Why the Doctors Lost Their Strike American MD's accept Medicare, but Saskatchewan

The Canadian doctors walked out on Ju!y 1, 1962, the day the" Mcdkal Care Insurance Act went into cfle~ in Saskatchewan.'"

doctors fought such a plan. Why the difference ? JANET WALKER G O U L D N E R

Janet Walker Gouldner, whose first article this is, conducted research in Saskatchewan which was financed in part by the Medical Care Research Center of Washington University. She is also interested in studies of deviant behavior and social change. She is working with her husband, Alvin W. Gouldner, on a study of the social organization of European social science.

14

After years of steadfast opposition to "socialized medicine," the American Medical Association has given a grumbling acceptance to the Medicare plan that goes into effect on July 1, 1966, The AMA's legislative body, the House of Delegates, has rejected resolutions advocating refusal to participate in Medicare. It has merely promised to "investigate all aspects of the law to determine possible court action to test the legality and constitutionality of any provision or regulation issued under the law." Only a die-hard group, the Association of American Physicians and Surgeons, is urging its members to boycott Medicare. For 20 cents each, it sells placards for office display that proclaim "I am Not a Government Doctor" or "I am Not Participating in Medicare." But the small membership of the AAPS, even if they refuse to participate, will not derail the government's medical plan. However, doctors in other countries have gone on strike against government medical plans--causing either disruption of the government or of medical practice, or both. In Belgium during the winter of 1965 a doctors' threat to strike brought on a government crisis. And in 1962 Canadian doctors in the prairie province of Saskatchewan walked out for three weeks--leaving only minimal medical care for citizens--in protest against a medicare plan. The Saskatchewan legislation was far more comprehensive than the American plan about to go into effect. It was not limited to the elderly; it was financed through general taxation; it paid for physicians' services in offices as well as hospital calls. The Canadian doctors walked out on July 1, 1962, the day the Medical Care Insurance Act went into effect in Saskatchewan, and the so-called "emergency" service by the striking doctors started. From press reports medical services were technically adequate during the strike, but the public's psychological reactions were geared to a medical crisis. On July 23, the Saskatoon Agreement, which is described later in this article, was signed between the government and the doctors' organization, the Saskatchewan College of Physicians and Surgeons. The medicare program has been operating in Saskatchewan ever since. Three questions emerge immediately. m Are there parallels between the situations of American doctors in 1966 and Saskatchewan doctors in 1962 ? TRANS-ACTION

9 Why did the government of Saskatchewan enact such a comprehensive scheme of medical protection ? 9 Why did the Saskatchewan doctors protest in such an extreme form--by striking ? The answers to the second two questions can be found in the special circumstances of Saskatchewan's past history. HERITAGE OF THE DIRTY THIRTIES Saskatchewan is a land of open prairie, with an economy largely based on the growth of one crop--wheat. There is little industry; the towns act as service and distribution centers for the surrounding farmland. During the 1930% drought and depression spread across the face of Saskatchewan. The price of wheat dropped to 19 cents a bushel. Crops failed in the longest and most severe drought in the history of the province. Dust storms rolled across the prairie. Out of the years of suffering that they still call the "Dirty Thirties," Saskatchewan farmers fashioned a pragmatic variety of agrarian socialism which is sharply different from the respectable, conservative outlook of the business and professional men of the towns. The farmers developed a consciousness of themselves as an exploited class and identified a set of enemies--the bankers, the men who owned the grain elevators, and the urban middle class generally. The farmers' experience in cooperative organizations like the Saskatchewan Grain Growers' Association and the Wheat Pool (a marketing cooperative) proceeded to the formation of a farmers* political party--the Cooperative Commonwealth Federation. Because labor had also been hard hit by the depression, and because both farmers and workers saw the urban business and professional interests as the enemy, working men joined farmers in support of the CCF. The CCF was voted into once in 1944 on a moderately socialist platform, and has remained in office until their defeat by the Liberals in 1964. Although basically a farmer's party, the CCF made initial attempts to establish state-owned and operated industry in the form of Crown Corporations. Most of these were financial failures, however, and many were subsequently turned into cooperatives. The party's most extensive reforms have been in the area of improving social services. Urban business and professional groups were and are vociferously opposed to the CCF. Their opposition reflects not only ideological differences, but also resentment over the lack of industrial expansion in the province--a condition businessmen deplore and attribute to the CCF's agrarian socialist policies. Many of Saskatchewan's professional people did not live in the province before the war, and have no personal memories of the Dirty Thirties. Many doctors in the province are emigrants from Britain; in many cases, a dislike of the British national health plan impelted them to leave England, and they are naturally hostile toward similar proposals in their adopted home. tt has been difficult to secure adequate medical services for Saskatchewan. The farmers always had trouble getting .x~Ay/ j UNE

