The Rise of the Modern Welfare State BritainCanada.
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The Rise of the Modern The Rise of the Modern Welfare StateWelfare State
BritainBritain
CanadaCanada
BritainBritain
National Health Service Act (1946)National Health Service Act (1946) Universal coverage for:Universal coverage for:
– Physician visitsPhysician visits– Hospital staysHospital stays– Public healthPublic health
100 years earlier, no provision for 100 years earlier, no provision for government sponsored health caregovernment sponsored health care
This lecture will examine the forces This lecture will examine the forces that created this dramatic change in that created this dramatic change in the financing of health carethe financing of health care
3 landmark pieces of legislation3 landmark pieces of legislation– 1834 New Poor Law1834 New Poor Law– 1911 National Insurance Act1911 National Insurance Act– 1946 National Health Insurance Act1946 National Health Insurance Act
Have already consideredHave already considered– 1601 Poor Law1601 Poor Law– 1834 Poor Law1834 Poor Law
Have discussed their connections to:Have discussed their connections to:– Medical careMedical care– Rise of health care institutionsRise of health care institutions
Medical care for the sick poor Medical care for the sick poor created another dilemmacreated another dilemma
Fears that the poor laws might be Fears that the poor laws might be creating a disincentive to workcreating a disincentive to work
““The superiority of the condition of the The superiority of the condition of the paupers over that of the independent paupers over that of the independent labourers as regards medical aid labourers as regards medical aid will . . . encourage a resort to the will . . . encourage a resort to the poor-rates for medical relief . . . and poor-rates for medical relief . . . and will thus tempt the industrious into will thus tempt the industrious into pauperism.”pauperism.”
Existing institutions could not keep up Existing institutions could not keep up to demand for hospital/medical careto demand for hospital/medical care– Voluntary hospitalsVoluntary hospitals– Workhouse infirmariesWorkhouse infirmaries
Many patients excluded from Many patients excluded from treatmenttreatment– ChildrenChildren– Terminally illTerminally ill– Chronically illChronically ill– Contagious diseasesContagious diseases
Many sick who had no access to careMany sick who had no access to care
Only resort was the poor lawsOnly resort was the poor laws– Significant stigmaSignificant stigma– Until 1885, anyone using poor law Until 1885, anyone using poor law
medical service lost the right to votemedical service lost the right to vote
First reforms came in 1860sFirst reforms came in 1860s LancetLancet expos exposé of conditions in é of conditions in
workhouse infirmariesworkhouse infirmaries Forced government inquiryForced government inquiry
New poor law (1867)New poor law (1867)– Sick poor should be housed separate Sick poor should be housed separate
from rest of workhouse populationfrom rest of workhouse population
In London, separate facilities builtIn London, separate facilities built Became England’s first state hospitalsBecame England’s first state hospitals
1905 Royal Commission on the Poor 1905 Royal Commission on the Poor LawsLaws
Two reasons for this developmentTwo reasons for this development– More women elected as GuardiansMore women elected as Guardians– More working class people could vote for More working class people could vote for
GuardiansGuardians
Report published 1909Report published 1909 Attributed half the destitution in the Attributed half the destitution in the
nation to sicknessnation to sickness
Majority report:Majority report:– Tinkering with current systemTinkering with current system– Replacement of workhouses with more Replacement of workhouses with more
specialized institutions catering to specialized institutions catering to specific populationsspecific populations
Minority reportMinority report– Dismantle systemDismantle system– Emphasize prevention of destitution Emphasize prevention of destitution
rather than relief of destitutionrather than relief of destitution
Liberal government of the time chose Liberal government of the time chose not to act on either reportnot to act on either report
Still strong indication that the moral Still strong indication that the moral assumptions underlying poor laws assumptions underlying poor laws were collapsingwere collapsing
