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Bob Dole in the Year 2025
By Steven A. Lyons
I was less than 60 seconds into my interview with Dr. Barootes -- the physician who led the crusade against Canada's health care system in the early 1960s -- and things were not going well. People familiar with the disposition of my subject had warned me to expect a less than warm reception. They were optimistic.
Already suspicious of an American interested in the health policy opinions of a 76-year-old urologist from Saskatchewan, things turned from bad to worse: And what is your position on health care reform? he inquired. Well, I'm trying to write an objective article, I replied. That . . is . . not . . what . . I . . asked, he growled.
The U.S. Congress killed government-led health reform ostensibly out of fear that it would interfere with the patient-doctor relationship, increase bureaucratic overhead, limit patient's choice in doctors, and ultimately lead to rationing health care.
Now we are spiraling toward the Orwellian form of health care purportedly feared by the last Congress. But this time, Big Brother is not the government. Rather, as huge managed-care corporations control larger and larger portions of the health delivery system, profit, not quality patient care, is driving the health care industry. Every fear that the 103rd Congress said it had of a big, government health insurance program is coming true thanks to the big, private health insurance companies.
Lawmakers claimed that the Clinton health care plan would limit our choice of doctors. However, all managed-care programs limit the patient's choice of doctor to providers that are employed by or approved by the insurance company.
People attacked the Clinton health plan as increasing government bureaucratic waste. However, in a recent study, the California Medical Association found that California's private health insurers squander eight times more in administrative overhead than the state-run health insurance program. Nationwide, about one of every four dollars is wasted on overhead by the private insurance industry.
Congress claimed to fear that the Clinton health plan would intrude on the doctor-patient relationship. But under private health insurance plans, three out of four doctors sign contracts surrendering their medical decisions to insurance company oversight. The managed-care plan of one large company prohibits patients from calling their doctor directly. Instead, employees must call an insurance company representative, who in turn calls the doctor.
People feared that government health insurance would lead to rationing health care. Currently, under private health insurance, hospitals are discharging patients quicker and sicker to save money. With managed-care plans discharging mothers and their newborns as soon as eight hours after birth, legislators have had to intervene to force the insurers to cover at least 48 hours of postnatal care.
In 1993, when Representative Jim McDermott and Senator Paul Wellstone proposed a Canadian-style single payer health care program for the United States, it was considered politically impossible. The proposal never made it to the House floor, even though the Congressional Budget Office estimated the system would save $175 billion annually by the year 2003, completely eclipsing the savings of any other health reform proposal.
Since managed care is rationing health care, interfering in the relationship between doctors and patients, and burying everyone in paperwork, we might ask an innocent question: Tell us again why we should avoid a single-payer system?
Canadians have lived with their version of health reform since 1962, when the Canadian government began providing cradle-to-grave health coverage for all citizens. On the surface it seems it can't be any worse than the direction the U.S. system is headed.
But opponents to the single payer system contend that Canada rations health care and provides a lower standard of care, all due to its tax-financed health system. I decided to search for the tender underbelly of the Canadian system, to determine who was right.
My search for the dark side of the Canadian Medicare system (as it is called) quickly led me to one man. If the Canadian system has any shortcomings, Dr. Efstathios W. Staff' Barootes would be more than happy to expose them. Barootes, in the early 1960s, vigorously crusaded against the implementation of government-sponsored health insurance in Canada. Canada's single-payer health care system began in Saskatchewan. Barootes was vice president, and later president, of the Saskatchewan College of Physicians and Surgeons, a group determined to prevent any program that involved tax-financed health care for the entire population. He was president of GMS, the doctor-sponsored private medical insurance plan in Saskatchewan. Barootes, in a 1960 televised health-care debate with the premier of Saskatchewan, argued against the proposed health insurance scheme. In 1962, in an emotionally charged speech to a mass meeting of doctors, he received the loudest applause when he proclaimed that never . . . has there been such legislation reversing the civil rights and liberties of citizens. And Dr. Barootes served as Saskatchewan's conservative party senator in Ottawa from 1984 until retiring in 1994.
