Vol. 34 The Proposed Canadian National Health Bill* J. J. HEAGERTY, I.S.O., M.D., C.M., D.P.H. Chairman, Advisory Committee on Health Insurance, Department of Pensions and National Health, Ottawa, Canada CANADA has been careless of the health of her people. This is indicated by the high death rates which prevail. It has been thought in Canada that every person was capable of earning an income sufficient to provide his own health needs and those of his family. The depression showed we were wrong, but the depression alone was insufficient to cause legislators to take steps to provide the people with adequate housing, nutrition, and health facilities. It needed a war to do so. Indifference, neglect, and special privilege have stood in the way of improving living conditions and of reducing morbidity and mortality. Health departments have never had sufficient funds nor adequate leadership comprising personnel fully trained in various public health activities. Not only are death rates in Canada excessive, but the percentage of physical defects is high. Forty per cent of recruits suffer from physical defects. In a study in one province of Canada it was found that 70 per cent of young people between the ages of 13 and 30 have one or more remediable defects. Some of these are serious. Maternal mortality, infant mortality, tuberculosis, venereal diseases, and mental diseases are excessive. Diseases of middle age, such as heart disease, cancer, and * Presented at a Special Session of the American Public Health Association at the Seventy-second. Annual Meeting in New York, N. Y., October 14, 1943. diseases of the arteries and kidneys are increasing. The solution is the adoption of a modern Public Health and Health Insurance Plan which will include a comprehensive reorganization of public health departments and the provision of full and complete medical care for all of the people of Canada. With this object in view the Honorable Ian A. Mackenzie, Minister of Pensions and National Health, in May, 1941, issued instructions to the officials of the Department of Pensions and National Health to discuss the subject of the health of the people of Canada at the next meeting of the Dominion Council of Health with the object of initiating a comprehensive study of public health and medical care leading to the adoption of a Public Health and Health Insurance Plan for the Dominion. To this meeting were invited representatives of the Canadian Medical Association, Canadian Hospital Council, the medical faculties of universities, the Royal College of Physicians and Surgeons, and voluntary health organizations, as well as representatives of interested governmental departments. The Director of Public Health Services presented the subject of public health and medical care for discussion. Deficiencies in the field of public health were stressed and particularly those respecting tuberculosis, mental diseases, maternal mortality, infant mortality, and the diseases of middle age, all of which are controllable by known public [117]
AMERICAN JOURNAL OF PUBLIC HEALTH 118 Feb., 1944 health measures. The discussion brought out the following facts: Both incidence and mortality of tuberculosis are excessive. Moreover, the rate of reduction of mortality is much more rapid in some provinces than in others and especially in those provinces in which adequate preventive and treatment services are provided. A striking feature of tuberculosis is the high mortality rate in Quebec and the Maritimes. It is believed that the most effective factor in the reduction of tuberculosis is free treatment integrated with preventive services. Tuberculosis should not exist in any civilized community. The presence of tuberculosis in a community is an index of lack of interest in the health and welfare of the people. In respect of mental diseases, it was made clear that the situation is grave. The number of cases is increasing. There is a shortage of 10,000 beds and there are many mentally ill persons walking the streets for whom no accommodation is available. It is the Canadian experience that more beds are utilized for the treatment of mental illness than the total number of beds required for the hospitalization of all other diseases. Apart from the question of accommodation, there is lack of professional staff-doctors, nurses, and other personnel. Many providing services for mentally ill persons are inadequately trained and facilities for occupational therapy and recreation are few. The number of psvchiatric clinics is small. There is no organized system of supervising discharged patients, of finding work for them, of teaching them to care for themselves, or of teaching their families to care for them; nor is there a program of vocational guidance and training for mental defectives. Organized community care is negligible. Although it is known that we should be concerned with problems of mental health relating to earliest childhood. school age, working life, and home life, little, if anything is done in that direction. The seriousness and scope of the mental problem in Canada is causing concern. In order to insure progressive improvement of all methods of control of mental illness, future planning should comprise ample facilities, including scientific research. Statistics regarding the venereal diseases are incomplete, inasmuch as doctors, generally, do not report their