Until it was gradually overtaken by “the Tories will ban abortion” beginning in the 2000 Canadian federal election, the favourite, and not wholly inaccurate or illegitimate scare tactic used by Canada’s Liberals and New Democrats was to claim that conservatives, if elected, would institute “two-tier health care.”
For decades, this claim was repeated. It was understood to mean that provincial conservative governments would violate the Canada Health Act or that the federal Tories would amend the Act and permit private medical businesses to opt-out of the state’s single-payer health insurance system, thereby creating a second tier of health care that permitted other forms of payment such as cash or private insurance.
Before I go any further, I should take a moment to explain how Canadian public healthcare came about and how it is structured because there are many romantic myths about it, often less popular in Canada than in countries, especially the US, where our system is inappropriately and excessively romanticized.
The History of Canadian Public Healthcare
In 1948, Clement Atlee’s Labour Party government in the United Kingdom nationalized private hospitals and medical practices, severing prior employer-employee relationships, expropriating hospitals and other medical facilities from charities, churches and private corporations and turning Britain’s health care system into a unified, publicly owned system in which doctors were now government employees. They also intervened in medical licensing so as to prevent doctors using their syndical power to ration their labour or otherwise subvert the government’s agenda of expanding the scope, reach and accessibility of the system.
But what they did not do was attempt to enforce a monopoly, nor did they coercively expropriate for the most part. Instead, they lured doctors away and institutions away from the private system by making the public system a more lucrative and stable place to work. Similarly, their interventions in medical licensing entailed purchasing a majority on the board of the medical association through what was tantamount to bribery. The health minister in charge of the nationalization, was quoted as saying, of the doctors, “ultimately I had to stuff their mouths with gold.”
Such an arrangement was untenable as consumer use of the NHS grew rapidly. Soon, doctors began leaving the public system but the UK was able to use the decolonization of its collapsing empire to flood the labour market with doctors and nurses who were Wind Rush migrants.
The Cooperative Commonwealth Federation government of Saskatchewan, the only social democratic government in early Cold War Anglo America, studied all this carefully and figured that, to create a truly public, truly universal system, they were going to have a fight on their hands. So they spent sixteen years paying off the province’s debt making it the most prosperous jurisdiction in the country before attempting to socialize health care.
The province’s doctors balked at becoming government employees and having their hospitals and general practices made state property under any circumstances or level of compensation. And a strike ensued, resulting in the government’s defeat and the deaths of some innocent people.
Perhaps having anticipated this turn of events, Tommy Douglas, the premier who had conceived of this had resigned the premiership, leaving his successor, Woodrow Lloyd to wear the defeat while he became leader of the federal NDP and entering the House of Commons where, following the 1963 election, he held the balance of power.
Lester Pearson, the Liberal Prime Minister was what one might call a Great Society Cold War hawk. Like John F Kennedy and Lyndon Johnson whose election interference and public contempt for his Tory predecessor, John Diefenbaker, had helped win him the Prime Minister’s office, Pearson believed that the West could only win the Cold War if it matched or exceeded the state’s material guarantees of health care, housing and employment that the USSR promised. But the point of expanding the New Deal order and creating the Great Society was understood as a means of saving capitalism not dismantling it.
So, in collaboration with Douglas, Pearson worked to create a made-in-Canada solution to the problem of universal healthcare. Canadian Medicare did not seek to expropriate medical facilities nor to turn doctors into government employees and it left their syndical associations, the College of Physicians and Surgeons and Medical Association unmolested. Instead, Medicare created one territorial and ten provincial health insurance companies and prohibited the private sector from selling health insurance.
While provincial governments created new hospitals, the old hospitals remained, for decades, in the hands of churches and private interests. Clinics and individual practices remained private businesses, as they do to the present day. Doctors continued being compensated on a fee-for-service basis by the new state insurance companies just as they had been by the old private ones.
While NHS-like aspects have gradually crept into the system with a small minority of salaried doctors and nurse-practitioners at government-created clinic-like health centres and with an increasing portion of large health facilities becoming state-owned, the fundamental structure of Canadian Medicare has remained intact: a private health care system paid through a state-owned health insurance monopoly. What makes Canadian healthcare universal and public is its insurance companies not its health facilities or their employees.
The Collapse of Canadian Public Healthcare
Since the rise of neoliberalism in the 1990s, with its widening gap between rich and poor, increased labour mobility and increased costs of graduate degrees, public healthcare systems throughout the Global North have struggled to meet rising demand, expanding mandates, increased labour costs and increasing struggles with high-wage labour retention. In most places, this has resulted in more of the wealthy using privately insured or fee-for-service medical services to, as Canadians would think of it, “jump the queue” and obtain higher quality and faster service through their greater wealth.
Because Canada borders the United States and most of our population lives near the border or can cross it via air or land with relative ease, as our system degraded, Canadians became world leaders in medical tourism, nipping across the border for whole procedures or just for tests whose results would move them up the queue in Canada for expensive and urgent treatment, for instance, of cancer.
And as more Canadians of middle and high income made a habit of holidaying in Mexico and as ties between Canada and India deepened, India and Mexico began to compete with the United States in attracting Canadian medical tourists, offering cheaper procedures and, in Mexico’s case, medical and dental treatment mixed with resort living.