Consensus that stigma attached to Consensus that stigma attached to medical relief deterred people from medical relief deterred people from seeking legitimate medical aidseeking legitimate medical aid
Reluctance to go of concerns about Reluctance to go of concerns about the character of the poorthe character of the poor
Still focussed on self-sufficiencyStill focussed on self-sufficiency
Poor should provide for themselvesPoor should provide for themselves
Public assistance should be last Public assistance should be last resortresort
Sickness insurance was available at the Sickness insurance was available at the timetime
Very selective as to who they would insureVery selective as to who they would insure
Many conditions excludedMany conditions excluded
Failure to pay premiums resulted in loss of Failure to pay premiums resulted in loss of all accumulated benefitsall accumulated benefits
National Insurance Act (1911)National Insurance Act (1911) Two parts:Two parts:
1. Medical insurance1. Medical insurance– Compulsory medical insurance with Compulsory medical insurance with
contributions from employer, employee contributions from employer, employee & state& state
– Replacement of lost earningsReplacement of lost earnings– Free medical care for insured workerFree medical care for insured worker
2. Employment insurance2. Employment insurance
Provided 15 million working people Provided 15 million working people with medical care & protection from with medical care & protection from earnings lost by sicknessearnings lost by sickness
Rejected idea that poverty was the Rejected idea that poverty was the individual’s faultindividual’s fault
Paid benefits even when worker Paid benefits even when worker might have been at faultmight have been at fault
Rejected the idea that public Rejected the idea that public assistance weakened self-reliance or assistance weakened self-reliance or independenceindependence
Major opposition came from Major opposition came from physiciansphysicians– Insisted that upper income limit be Insisted that upper income limit be
imposedimposed– Middle class continued to rely on private Middle class continued to rely on private
medical caremedical care– Argued with the Lloyd George Argued with the Lloyd George
government over compensation under government over compensation under the planthe plan
– Tried to orchestrate profession-wide Tried to orchestrate profession-wide refusal to accept NIA patientsrefusal to accept NIA patients
– GPs refused to complyGPs refused to comply
Profitable for private insurance Profitable for private insurance companiescompanies– Collected NIA contributionsCollected NIA contributions– Paid out benefits on state-mandated Paid out benefits on state-mandated
scalescale
Served as basis for more Served as basis for more comprehensive program that was comprehensive program that was established after WWIIestablished after WWII
Gaps in NIAGaps in NIA– Did not cover hospitalizationDid not cover hospitalization– Did not cover dependentsDid not cover dependents
1941 opinion poll:1941 opinion poll:– 85% favoured state organized medical 85% favoured state organized medical
serviceservice– 55% favoured nationalizing hospitals 55% favoured nationalizing hospitals
and medical careand medical care
Beveridge Report (1942)Beveridge Report (1942)
Actually concerned with post-war Actually concerned with post-war reconstructionreconstruction
Five great giants on the road to Five great giants on the road to reconstructionreconstruction– WantWant– IgnoranceIgnorance– IdlenessIdleness– DiseaseDisease– squaloursqualour
Included proposals for:Included proposals for:– Social insuranceSocial insurance– Comprehensive publicly funded medical Comprehensive publicly funded medical
insuranceinsurance
Paved way for establishment of Paved way for establishment of National Health Service (1946)National Health Service (1946)
Role of women in the development of Role of women in the development of the welfare statethe welfare state
11stst wave feminism wave feminism Diverse group of women Diverse group of women
– Similar concerns re: women & childrenSimilar concerns re: women & children– Different political agendasDifferent political agendas
Earlier historians referred to this Earlier historians referred to this phenomenon as maternal feminismphenomenon as maternal feminism
Contemporary historians have Contemporary historians have categorized them as:categorized them as:– Sentimental maternalistsSentimental maternalists– Progressive maternalistsProgressive maternalists– FeministsFeminists
What was their impact on the welfare What was their impact on the welfare state?state?
