Monique Begin: Ladies Up Stairs!

In January 1973, Monique Bégin was among the newly elected MPs rushing into the House of Commons for the opening of Parliament, when she was stopped at the doors by a Security Commissioner.  Bégin was entering Parliament as one of the first three female MPs ever elected in Quebec, sharing the honor with the late Jeanne Sauvé and Albanie Morin.  The women explained they were both newly elected MPs.  He was directing Bégin and Morin to the public galleries reserved for visitors. He said, “Oh no, there’s no women MPs.”

And he made us stop on the stairs, wait, and he goes and checks.  The commissioner then shouted: “Ladies, upstairs!”

That defining moment is one of many Bégin recounts in her new memoir, aptly titled Ladies, Upstairs!: My Life in Politics and After.  She writes that “such were the times” that there were no women’s washrooms near the House of Commons, and it took months to get one. It was the year 1972 women accounted for 1.9 per cent of MPs; today that figure is 27 per cent.   Before we go into Begin’s story I’d like to highlight below just some of those attitudes and experiences she had to endure when female politicians were very few:

Monique Bégin, left, was first elected as an MP in 1972. In this picture from Sept. 1977, Bégin stands with Jean Chrétien, centre. as Prime Minister Pierre Trudeau announces a cabinet shuffle, in which she was named minister of national health and welfare. (McGill-Queen’s University Press)

On Learning the Ropes in Parliament:

“The only concrete and specific point that remained with me from those presentations was that political parties never assign “safe riding” to women candidates.  It was on the strength of this assertion that I had based my conditions to the PMO before agreeing to run for office.”

“In high heels and a Chanel style white suit, slim and tall, much younger looking than my forty years of age, I enter the Connaught Building dark lobby when the Commissioner asked what I wanted.  I explained I was the new minister.  “Oh! No, Ma’am, I just heard it on the radio: our new minister is a man called Monikue Beghin! I said my name in French and took me, still dumbfounded – a woman and a french Canadian – to the seventh floor to Peter Connell, the deputy Minister. [Later that evening] “And Minister I want you to know that I am also a gentleman farmer from Quebec and mu favorite, cow is called Monica.” I did not react, kept my smile wondering in petto if I should slap him in the face.”

“To tell you the truth, as a woman at the time, one went through moments clearly unacceptable by today’s standards, not reacting add telling oneself, She laughs best who laughs last! Two months later, the same deputy minister [Peter Connell] – at the end of my short speech during the closing dinner for his senior staff workshop in Chateau Montebello, the only woman at the table – pulled my chair back when I tried to sit down, and I found myself on the floor with the guys finding it very funny and laughing.  I decided that that particular half on my first portfolio shed the “officers’ mess” culture.”

Monique Begin [Source: uottawa.ca]

“It was taken for granted that Quebecers were bilingual.  My biggest problem was idioms, which could be identical in our two official languages or completely different!  Which of course, on never learns at school.  So I regularly replied to questions in House by translating the French idiom to English word-for-word: Mr. Speaker I always call a cat a cat!”  I never heard a word about it.  It was only years later when Judy Eroke joined Parliament that she asked me what I meant, that I learned the English idiom: to call a spade a spade.”

“For all practical purposes, in the daily Liberal environment I was the only woman in an eminently male world constantly punctuated by a language that I had never heard before that was not mine. …”Kill a bill”. Discussions constantly focus on “the enemy” or “the adversary,” “attacks”, “traps”, “ambushes”, electoral “battles” and “victories”.  “To resort to the use of force,” “the strategy” and “the strategists,” “reserves” and “tactics” are expressions used in many cases.  “To have your back to the wall,” “trench warfare,” “to go on the offensive” or on the “counter-attack,” “covering the rear” are others.”

“As the regiment mascot, I was treated in a friendly manner by my colleagues in the Quebec caucus during my very first year.  Then without understanding why, I began to hear nasty and slanderous remarks about me, which hurt.  It was not until much later that I realized that this change coincided with my first responsibilities: co-presidency of the first national party convention to review the Trudeau leadership appointment as permanent delegate to the United Nations, and elected vice president of the national Liberal caucus.  I was no longer the charming caucus newcomer; I was a competitor, and it was war.”

Five women framed by the arches of Centre Block on Parliament Hill. [Source: Globe and Mail]

Although Begin co-founded the Quebec Federation of Women in 1966 under Therese Casgrain’s leadership, you don’t get the sense that she thought of herself as a “feminist” but was often labeled as one.  “Because there were so few women and because I was “The official Feminist”, I want to clarify that I was never the only woman in Cabinet, and that I was never responsible for the Status of Women!  Most people still state that I was!”