After Dr. Barootes initial interrogation of me, he launched into a two hour monologue. Health is a state's right here; it's a provincial responsibility, began Dr. Barootes. The federal government can only influence provincial programs indirectly, by saying if you follow certain standards that we set, then we will share your health care costs. This is different from the U.S., where your health programs are national and state governments are administrators of your national programs.
Because health is the responsibility of each of Canada's provinces, it is not surprising that the current Canadian system evolved province by province. Even today, there is no Canadian health care system. There are provincial health care systems. However, each provincial health care system has certain similarities.
As Barootes points out, Saskatchewan has a long history of health care innovation. For example, at the beginning of this century many lives were lost to tuberculosis. The people of Saskatchewan joined with doctors to form Anti-Tuberculosis Leagues. With vans roaming the country, testing citizens for TB, Saskatchewan provided free prevention and treatment. In the fight against cancer, Saskatchewan provided free cancer treatment centers. The world's first Betatron unit and the first Cobalt-60 therapy treatments were developed in Saskatchewan.
Saskatchewan's innovations in treatment were paralleled by their innovations in health policy. Just north of Montana, Saskatchewan is about the size of Texas but has about 1/15th its population. Because of the harsh climate, rural isolation, and dependence upon a one-crop, boom-or-bust economy, the people of Saskatchewan have survived by helping each other through collective and co-operative action. After World War II, this spirit of cooperation was reflected in the conversion of deserted military air fields into air ambulance stations to serve the health needs of isolated rural farmers. Similarly, locally funded community hospitals sprouted up to cover the rural population. By 1951 Saskatchewan boasted more hospitals than the much more heavily populated province of Ontario. Despite the innovations in treatment and coverage, by 1960 less than half the population had health insurance.
Onto this scene strode Tommy Douglas, the charismatic and colorful Baptist minister who was premier of Saskatchewan from 1944 to 1962. Douglas really should be regarded as the father of health care in Canada, because what he set up was copied by the other provinces, continues Dr. Barootes. Tommy Douglas was a Baptist minister who left the ministry for politics. He had osteomyelitis as a young man, and had required many operations on his leg, which were done through the charity of doctors. He was not very well off, he was a Scottish immigrant. He swore all his life that whenever he could, if he ever had the power, that he would make health care as available to the people of Canada as education. That was his objective and he never deviated from it.
By the 1960 provincial elections, Douglas was ready to act on his vision of universal, comprehensive, publicly administered health insurance. And the doctors of the province were equally ready to oppose him. With the doctors rallying against Douglas's health care platform, soon the only issue of the campaign was health reform. But Douglas's party, the Co-operative Commonwealth Federation (CCF), was ultimately victorious, winning 38 of the 54 seats in the legislature. Douglas took that as a mandate, and vigorously began to orchestrate his health care plan. This incited the tightly organized doctors of the province to attack the plan with even greater passion. And at the forefront of the fight was Dr. Barootes.
At first people were apathetic, it was just another extension of health care services that Douglas had always preached about, until the doctors got in the game, Barootes recalls.
Our concern was that once the government took over physician care services, that . . . we would become technicians or tradesman being paid salaries by only one pay master.
As the day for implementing the plan approached, July 1, 1962, doctors put up large signs in their offices:
These threats were not made by a lunatic fringe group of physicians. Nearly every doctor in the province announced his or her intention to leave the province, or at a minimum to withhold services. And they made sure their patients knew of their intentions.
The implication of this threat was not lost on the people. Once public health insurance was enacted, they would no longer receive health care.
Barootes continues, We had public debates on television, we ran a propaganda campaign, and gradually people caught on to this, eh? The citizens formed `Keep Our Doctors' committees. These sprouted up like mushrooms.
The slogan of these Keep Our Doctors (KOD) committees was Political Medicine is Bad Medicine. These committees focused their wrath on the government and anyone associated with the government's plan. The combination of the doctor's and the KOD committee campaign raised public emotion to the boiling point.