Lobbied for special protection of Lobbied for special protection of women and childrenwomen and children– Child welfare programsChild welfare programs– Mothers allowanceMothers allowance
Lobbied for programs to strengthen Lobbied for programs to strengthen familiesfamilies– TemperanceTemperance– PensionsPensions
Lobbied for programs to support the Lobbied for programs to support the male breadwinnermale breadwinner– Unemployment insuranceUnemployment insurance– Health insuranceHealth insurance
Lobbied for franchise for womenLobbied for franchise for women– This platform tended to set the feminists This platform tended to set the feminists
aside as a distinct groupaside as a distinct group
CanadaCanada
Developments similar to other Developments similar to other countriescountries
Exact details shaped by Canadian Exact details shaped by Canadian form of governmentform of government
Federal rather than unitary Federal rather than unitary
Health a provincial responsibilityHealth a provincial responsibility
In 19In 19thth century, provinces left welfare & century, provinces left welfare & health issues to municipalitieshealth issues to municipalities
Voluntary hospitalsVoluntary hospitals– Municipalities often provided some fundingMunicipalities often provided some funding
Charitable organizationsCharitable organizations
Public funding for care of destitutePublic funding for care of destitute
Aftermath of WWI forced some Aftermath of WWI forced some changes to the systemchanges to the system
Federal program for returned Federal program for returned veteransveterans– Social assistanceSocial assistance– Medical assistanceMedical assistance
Provincial initiatives to improve Provincial initiatives to improve citizens’ livescitizens’ lives– Highway constructionHighway construction– EducationEducation– Mother’s allowanceMother’s allowance– Old age pensionOld age pension
Most significant influence on Most significant influence on development of Canadian welfare development of Canadian welfare state was the Great Depressionstate was the Great Depression
Bankrupted municipalitiesBankrupted municipalities
Nearly bankrupted several provincesNearly bankrupted several provinces
Winnipeg doctor’s strikeWinnipeg doctor’s strike Physicians always did some charity Physicians always did some charity
workwork By 1933, believed they were By 1933, believed they were
undertaking unfair burdenundertaking unfair burden Wanted a municipal subsidy Wanted a municipal subsidy Refused to treat non-emergency cases Refused to treat non-emergency cases
who were on reliefwho were on relief Began July 1, 1933Began July 1, 1933
In early 1934, imposed very stringent In early 1934, imposed very stringent definition of emergencydefinition of emergency
City came to agreement with City came to agreement with Winnipeg Medical Society in Feb. Winnipeg Medical Society in Feb. 19341934
Underwrote medical care of the Underwrote medical care of the indigent in Winnipeg until 1960sindigent in Winnipeg until 1960s
Great Depression had similar impact Great Depression had similar impact on other parts of the countryon other parts of the country
Only Ontario provided provincial funds Only Ontario provided provincial funds to defray medical relief coststo defray medical relief costs
All other provinces left it to All other provinces left it to municipalitiesmunicipalities
After depression 4 provinces followed After depression 4 provinces followed Ontario’s exampleOntario’s example
Federal government had limited Federal government had limited capacity to respond to the crisiscapacity to respond to the crisis– BNA Act gave these responsibilities to BNA Act gave these responsibilities to
the provincesthe provinces– Also, sometimes, limited interest in Also, sometimes, limited interest in
doing sodoing so
Royal Commission on Dominion Royal Commission on Dominion Provincial Relations (Rowell-Sirois Provincial Relations (Rowell-Sirois Commission): 1937Commission): 1937