“1975 opened on the theme of women, with the first UN “International Women’s Year”.  At the end of February and beginning of March, Franciose Giroud, the well-known journalist and co-founder of the magazine L’Express, by then appointed Secretary of State for Women, invited women politicians and feminists senior civil servants to Paris for a conference-celebration..My memory is of a rather elitist and arrogant attitude of the French organizers and participants towards us, although they did not have much to teach us.  But I will always remember with pleasure the grand and very elegant evening they offered to host us at the Opera Garnier, which as a poor student, I had known only from the outside!”

“A month after my appointment, on November 20, General Francisco Franco, of Spain died after a long illness…I had to leave Ottawa at once for the state funeral, welcomed by our ambassador Georges Blouin and his wife, Denise, at their official residence.  The weather was gorgeous on the morning of my landing in Madrid but on the cold side.  Blouin informed me that my elegant black coat I had just bought at Holt Renfrew – not reimbursed, no need to say – was “not on level” with the situation- it was not chick enough.  Our ambassador asked me to wear his wife’s fur coat, which I politely refused to do. He then had his chauffeur take us to an elegant shoe store, where he asked me to try on and purchase (at my expense, not reimbursable, of course) a pair of high heeled, exquisite, long, fine, leather, black boots, very expensive and totally impossible to wear in our Canadian weather!  As a sociologist, I was starting to discover the standards of the super-wealthy and powerful Spanish aristocracy, but I was also insulted by the requests of our ambassador, otherwise a fine human being.”

Begin has achieved many accomplishments under her belt during her life as a politician, bursting early on to the scene she became executive secretary of the Royal Commission on the Status of Women, she ran for the House of Commons and served various cabinet positions yet her most notable accomplishment was her work spearheading the landmark Canada Health Act (1984).

What’s wrong with Medicare

The Canadian system  was mandated to control three sub-sections; hospitals, physicians and administration.  No other sector.  In 1971 both nations, Canada and the US’s health care costs stood at 7% GDP.  It was a time Canada decided to convert its health care system to the publicly controlled single-payer system and the US decided to stick with a market-driven private system.  In 1975, Canada’s public funded more than three-quarters (76.4%) of the total health-care bill, while private insurance and direct-out-of-pocket payments covered 23.6% .  Since then the public health system is being partially replaced with unpaid (mostly) women’s work and for-profit health care.  By closing hospital beds and laying off nurses, our political leaders have effectively offloaded their responsibility onto the community – still another form of privatization.  Families and friends (mostly women) are having to do what the system used to do for us.  When  this is done we then none of the work that is carried out, which used to be paid work, is accounted for in the monetary economy.  At a time where provinces, especially Ontario, are having to conduct massive cuts to public health in favor of paying off the provincial deficit and privatization, we should pause and reflect the nature of the our health care system which is a characteristic of our national identity. Our healthcare system is  envied around the world.

Jovial adversaries: Federal Health Minister Monique Begin promises to send Keith Norton, her Ontario counterpart, a little calculator so he’ll see Ottawa pays its fair share for Medicare. But Norton said he’ll give Begin a free course in arithmetic. [Toronto Star License – Toronto Public Reference Library – Digital Archives]

During her time as a Liberal MP in former Prime Minister Pierre Trudeau’s cabinet, Bégin advanced federal policies concerning issues of inequality, health, poverty and women’s rights.  She introduced the child tax credit — her “number one victory” — to ensure the universality of social programs and family allowances.  Bégin is best recognized for spearheading the Canada Health Act, which sought to remove economic barriers to health care. The story of Monique Begin and the Canada Health Care Act shows just how contentious relations can be between provinces and the feds. “I had no idea at the time that simple phone call in 1979 would be the beginning of over five years of more or less uninterrupted negative, and then very unpleasant, mostly public interactions between the provincial health ministers, me and the federal minster, about our health-care system.  I had no idea that it would turn into serious accusations from the provinces, followed by vicious public comments about how stubborn I was.” The policy sparked heated debates across the country and Bégin endured vulgar, often sexist insults from doctors and provincial ministers for years. “It is hard even to relive it. It was very painful,” she recalled.

