare in Canada in 2018, dating Medicare from 1968 when the Medical Care Act 1966 was implemented. It is made clear that this collection is not a celebration of Medicare but rather an opportunity to reflect on the degree to which Medicare has delivered health equity for Canadians and to consider Medicare through the lenses of gender, race, ability, and sexuality. Drawing on government archives and reports, personal archives, and oral histories, the authors show that Medicare has not provided universal health coverage to Canadians, as the care provided is neither complete in terms of services nor have the benefits of Medicare been enjoyed equitably by all Canadians. Some authors consider Canada as a whole, while others focus on a specific province or a smaller geographical area. The editors situate this collection within the limited existing historiography on Medicare as well as considering how some anniversaries in Canada have been publicly commemorated while others have been ignored or accorded little attention, with the anniversary of Medicare falling into the latter category.

While focusing on the specific factors that led to the development of Medicare in Canada, various authors also acknowledge the influence of ideas and practices from outside of Canada, which were transmitted in a variety of ways, including through the role individuals played in shaping policy, the arrival of immigrant health professionals, and an awareness on the part of Canadian policymakers of developments in health systems elsewhere, particularly the United States and Britain but also New Zealand.

The first section of the book, which examines the origins of Medicare, pays particular attention to transnational influences. For example, J. T. H. Connor examines the role of Dr. Frederick Dodge Mott, who became the deputy minister of health in Saskatchewan and played a key role in the development of the health system in that province, which then influenced the establishment of Medicare across Canada. Connor asks readers to reconsider how they conceive of "national histories" and suggests that the role of Americans, such as Mott, has been underappreciated because it challenges Canadian identity. The other chapters in the first section of this collection examine the role of nurses in advocating for public provision of healthcare (Kathryn McPherson) and the history of socialized medicine (Esyllt W. Jones and Aaron Goss), which, like Connor’s chapter, emphasizes the key role that Saskatchewan played in developing the ideas which led to Medicare.

The second section of this book considers those who were omitted from Medicare’s coverage. As these chapters show, First Nations citizens, those with disabilities, those with mental illness, women, the elderly, and those in rural areas have not always had their health needs adequately met. For those who study health systems in other countries, these particular inequities will not be surprising. Mary Jane Logan McCallum and Maureen Lux consider the attempted assimilation of First Nations peoples by the removal of the federal health provision provided by the Indian Health Service at the time Medicare was introduced. This was challenged by First Nations peoples who argued that "medicine chest" clauses included in some treaties obliged the federal government to continue to provide healthcare to First Nations peoples. Whitney Wood highlights the increasing hospitalization of births in the first half of twentieth century. She argues that the introduction of Medicare increased the movement away from midwife-led births to physician-led births in hospitals. This shift toward increased medicalization of childbirth, however, was not experienced by all Canadian women in the same way. Poor, rural, and Indigenous women experienced highly medicalized births, while affluent white women had more choice, with many opting to use a midwife or doula and choosing not to give birth in a hospital.

Erika Dyck explores the history of mental health and how it has followed a different trajectory than most other forms of healthcare under Medicare. While much medical care in Canada has focused on hospital-based services, the history of mental health care in Canada, as in many other countries, has moved away from hospitals to community-based care. This shift was occurring at the same time as the foundation of Medicare. Dyck questions the use of the term "deinstitutionalization" to describe this process and instead suggests, as others have, that "trans-institutionalization" is a more accurate term, as many of those who left mental hospitals did not remain in the community but rather ended up in other institutions ranging from nursing homes to prisons.

Geoffrey Hudson shows how those with disabilities were not adequately provided for by Medicare. Through an examination of the Ontario Advisory Council on Disability Issues, Hudson explores the development of the Assistive Device Program in Ontario and the challenges involved in obtaining limited support for the cost of necessary devices for disabled Ontarians. The final chapter in this section, by Megan J. Davies, considers the provision of home care for the elderly through a case study of a nonprofit home care support organization that operated on Hornby and Denman Islands in British Columbia during the 1980s. Her chapter highlights the gendered nature of voluntary work, with all the volunteers of the home care organization being women who worked long hours to provide care to the islands’ elderly residents.

The final section of the book looks at how professional healthcare organizations reacted to Medicare and then created opportunities for themselves in its aftermath. Catherine Carstairs considers the omission of both dental care and pharmaceuticals from Medicare at its inception, and the factors—primarily cost and the opposition of dentists—that have prevented these services from being incorporated into the Medicare system. While many Canadians have the cost of pharmaceuticals and dental care covered by employee benefits, a substantial number do not, adding further to health inequities. Julien Prud'homme and Antoine Rossignol examine the often-ignored role of allied health professionals using Quebec as a case study. They consider how groups such as occupational therapists and psychologists navigated the new structures of Medicare and how the creation of the public Medicare system then shaped the subsequent private provision of allied health services.

In her chapter on physicians’ complaints about Medicare, Jacalyn Duffin suggests that doctors have been primarily interested in protecting their incomes. At the same time, she argues that most doctors are content with the Medicare system, and that the views which are most publicized often reflect a vocal minority rather than most of the medical profession. Likewise, Sasha Mullally and David Wright also consider how doctors practiced under Medicare using oral history interviews with foreign-trained doctors who practiced in Thompson, Manitoba, in the 1960s and 1970s. Resource towns often struggled to recruit doctors and so were able to benefit from the arrival of foreign doctors, who were enticed by the higher salaries offered in Canada.

Like many health systems, the Canadian system is structured around curative approaches to health rather than preventive measures. In the final chapter of this collection Heather MacDougall considers the role of public health in Canada and in particular the Lalonde report of 1974, A New Perspective on the Health of Canadians. MacDougall highlights the irony that, on the one hand, preventive measures had the potential to save the government money, but conversely, academics, politicians, and civil servants often found it hard to get support for preventive programs due to a lack of funding.

This insightful collection will be of interest to historians of medicine and health systems as well as historians of twentieth-century Canadian history more generally. For those historians considering further research on the history of Canada’s health systems, this book will act as a key text, as it both provides an up-to-date summary of the historiography and highlights many areas which require further research. For historians of health systems, particularly in other high-income countries, many of the themes in this collection will resonate, even when explicit transnational connections or comparisons are not made. Combined, these contributions highlight the changes Medicare made to the provision of healthcare for Canadians as well as its omissions and should be key reading for all Canadian health policymakers.

Citation: Hayley Brown. Review of Jones, Esyllt W.; Hanley, James; Gavrus, Delia, eds., Medicare's Histories: Origins, Omissions, and Opportunities in Canada. H-Sci-Med-Tech, H-Net Reviews. March, 2023. URL: https://www.h-net.org/reviews/showrev.php?id=58107