and keeping good doctors at a price they could afford to pay. Medical services were spread over a thinly populated area, large parts of which became inaccessible during fierce winters. The mayor of a tiny hamlet called Limerick has described a typical rural experience with trying to get medical care: We'd get the drifters, D'you see. There was this Irish doctor. The ladies filled his 'fridge with home baking, see. Well, he come here, ate his way through the 'fridge, and went back to Dublin. Then there was the Englishman. Never sober from the day he come to the day he left. We had a Jamaican for a time. Nice young feller but couldn't git along with the old uns. Finally he had a bust-up with Old George, who can't hear too well on account of wax in the e a r s . . , and off he goes too. "The existence of protest groups made it possible for the doctors to feel doubly justified; they were defending not only their right to private fees, but the whole free-enterpriseway of life."

Early government programs designed to help rural communities support a general practitioner were limited to what a country general practitioner, working alone, could provide. Other medical service innovations followed, sponsored by federal legislation, various provincial parties or community action itself. Health insurance plans sponsored by doctors were introduced in Saskatchewan in the late 1940's, and grew rapidly, but they remained beyond the means of many and incomprehensive for others. Finally, in December of 1959, provincial Premier T. C. "Tommy" Douglas announced his government's intention to establish a comprehensive medical care program, in accord with five basic principles: 9 prepayment; 9 universal coverage; 9 high quality of service; 9 administration by a public body responsible to the legislature; 9 acceptability to doctors and public alike. RADICAL ELITES There was nothing new or unexpected about the opposition of Saskatchewan doctors to such a plan. They had been registering their total opposition to what they regarded as "state medicine" in publications of the Saskatchewan College of Physicians and Surgeons as far ba& as the early 1930's. In those days, the doctors were a solid part of the "hegemonic" group of Saskatchewan; that is to say, they were a part of the urban elite whose political and economic values dominated the life of the rural province. The farmers, on the other hand, were a "marginal" group at that time. Their needs and preferences, often at variance with the elite group, did not constitute a serious consideration in provincial politics and they did not have the power to enforce them. Doctors coming into the province from eastern Canada or England brought with them expectations of the social status and economic rewards that their colleagues got at home. These expectations were fulfilled, even in this predominantly agricultural society, by the high social standing and income of doctors as compared to the farmers. The doctors were representatives of an older, urban elite in a frontier world. Such hegemonic groups typically resist social change; they are committed to preserving the status quo. These groups take for granted the existing social structure, which seems to express the natural order of things. If a crisis occurs, they attribute it to some force outside the existing social structure. They feel sure that the disturbance will be removed eventually and life will resume its normal course. When the depression struck Saskatchewan in the 1930% the doctors responded in the characteristic fashion of hegemonic groups. In some parts of the province, so many patients had ceased to pay their bills that doctors themselves were on the verge of economic disaster; but many were also 16