cases. Nevertheless, statistical reports provided by venereal disease clinics indicate that the incidence of syphilis and gonorrhea is high. It is considered that venereal disease control measures are inadequate, and a new and farreaching venereal disease program is necessary, as it has been demonstrated that in countries where adequate measures for the control of venereal diseases have been adopted a definite reduction in incidence has been obtained. There is no doubt that a complete program would effect a reduction not only in the incidence of the venereal diseases but in institutional and hospital care generally, as well as in mothers' allowances, old age pensions, and poor relief, all of which bear a relation to these diseases. In Sweden, approximately only 7 new cases of syphilis occur annually for every 100,000 of population, whereas in Canada at least 70 new such cases are reported by clinics alone. It is clear, therefore, that the problem is one that requires active consideration. The maternal death rate in Canada is extremely high when compared with other countries with a similar standard of living-and, in fact, may be considered excessively so. Our experience in Canada indicates that, wherever special measures have been adopted to provide adequate maternal services, the death rate decreases rapidly. Infant mortality parallels maternal mortality. Each year during the last 10 years Canada has lost on an average
Vol. 34 CANADIAN PUBLIC HEALTH 119 15,000 children under 1 year of age. These deaths are largely due to causes which are preventable or controllable. Where active measures are adopted to reduce infant mortality, they are successful. For example, in certain cities of the United States in 1900, 1 out of every 6 children died during the first year of life; by 1920 the ratio had dropped to 1 in 12, and by 1940 to 1 in 21. Infant mortality is very definitely one instance where money can purchase life Ṫhe rate of population growth in Canada over the past 30 years has been decreasing rapidly. From 1911 to 1921 the rate of increase was 34.17 per cent; from 1921 to 1931, it was 18.08 per cent; and from 1931 to 1941 only 10.8 per cent. Maternal and infant death rates, together with the aging of the population and the cessation of immigration, are a serious matter from the standpoint of the future of the country. Communicable diseases take an unnecessarily large toll of life. This is due to inadequacy of health services and particularly of local health services. In fact, one of the greatest needs of the present day is the establishment, maintenance, and extension of local health services. The adoption of such services in rural areas would have the immediate effect of reducing morbidity and mortality of communicable diseases and especially of maternal and infant mortality. Inasmuch as essential preventive services are inadequately provided throughout the country, it is clear that new measures must be formulated and adopted. In the realization that the adoption of such measures requires a broad and comprehensive plan to cover the entire country, a Public Health and Health Insurance Bill was prepared. For the purpose of formulating such a plan, it was considered essential that the views of the most representative groups in the country should be obtained. For this purpose, an Advisory Committee on Health Insurance was formed. This committee, after formulating a general plan, requested representative groups throughout the country to create public health and medical care committees. The following organizations formed such committees: The Canadian Medical Association The Canadian Dental Association The Canadian Pharmaceutical Association The Canadian Nurses Association The Canadian Hospital Council The Catholic Hospital Council of Canada The Canadian Public Health Association The National Council of Women The Catholic Women's League The Federated Women's Institutes of Canada La Federation des Femmes canadiennes francaises The Canadian Welfare Council and Canadian Association of Socal Workers The Trades and Labour Congress of Canada The Canadian Federation of Agriculture The Canadian Manufacturers Assocation The Canadian Life Insurance Officers Association. The great majority of these organizations made direct representations and approved the general principles laid down in the draft Health Insurance Bill. Perhaps the culminating achievement of the Advisory Committee on Health Insurance, aside from the draft proposals which constitute its report, was the unprecedented assembling between annual conventions, for the first time in 75 years, of the General Council of the Canadian Medical Association, when this great and influential body formally went on record in favor of the principle of health insurance. The modern conception of health insurance is the reduction of morbidity and mortality by prevention and treatment, and it was with this object that the Advisory Committee on Health Insurance drafted a combined Public Health and Health Insurance Bill. Subject to the provision of this draft Bill, the Governor in Council may make an agreement with the Lieutenant-