But for those of us for whom this was out of reach, things have grown steadily more dire as has the situation for all Canadians requiring emergency or urgent care near them quickly. Fewer and fewer Canadians have family doctors. “Walk-in clinics,” once the pressure release valve on the system now rarely accept walk-ins and require appointments to “walk in” weeks or months in advance. Furthermore, many of those clinics now refuse to grant in-person appointments at all and book fifteen-minute telephone consultations that are still usually weeks in the future and which allow the patient to discuss only one individual health problem often making it impossible for doctors to evaluate their condition, having neither physical contact nor a full description of the patient’s symptoms. And if, unable to tolerate this gatekeeping, Canadians present themselves to a local hospital emergency ward, they can face a wait of up to twelve hours before they can be seen by anyone and might still be turned away for having an insufficiently urgent condition.
Having personally spent three and a half years on a waiting list to see a specialist I ultimately never did get to see, I cannot over-emphasize the degree to which things often become more dire if your condition requires a referral in Canada. Months and even years are spent on the waiting list to see medical specialists, even oncologists and other specialists treating conditions that have an inherent urgency to them.
Except that this is not your experience of the Canadian medical system if you come from the correct social class.
The Rise of Class-Based Health Care
From 2013-15, I was in a live-in relationship with a highly educated woman with a PhD. Although not a MD, per se, she held a senior position as the manager of a government-run healthcare facility, presented at medical conferences and had even been published in The Lancet. The first New Year’s party we attended together was in the palatial home of a friend of her who also held a senior position in the healthcare system. There were doctors aplenty at the event, specialists, general practitioners, bureaucrats and officials in syndical organizations like the BC Medical Association, College of Physicians and Surgeons, running things like the International Medical Graduate program (which allows doctors to control which immigrants are permitted to join their profession immediately and which have to jump through hoops).
Within two weeks of moving in with her, I had a family doctor for the first time in years. And when she or I received referrals from our GP and we did not promptly see a specialist, a few calls could be made and that specialist appointment was soon available.
You see, whereas the two-tier medical systems of the other Global North countries make access to prompt and quality care increasingly contingent upon wealth, Canada’s system makes these things contingent upon class. Whom one knows, with whom one socializes and who is inside one’s larger social world determines access to health care in Canada.
Like old school class systems, the Canadian system looks down on those who might be termed nouveau riche and shunts them into poor person healthcare or out of the country. Healthcare access in Canada is about class and culture in the traditional sense, measuring one’s social refinement, family history, educational background, literally what parties you attend and how much sophistication and decorum one can show there. One’s socio-cultural proximity to the commissars and bourgeoisie, of which wealth is merely one very important facet, determines your access to Canadian healthcare.
For the members of Canada’s commissar class and liberal bourgeoisie, there is no healthcare shortage, no access problem. The system functions for them as it once did for all of us.
Two-Tier Rental Housing
While best dramatized through the story of healthcare, the increasing importance of class, as opposed to mere wealth, in accessing the basics for a healthy and successful life in Canada, applies across the board.
When I returned to Vancouver in 2022, following my fatwa, I had some extraordinarily good fortune. A friend was part of an upwardly mobile family that had acquired a small real estate empire of two or three properties and was renting out subdivided houses and a laneway home. While my friend was, like me, a college professor, his father was an autodidact whose prodigious hard work and canny business sense had helped to create small complex of rental housing over which the family presided. While riding high financially, after some bad experiences with tenants, he asked his son to find a higher class sort of tenant for their recently vacated laneway house.
The presence of a more educated, more respectable, more credentialed tenant was something of value to him. And so, with his son carefully concealing my recent expulsion from progressive society and emphasizing my teaching and publishing record, I received a lease at a discount of somewhere between 30% and 50% relative to market rates.
As what some clever person called “artisanal landlording” becomes more popular for Canada’s commissars and bourgeoisie, with constantly rising rents and property values, the only true “sure thing” in the Canadian investment scene, such arrangements are growing more common.
As with medical care, one’s access to affordable housing is conditioned not merely by wealth but by class. If you know a landlord, just as in health care, costs fall, waiting lists vanish and insecurity, fear and precarity recede.
The Rising Stakes of Cancelation
Naturally, when faced with such egregious unfairness, things like healthcare user fees appear egalitarian and leveling by comparison. Private healthcare becomes saleable to the working poor in new ways because it grants levels of access currently beyond their means. Instead of the wealthiest among us beating the drum for the eviscerating of the Canada Health Act, it is increasingly the proletariat and lower middle class.
To be clear, much as I am downwardly mobile and a higher and higher velocity, I don’t want user fees. But they are popping up anyway despite half-hearted and haphazard efforts by government to suppress them. The largest chains of clinics in BC, those run by Telus (a company whose other operations receive massive government subsidies) and Loblaws, do now charge user fees for seeing doctors in person. Only telephone consultations are free now. Smaller clinics and chains are introducing subscription fees and charges to stay on the patient list and have permanent files and repeat visits to the same doctor.
And those paying those fees are now being pushed into defending them, knowing that if the fees vanish, so do the “services” for which they pay.
This is not, furthermore, merely about access to the basics of life, including housing and healthcare. It also fits into the larger matrix of rising authoritarianism. Not only might you be fired for saying something unorthodox and facing cancelation; your expulsion from polite society could cost you your housing (a small landlord just needs to say a family member needs your suite to legally evict you) and your access to medical care.
By linking housing and healthcare to class, rather than mere wealth, Canada has made cancelation scarier yet as the range of acceptable political opinions in polite society continues to contract.