concerned that government aid should not disturb the fee-for-service relationship between doctor and patient. It is the groups which are marginal to a society, groups which do n o t have a stake in the status quo, which seek radical solutions in time of crisis. Thus in the 1930's it was the farmers of Saskatchewan who sought radical changes in the existing social structure; the established groups simply tried to hold on until the crisis was resolved. By the 1940's the doctors and the farmers in Saskatchewan had traded positions. The farmers had by then become the hegemonic group. Their ideology had been established in the ruling CCF government. The doctors, although their income and social position remained high, lost ground politically. The free competition economic ideology of the doctors, which was once the dominant ideology in the province, was displaced by the prevailing cooperative ideology of the farmers and workers. The doctors and their allies in the middle class have been displaced from their old positions high up on the power pyramid. Doctors thus became what Economist Everett E. Hagen has called a "displaced elite," ripe for radical solutions in time of crisis. When the CCF first came to power, the displacement of the doctors was obscured by their continuing social and economic rewards. The government, by the slow pace of its social reform measures, contributed to the doctors' illusions about their position. As 1959 came closer, the doctors' approach changed. The strength of the CCF position and the marginality of the doctors' became increasingly obvious. Doctors' pubiic pronouncements adopted a shrill, defensive tone. When Premier Douglas announced in 1959 that he would fulfill his promise of a medicare program if he were reelected, the doctors attempted to mobilize public support, not only for their opposition to medicare, but to the whole orientation of the CCF. Their failure to unseat the CCF government in the 1960 elections, and the enactment of the medicare legislation, forced doctors and their supporters to extreme measures in their challenge to the provincial government. THE DOCTOR DOESN'T ANSWER The Medical Care Insurance Act was passed by the Saskatchewan legislature on November t7, 1961, and was scheduled to go into effect the following April. As soon as the act had passed, events began building swiftly to a crisis: 9 The College of Physicians and Surgeons immediately denounced the act, accusing it of giving doctors "no rights or privileges," while granting to government "wide powers of control over medical practice." 9 Doctors and their partisans began to form protest groups. Propelled by the force of "status sympathy," business and professional people from the towns and cities flocked to organizations such as the Keep Our Doctors Committee. Like the doctors, these once powerful business and professional people felt the squeeze of social change in Saskatchewan. Their protest against displacement had TRANS-ACTION

'Saskatchewan is a land of open prairie, with an economy largely based on the growth of om ~,,,p ~ I,eat. Medical services were spread oxer a thinly populated area, large parts of which became inaccessibleduring fiercewinters."

been expressed through the opposition Conservative and Liberal patties and through organizations like the Chamber of Commerce. Now they could hitch all their grievances against the CCF government to the medicare issue. At various times the KODC contended that under the government plan patients' confidences would be exposed, religious dogma in regard to birth control would be violated, doctors and patients would be enslaved; and the act was seen as a prelude to the takeover of a Communist regime. The existence of these protest groups made it possible for doctors to feel doubly justified; they were defending not only their right to private fees, but the whole free-enterprise way of life. 9 During the winter and spring, all attempts at a settlement (including a government postponement of the implementation of the act from April 1 to July 1) were unavailing. The doctors continued to threaten a refusal to work within the act. 9 At a meeting of the College in May, the physicians set up their plan to withdraw all normal medical services and to provide free emergency service if and when the act went into effect, 9 In the last days of June, meetings between the doctors and the cabinet were called in a last attempt to reach a settlement. The talks ended on June 25 with the announcement that the government, without abandoning the act, had offered doctors the right to practice privately if they wished, and that the College had turned down the offer as unrealistic. 9 On July 1 the act went into effect, and the strike was on. At that time of year, the holiday season for many doctors, the usual number actively practicing in Saskatchewan was roughly between 430 and 470. When the strike was called, 2o0 of these doctors remained available for emergency service, as the College had promised. Saskatchewan's medical needs were provided for, additionally, by some 20 to 40 doctors who opposed the strike and were willing to practice under the act, and by about 80 doctors imported by the government for the emergency, and by an unknown but significant number of doctors who practiced sub rosa. MAY / JUNE

The strike closed all but 34 of Saskatchewan's 148 hospitals, but the doctors' voluntary emergency service kept about 70 percent of the province's hospital beds available for patients who needed them. The doctors' strike, then, never entirely cut off medical services. THE STRIKE BREAKERS The imported doctors were recruited by the Medical Care Insurance Commission, mostly from England, to serve for between two weeks and a month at a guaranteed pay of from $900 to $1800, plus expenses. Of the 102 doctors recruited by the Commission, 87 were reluctantly registered for practice in Saskatchewan by the College of Physicians and Surgeons. The College regarded these imported doctors as strike breakers, but was compelled by its reciprocal agreements with the British Medical Association to grant registration to qualified British doctors. The government supplied these imported doctors to communities which requested their services. In some cases a town council made such a request, only to have the doctor who came to them refused hospital privileges by a local hospital board sympathetic to the striking doctors. But neither the College's refusal to register some imports, nor the antagonism of some hospital boards, could stem the tide. The wages offered were so attractive that applicants continued to arrive. The imported doctors agreed by contract to practice under the Medical Care Insurance Act. Many of them staffed the cooperative clinics which cropped up in numerous communities to provide medical services during the strike. The striking doctors and the Keep Our Doctors Committee regarded them as "scabs, strike breakers, and undesirable economic competitors." When the strike began on July 1, the doctors refused even to negotiate unless the act was suspended or repealed. But by July 18, the leaders of the profession recognized that the emergency service could not be operated satisfactorily for an indefinite period, that many doctors yearned to get back to work, and that the government with its imported doctors was undermining their position. They agreed then to negotiate w i t h o u t suspending the act. The government 17