AMERICAN JOURNAL OF PUBLIC HEALTH 120 Feb., 1944 Governor in Council of any province to make grants for public health and medical care, provided that the province makes provision for utilizing both grants. The grants are specified in the First and Third Schedules to the Bill and the proposed statutory provisions are contained in the Second Schedule. The draft Bill is based on compulsory and contributory insurance. It is planned to include all persons resident in Canada by agreement with the provinces. It is considered essential that everyone in Canada should be provided with health insurance; nevertheless, no compulsion is placed upon the provinces in this respect other than that all indigents must be included in the plan. To provide health insurance, it will be necessary to create a Health Insurance Fund comprising money contributed by insured persons, employers, Provincial Governments and the Dominion Government. By so distributing the cost, the financial burden will be considerably lessened. After careful thought and consideration, it is believed advisable from the standpoint of the collection of contributions to divide insured persons into two classes: " employed insured persons " and " assessed insured persons." The payment of contributions has been so devised that these classes will contribute in proportion to their wage or income. If an employed person is capable of paying the entire cost for himself and his dependents, he shall be obliged to do so. If unable to pay the entire cost, his employer will pay the difference for him, and the province for his adult dependents. The combined contributions of employer and employee will be supplemented by a Dominion grant. Assessed insured persons are the unemployed who have an income from a source other than wages, or who are indigent. Like the employed insured persons, the assessed insured person, if he can do so, will pay the entire cost for himself and adult dependents; if not, the province will pay the difference. Financial assistance will be provided by the Dominion Government. There will be no charge for children up fo a prescribed age- 16 years. As soon as health insurance is adopted in a province, all residents will be registered and classified and will be instructed to select a doctor from a list provided after consultation between the Provincial Health Insurance Commission and authorized medical committee appointed for the purpose. If the insured person wishes, he may select a clinic instead of a private practitioner. The method of payment of physicians, nurses, and others will be left to the decision of the Provincial Health Insurance Commission. Also, it is considered desirable that the services of the physician should be utilized for prevention as well as treatment. Thus, the physician will have a responsibility for the health of each member of the family and be responsible for public health measures designed to reduce morbidity and mortality. He will act as counsellor and adviser in respect of the health of the family as a unit. The benefits comprise prevention of disease and the application of all necessary diagnostic and curative procedures and treatments, including medical, surgical, obstetrical, dental, pharmaceutical, hospital, and nursing benefits and such other ancillary services as may be deemed necessary. Provision is not made for cash benefit due to unemployment caused by illness, as it is considered that such benefit should be provided by other means. Medical benefits include the services of a general practitioner, consultant, specialist, surgeon, obstetrician, hospitalization and nurse, and ancillary services. Nursing in the home is con-
Vol. 34 CANADIAN PUBLIC HEALTH 121 fined to the visiting nurse, except where the circumstances are such that bedside nursing is essential. Dental benefit must of necessity be restricted, as the number of dentists in Canada is insufficient to provide full and complete dental care for all. It is proposed that a committee of the Provincial Dental Association shall make an arrangement with the Provincial Health Insurance Commission to provide every child up to 16 years of age with a semi-annual dental examination and such reparative dentistry as is needed. Dental care may be provided others to the extent that the funds and the number of available dentists will permit. Pharmaceutical benefit shall be provided in accordance with a list of drugs to be drawn up in cooperation with the Provincial Health Insurance Commission and a committee of the Provincial Pharmaceutical Association. Special provision may be made respecting drugs and pharmaceutical preparations known as specialties. Hospital benefit is to include general ward services unless the insured person wishes by paying the difference to obtain semi-private or private room. In special cases accommodation other than general ward may be provided. The terms of agreement for hospitalization will be arranged by the Provincial Health Insurance Commission with a committee of the Provincial Hospital Groups. Nursing benefit, outlined above, will be provided by the Provincial Health Insurance Commission in cooperation with a committee of the Provincial Nursing Groups. Provision is made for administration through a Health Insurance Commission in each of the provinces. In considering the question of administration, it was the opinion of the Chief Medical Officers of Health of the provinces and the Advisory Committee on Health Insurance that administration should be by the Government for the people through Provincial Departments of Health. Nevertheless, the Canadian Medical Association and other professional and lay groups favored a commission. In