Report tabled 1940Report tabled 1940
Acknowledged that municipal & Acknowledged that municipal & provincial governments had limited provincial governments had limited capacity to provide medical & social capacity to provide medical & social servicesservices
RecommendationsRecommendations– Transfer jurisdiction over taxation to Transfer jurisdiction over taxation to
fedsfeds
– Feds assume responsibility for Feds assume responsibility for unemployment insurance & old age unemployment insurance & old age pensionspensions
– Provinces to retain responsibility for Provinces to retain responsibility for healthhealthBased on assumption that medical care of Based on assumption that medical care of
indigent would continue to be provincial indigent would continue to be provincial responsibilityresponsibility
Many physicians were committed to Many physicians were committed to state sponsored medical insurancestate sponsored medical insurance
Had established physician sponsored Had established physician sponsored health insurance planshealth insurance plans
Endorsed by CMA in 1934Endorsed by CMA in 1934
Private insurance market developedPrivate insurance market developed
Many plans also sponsored by Many plans also sponsored by physiciansphysicians– Ontario, 1938Ontario, 1938– By 1950, all across CanadaBy 1950, all across Canada
In Manitoba, Manitoba Medical In Manitoba, Manitoba Medical InsuranceInsurance
Most were not-for-profitMost were not-for-profit
Pressure continued to be exerted on Pressure continued to be exerted on feds to respond in some wayfeds to respond in some way
Post war reconstruction planningPost war reconstruction planning
Two reports released in 1943Two reports released in 1943
Report on Social Security for Canada Report on Social Security for Canada (Marsh Report)(Marsh Report)– First comprehensive plan for social First comprehensive plan for social
securitysecurity
Report of Advisory Committee on Report of Advisory Committee on Health Insurance (Heagerty Report)Health Insurance (Heagerty Report)– Recommendations for creation of Recommendations for creation of
national health insurance programnational health insurance program
Constitutional changes needed to Constitutional changes needed to implement these initiativesimplement these initiatives
In post-war period, only 6% of In post-war period, only 6% of Canadians had health insuranceCanadians had health insurance
Rose to 50% by 1950sRose to 50% by 1950s
Insurance plans had problemsInsurance plans had problems– Restrictions or caps on coverageRestrictions or caps on coverage– Incomplete coverageIncomplete coverage
By 1960s, pressure began to mount By 1960s, pressure began to mount again for a national solutionagain for a national solution
Insurance companies recognized that Insurance companies recognized that they would never cover everyonethey would never cover everyone– Unemployed/unemployableUnemployed/unemployable
Accepted that these people were Accepted that these people were legitimate responsibility of legitimate responsibility of governmentgovernment
Saskatchewan (as usual) led the waySaskatchewan (as usual) led the way
Developments in this province Developments in this province started in 1920sstarted in 1920s– Municipal doctors plansMunicipal doctors plans– Union hospitalsUnion hospitals
Election of CCF Election of CCF government in government in 19441944
Leader, Tommy Leader, Tommy Douglas (1904-Douglas (1904-1986), committed 1986), committed to medical to medical insuranceinsurance
What does this What does this man have to do man have to do with our “Greatest with our “Greatest Canadian?”Canadian?”
Discontent with the inequities Discontent with the inequities between the provincesbetween the provinces
““Canada is like an old cow. The West Canada is like an old cow. The West feeds it. Ontario and Quebec milk it. feeds it. Ontario and Quebec milk it. And you can well imagine what it's And you can well imagine what it's doing in the Maritimes.”doing in the Maritimes.”