had brought in a special mediator, Lord Stephen Taylor, to help find a settlement. Lord Taylor was a doctor, a Labor Party parliamentarian, and one of the architects of Britain's national health plan. Lord Taylor arrived in Saskatchewan on July 16; on July 23 a settlement, called the Saskatoon Agreement, was signed by the government and the College. In the agreement, the government agreed to amend the act to provide the doctors with several options on how they could practice: 9 under the act as initially planned, whereby the doctors received payment directly from the Medical Care Insurance Commission ; 9 by billing their patients directly, with the patients then sending the bill on to the commission for reimbursement; 9 in traditional private practice, "outside the act"; 9 by participating in any of several approved private insurance plans. The basic nature of the act--that it was compulsory, comprehensive, and government-run--remained unchanged. The doctors accepted it. AFTERMATH OF A WALKOUT What has happened to Saskatchewan doctors now that the medicare plan has been in operation for several years? In June, 1964, U.S. News and World Report found that the number of doctors practicing in Saskatchewan was up 5 percent since June 1962 ; the doctors were busier and better paid than even before. In October 1965, the ]ournal of the Canadian Medical Association published the results of a questionnaire designed to show how Saskatchewan physicians feel about medicare after three years' experience. The results were based on 242 usable returns on a questionnaire sent to all doctors who had submitted claims for payment to the Medical Care Insurance Commission. These are the findings: 9 How would you vote on a secret ballot to decide whether continue or discard the medicare program ? To continue: 160 To discard : 62 No answer: 20 When respondents are divided into those who practiced in Saskatchewan before the plan and those who have arrived since, 64 percent of the "pre-adoption" doctors and 87 percent of the "post-adoption" doctors would vote to keep the plan. 9 Is the plan a success ? Yes: 149 No: 54 Partially: 11 No answer: 28 Again, the newcomers are more favorably disposed than the old-timers ; 89 percent of doctors who came to Saskatchewan after the plan's adoption thought it successful, compared to 64 percent of those who had practiced in Saskatchewan before medicare. 18

9 Are the medical needs of the citizens being met ? Better: 78 About the same: 94 Not as well: 35 No answer: 35 If the first two groups are combined, then 83 percent of the respondents believe that medical care is **at least as good" as it was before the government plan was established. This survey, reflecting the relative contentment of Saskatchewan doctors with medicare, was conducted by W. P. Thompson, president-emeritus of the University of Saskatchewan. There were vehement protests from the Saskatchewan College of Physicians and Surgeons. The College went so far as to send a letter to all doctors in the province objecting to the questionnaire, asserting that the author was prejudiced, and asking those doctors who chose to respond to send a copy of their reply to the College. This pattern of strong ideological opposition being expressed by a professional organization at the very time its members are adjusting to the status quo is not unusual. The College is publicly committed to an opposition stance and condemning "state medicine" has become part of its function. But the members of the College are engaged, not in ideological combat, but in practicing medicine; they have found that they can work with the act, that their rewards--financial and professional--are more than they had expected. What does this Saskatchewan experience suggest about the current Medicare program in this country? In the America of 1966, one does not speak of a business and professional hegemony, one speaks of the Great Consensus. The function of the Great Consensus is to project a picture of power as diffused rather than as centralized and hierarchical. Doctors are not as near to the power center as they once were. It is their obscured position in the Great Consensus, not dominant but unmistakably included, that dilutes most doctors' fears and opposition to Medicare. Knowing that they still exert some influence, they do not feel impelled to resort to the extreme solutions that a more completely displaced elite would. Even if most doctors were more actively opposed to Medicare, they probably still could not mobilize the wide base of public support that "status sympathy" gave their Saskatchewan counterparts, because their natural allies (other professionals and businessmen) are solidly burrowed into the consensus. That the small AAPS urges open revolt shows the extent of its separation from the majority of doctors and its sense of displacement from the seat of power. Just as the Saskatchewan doctors have learned that they can work within their medical care plan although the College continues to register opposition to it, the American Medical Association will probably continue to perform its role of official protestor long after most physicians in the United States have become reconciled to working with Medicare.

TRANS-ACTION