view of this preponderance of opinion, provision has been made in the draft Health Insurance Bill for a commission comprising a chairman who shall be a doctor of medicine, the Deputy Minister of Health of the province (ex-officio), and such other number of persons as may be determined from time to time by the Lieutenant-Governor in Council after consultation with representatives of professional groups, labor, agriculture, industry, women's organizations, etc. Provision has been made to provide benefits only after the Health Insurance Commission has consulted with professional groups providing benefits but, should these groups not cooperate, the Health Insurance Commission is empowered to appoint committees for the purpose. The Health Insurance Commission is obliged to study the resources of the province and facilities available for providing benefits and to divide the province into health insurance administrative and public health areas. The supervision of the provision of benefits is to be placed under Regional Officers. The Health Insurance Commission may be authorized by regulation to establish such committees, councils, or other bodies or instrumentalities as may be deemed advisable for consultative, advisory, and executive purposes as well as for obtaining effective co6peration in the administration of the Health Insurance Bill. The constitution, duties, and powers of such committees, councils, etc., shall be prescribed by regulation. Inasmuch as Dominion administration is confined to the administration of Dominion grants, it is not considered
122 AMERICAN JOURNAL OF PUBLIC HEALTH necessary to create a Dominion Health Insurance Commission, as administration may be carried out by a Health Insurance Division in the Department of Pensions and National Health under a Director of Health Insurance. One of the chief disadvantages of administration of health insurance provincially is decentralization. To overcome this, provision is made in the Bill for the creation of a National Council on Health Insurance, comprising the Director of Health Insurance as chairman, the chief medical officer of health, as well as the chief administrative officer of health insurance of each province which has established a health insurance act, and such other persons, comprising a representative of the doctors, dentists, hospitals, pharmacists, nurses, labor, industry, agriculture, and urban and rural women, respectively, as may be determined by the Governor in Council. None of these will receive remuneration but will be paid travelling expenses and maintenance. The various Grants contained in the draft Bill are as follows: A Health Insurance Grant to assist the provinces in providing health insurance benefits as outlined. A Tuberculosis Grant to help provide free treatment for all persons suffering from tuberculosis, including the provision of additional buildings and bed accommodation. The reduction of mortality in those provinces which provide free treatment indicates that the provision of free treatment is an essential to the elimination of tuberculosis. A Mental Disease Grant to assist in the provision of free treatment for those suffering from mental illness, including the provision of additional buildings and bed accommodation. In this field, Dominion assistance is urgently needed. A General Public Health Grant to assist the provinces in establishing and maintaining public health services commensurate with the needs of their people. The same problem has Feb.) 1944 confronted the United States and has been solved by the provision of funds to raise the per capita expenditure on public health and to meet special needs. A Venereal Disease Grant to aid in providing preventive and free treatment for persons suffering from venereal diseases on the same basis as the original Dominion venereal disease grant of $200,000 which was discontinued in 1932. A Grant for Professional Training to afford financial assistance to doctors, sanitary engineers and others who wish to take university courses leading to degrees in public health. An Investigational Grant to enable the provinces to carry out special public health studies. It has been found impossible to carry out studies in public health and to provide skilled personnel during epidemics because of lack of funds. And a Crippled Children Grant to prevent and control crippling conditions in children. It will be clear from this brief summary that, apart from the reduction of morbidity and mortality of disease, the primary object is the integration of public health and nedical care for the purpose of raising and maintaining the standard of health of the people. The draft Bill as outlined above has been presented to a Special Committee on Social Security of the House of Parliament and has been approved in principle by that committee. The plan has been discussed with the Ministers of Health of the Provinces, who are cooperative. In addition, the Dominion Government has passed a National Physical Fitness Act creating a National Council on Physical Fitness and a Physical Fitness Fund. The object is to coordinate the efforts of all governmental and other agencies engaged in the field of physical development, physical culture, sport and recreation. NOTE: A Committee on Finance is at work on the question of collection of contributions. It is probable that the method recommended in this article will be modified.