Operating out of a hotel in Regina, one group had a 24-hour phone bank calling citizens of the area. With a recording of a crying baby in the background, the voice on the phone pleaded Help me, help me. My baby is dying and there is no doctor to help it. Government officials received threatening phone calls around the clock. The chair of the government's Medical Care Insurance Commission had his family under 24-hour security. His wife was pregnant but doctors refused to attend to her. The primary medical building in the capital was put up for sale because there would be no need for it once health reform was enacted, all the doctors would be gone.
What the government called universal coverage the doctors called compulsory state medicine. The doctors in Saskatchewan received publicity kits with the reminder: The concept of universal medical coverage is not new and the approach by government to seek support is just the same as when first enunciated by Karl Marx in his Communistic Theories . . . The kit contained a personal letter which you may wish to send to your patients. The canned letter informed the patient that the doctor's office would be closed until the government will allow me to treat you, as I have in the past, without political interference or control.
We used threats and so on, which incidentally worked very well, Barootes recalls. The KOD was formed because so many doctors said they would leave. You're a mother with kids or you're pregnant and expecting your doctor to deliver you, and all of a sudden the doctor you've been attending with for years says `I'm leaving' . . . that was a fear tactic we used. Another fear tactic we used, and I may have been part of it, was directed at the Roman Catholics and the Evangelicals. We said `the way this act is structured, the government could order us to do sterilizations and abortions.' We made a political cartoon about it.
July 1 came and, except for a few emergency centers, doctors withdrew services.
Allan Blakeney, later to become premier of Saskatchewan, was a minister in the cabinet at the time: People were in a semi-hysterical frame of mind. I have never seen anything approaching this level of public hysteria about an issue, he remembers. It lasted from late June to mid July. People were enormously upset. The hysteria was further whipped up by our newspapers. At that moment in time I would guess that 75 percent of the people would have wanted us to suspend the Medical Care Act. We felt we had a mandate to let the people look at it in operation, so we went forward.
On July 11, thousands of demonstrators marched on the legislature, carrying effigies of Premier Lloyd and Tommy Douglas, with the caption Down With Dictators.
Meanwhile, the government had initiated an emergency airlift of doctors from England to mitigate the crisis. In response, the Acting Chair of the KOD wrote to Premier Lloyd . . . We do not want doctors you and your commission can find in distant lands.
The strong emotions ran both ways. Dr. Barootes and his fellow doctors incurred the wrath of government sympathizers. We had eggs thrown at our windows, our windows smashed, car tires slashed, Barootes remembers. I sent my wife and kids to some friends and they stayed there during that period. Doctors had distinctive licenses in those days. You could recognize their cars. Many of our wives were run off the road. It was frightful.
Premier Lloyd was threatened, his family was threatened, we were threatened .... These were touchy times.
By the third week of the strike both sides were wearying. The tide was shifting. The public began to resent the doctors as well as the government. The doctors left in Saskatchewan saw outside doctors taking their place and threatening their livelihood. The government agreed to delete some of the more offensive language from the Insurance Act. The doctors relaxed their demands on the government. Instead of completely abolishing the health insurance act, now they were calling for the right to work outside the act and the right for patients to receive payments from health insurance agencies (which were sponsored by doctors). These agencies would then bill the government. The government agreed. By July 23 the strike was over.
By 1964 the scars left by the health reform struggle cost the party in power the election. The Co-operative Commonwealth Party did not regain power until 1971.
Now the dust has settled. Despite the grueling battle led by Dr. Barootes, he has had to practice under the Medical Care Insurance Act for 33 years. Did the nightmare predicted by Dr. Barootes, his fellow physicians, and the Keep Our Doctors Committees ever materialize?
Most of the things that we threatened would happen have not happened, admits Barootes. They have never interfered with the College of Physicians and Surgeons. Free choice of doctors remains. Do patients still have a concern about their doctor, do they still have respect for their doctors? Yes .... One of the concerns we had was that people's loyalty would transfer from the physician, who is providing care, to the government, that is paying for it. That has not happened.