Douglas’s 1Douglas’s 1stst act was to guarantee act was to guarantee medical coverage to destitutemedical coverage to destitute
Established survey of province’s Established survey of province’s health conditionshealth conditions– Headed by Henry Sigerist (1917-1957)Headed by Henry Sigerist (1917-1957)– Physician & medical historian at Johns Physician & medical historian at Johns
Hopkins UniversityHopkins University
Recommended expansion of Recommended expansion of provincial health programsprovincial health programs
Federal/provincial negotiations Federal/provincial negotiations stalematedstalemated
Saskatchewan decided to go it aloneSaskatchewan decided to go it alone
Hospital Services Act (1946)Hospital Services Act (1946)– 11stst compulsory tax supported hospital compulsory tax supported hospital
insurance program in North Americainsurance program in North America
Created tremendous pressure on Created tremendous pressure on other provinces and federal other provinces and federal governmentgovernment
Hospital Insurance & Diagnostic Act Hospital Insurance & Diagnostic Act (1957)(1957)– Federal legislationFederal legislation– 50/50 cost sharing of hospital costs50/50 cost sharing of hospital costs
By 1961, all provinces had hospital By 1961, all provinces had hospital insurance plansinsurance plans
Medical fees still not coveredMedical fees still not covered
Saskatchewan again led the waySaskatchewan again led the way
CCF won 1960 election on promise it CCF won 1960 election on promise it would create tax funded medical would create tax funded medical insuranceinsurance
SMA/CMA opposed this measureSMA/CMA opposed this measure
Saskatchewan Medical Insurance Bill Saskatchewan Medical Insurance Bill passed passed
To come into effect April 1, 1962; To come into effect April 1, 1962; physician opposition pushed date physician opposition pushed date back to July 1, 1962back to July 1, 1962
Precipitated most famous physician Precipitated most famous physician strike in Canadastrike in Canada
Withdrew Withdrew allall medical services (not medical services (not just to the poor)just to the poor)
Supported by other physician groups Supported by other physician groups across the continentacross the continent
Seemed to ignore political will of the Seemed to ignore political will of the peoplepeople
SK government recruited foreign SK government recruited foreign physicians to substitutephysicians to substitute
Furious public relations campaign on Furious public relations campaign on both sides of the issueboth sides of the issue
Anti-medicare lobby led by coalition Anti-medicare lobby led by coalition of Liberal supportedof Liberal supported
Organized mass rally where 30,000 – Organized mass rally where 30,000 – 40,000 were predicted to attend40,000 were predicted to attend
On July 11, only 5000 showed upOn July 11, only 5000 showed up
Clear that the strike was overClear that the strike was over
Public opinion clearly favoured medical Public opinion clearly favoured medical insuranceinsurance
Ironically the plan worked well for Ironically the plan worked well for physiciansphysicians
Guaranteed payment for services Guaranteed payment for services renderedrendered
Within 1 year, SK physicians were Within 1 year, SK physicians were highest paid in Canadahighest paid in Canada
Created tremendous pressure on Created tremendous pressure on federal governmentfederal government
Royal Commission on Health Services Royal Commission on Health Services (Hall Commission)(Hall Commission)
Established 1961, reported 1964Established 1961, reported 1964
Endorsed national health insuranceEndorsed national health insurance
Five principlesFive principles– ComprehensiveComprehensive– UniversalUniversal– PortablePortable– Publicly fundedPublicly funded– Publicly administeredPublicly administered
Medical Care Act passed in 1966 by Medical Care Act passed in 1966 by Liberal minority government under Liberal minority government under Lester PearsonLester Pearson
Implementation was very difficultImplementation was very difficult
Start date changed from July 1, 1967 Start date changed from July 1, 1967 – July 1, 1968– July 1, 1968
Initially, only 2 provinces qualified Initially, only 2 provinces qualified under the planunder the plan
By 1972, all 10 provinces and 2 By 1972, all 10 provinces and 2 territories were participatingterritories were participating
Short-lived physician strike in Short-lived physician strike in Quebec (1970)Quebec (1970)
This program was never a sure thingThis program was never a sure thing– Powerful Liberals opposed itPowerful Liberals opposed it– Created during an era of unusual Created during an era of unusual
prosperityprosperity
Impact on physiciansImpact on physicians– Incomes increased 31% relative to Incomes increased 31% relative to
increases attained by other Canadiansincreases attained by other Canadians
Many bumps along the road since Many bumps along the road since thenthen– Extra billingExtra billing– Threat of user feesThreat of user fees– Decrease in federal fundingDecrease in federal funding– GlobalizationGlobalization
WTOWTO
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