With all its warts and all its problems, and there are plenty of problems, universality, comprehensive benefits, accessibility, public administration and portability remain the principals of the Canada Health Act, by which the provinces can receive money. I'm a little prejudiced you know. I will tell you that today I support the universal health care program we have here. Our people are satisfied with it. Nobody that I know would be able to change it without a cataclysmic debate.
Should a similar system be implemented in the U.S., a waitor would have the same health insurance as a governor. Allan Blakeney was Saskatchewan's premier from 1971-1982. Was he satisfied receiving the same quality of care as a car mechanic?
Yes, Blakeney readily states. I was quite happy with the level of medical care I received and I'm sure the mechanic got the same level of care. I never felt the need for additional medical insurance.
Does the Canadian government insurance commission micro manage the decisions of the doctors? No, says Dr. Barootes plainly. There has been no interference in the decision making that goes on in a medical office or hospital between a doctor and his patient. We said there would be. Of course we threatened that. That was our big fear, that they would be telling us what to do. There is no intervention between an individual doctor with his individual patient, determining between them what they wish to have done. So we were wrong on that and I admit that.
While the government does not interfere with my judgment per se, there is intervention in another way, Barootes continues, and that is in the rationing of health services. As costs mount, the public purse can't support all of the services that are demanded or required or wanted.
Ah, the tender underbelly exposed. Barootes readily points to the source of Canada's financial problem. There may be an element of over-servicing by doctors, there may be an element of over utilization by patients.
With I-told-you-so glee, Dr. Barootes says We wanted co-payments. They did not implement that, and that was the one prediction of ours that came true, that costs would rise astronomically and that the government would cut back or ration services. We said that costs would rise unless there were brakes put on it, such as deterrent fees.
While Barootes describes Canada's health care costs as rising astronomically, Canada spends only two dollars per person for every three dollars per person that the U.S. spends on health care. Yet their life expectancy exceeds ours and their infant mortality rate is below ours.
Dr. Barootes, speaking philosophically, as a former senator in the Canadian conservative party, what is the conservative perspective on government-sponsored health care?
What kind of coverage do I as a conservative fear? I fear coverage that pays from the first dollar on. That will ultimately mean that brakes must be put on the services. You need co-payments.
Secondly, be certain that you have at least catastrophic coverage, so when a breadwinner or homemaker has to go into the hospital, with a protracted serious illness like cancer, that some kind of catastrophic coverage is available to enable that family to survive that tragedy. We don't have that now. Let's say the husband and wife are both injured in a car accident and are in the hospital for maybe three months. What are you going to do about that household? They've lost their salary. They have payments to make, they have kids to feed. Some kind of catastrophic coverage is needed.
Ever read Barry Goldwater's book The Conscience of a Conservative? Conservatives with a conscience want catastrophic coverage for families, they want health insurance for all, make sure everybody has it, that there are no cracks in the floor that people fall through. And make sure it can't be cheated on. Not some unemployment insurance type of thing.
And finally, if you do introduce say chiropractic and drugs and so on, for God's sake keep the funds separate from your basic services such as hospital, lab, X-ray, and doctor services. Compartmentalize that. Those dollars should be squirreled away from these other programs that are added and deleted at the whim of some politician. Don't let these programs that come and go encroach on the core services. The dollars that you collect through premiums and however else you do it, earmark them for basic services and make them sacrosanct so nobody can poach on it.
So, if we were to implement a similar health care system here, what might Bob Dole and other vocal opponents to comprehensive health care reform be saying in the year 2025, 30 years after implementation of the plan?
Barootes observes, Today a politician in Saskatchewan or in Canada is more likely to get away with canceling Christmas, than he is with canceling Canada's health insurance program.
Thirty years ago, when you were describing the Saskatchewan Medical Insurance Act as `legislation reversing the civil rights and liberties of citizens,' did you ever think you would hear yourself saying that? At that time I'd have rather cut my arm off, he replies.
Stephen A. Lyons works have appeared in The Progressive, The Bay Guardian, The East Bay Journal, and others.