“I had determined that medicare as an institution was a fragile equilibrium between the three parties: physicians (organized medicine), the federal government, and the provincial and territorial governments.  They could each take control of it. This delicate equilibrium had to be constantly renegotiated despite all of the negative situations, it was hard to figure out what had been completely polarized through to general elections and had turned highly partisan.”

Passing the Canada Health Act would be Begin’s last contribution to Canadian politics exiting the same time as Pierre Trudeau.  Having read the chapter on the Health Care Act, I developed a new appreciation for the job of federal ministers, a deepened respect for the challenges Begin had to face being a woman in politics, acknowledging the underpinnings of the Charter Rights embedded within the Health Care Act and a renewed sense of ownership that all Canadians should share for medicare – it was made for the public and it was the public that told Ottawa what they wanted and through Begin, medicare was saved.  This is Begin story about Medicare.

Royal commission: Education Minister Dave Cooke, centre, Introduces task force members: clockwise from his right, Gerald Caplan, Monsignor Dennis Murphy, Manisha Bharti, Avis Glaze, Monique Begin. [Source: Toronto Star License – Toronto Public Reference Library]

The Health Care Act (1984) was meant to address the problems of the day and it did with great success: the erosion of a free health-care system for all by additional payments “at the door.”  It addressed physician user fees and extra billing and physicians  were opted in and out of the public and private system. That had to end. They were either in or out.  “Surreptitious de-listing or de-insurance of services by provincial governments; private clinics operating both within and outside provincial plans for “medically necessary services” (and their medical practitioners keeping hospital privileges and having it both ways); treating  GPS or specialists directing their patients to private labs and clinics for regular procedures for the full out-of-pocket cost; hospitals charging partial costs for exams because these might not be “medically necessary” (wanting an MRI is not like choosing to color your hair!)” she said pointing to all these are the reasons for the erosion of Canadian medicare.  Additionally, a huge barrier leading to these breaches of accessibility is the unacceptable wait times at emergency departments and for surgeries.  I’ve highlighted below some excerpts from “Ladies Up Stairs!” to give you an understanding of how contentious it became trying passing  the Act and personal resolve on the part of Begin to get it done!

Creating the Canadian Health Act: Two Difficult Meetings

Justice Hall’s Report – September 29, 1980

Tommy Douglas, the father of Medicare, reflected on the continuing need for health system reform at the conference in Ottawa in 1979, Begin would have taken on the Canada Health Act within a year of his statement.  He noted that those involved in the original development of what became Medicare saw health system reform as a two-phase process with removing financial barriers being the first phase:

[Tommy Douglas Web Page]

“Phase number two would be the much more difficult one.  That was to alter our delivery system, so as to reduce costs, so as to place the emphasis on preventive medicine….What we have to apply ourselves to now is that we have not yet grappled seriously with the second phase.  We must now move increasingly to group practice….to make possible the practice of preventive medicine.  Only in that way we are going to be able to keep the costs from becoming so excessive that the public will decide that Medicare is not in the best interests of the people of this country.” (Douglas, 1979)

Justice Emmet Mathew Hall [Source: Wikipedia]

Emmet Hall was a lawyer and civil liberties advocate, he was known as one of the fathers of the Canadian Health Medicare along with fellow Saskatchewan Tommy Douglas.  Hall was appointed King’s Counsel in 1935 and elected a bencher of the Law Society of Saskatchewan and later became the President of the Society in 1952. He also taught law the the College of Law.   During the Royal Commission  on Health Services (1961)  about the induction of universal healthcare, Hall became  a member of the Supreme Court of Canada.  Hall was a strong  supporter and fierce defender of social justice always advancing its agenda ahead of “position” and although he was a member of Canada’s privileged elite, he developed a reputation for himself as an “establishment radical”. Therefore he was the best person to review and provide recommendations for improvement through his report on medicare.  Hall was a firm believer that medical care should always be accessible to Canadian on the same terms and conditions regardless of your financial status.  Therefore, Justice Hall was the best person to review and provide recommendations to Canada’s Health Care Act through his report and in effect preparing our legislation for “phase II” of medicare.

Cherished honors: It was one of the big moments of her life, said Monique Begin of U of T honors yesterday. With her are, left to right, Dr. Fraser Mustard, Dr. John W. Scott with U of T mace, John Black Aird, Emmett Hall. [Source: Toronto Star License – Toronto Public Reference Library – Digital Archives]

Justice Hall’s report was released to everyone at the same time, by personal delivery, the day he tabled it on September 2, 1980. The report was very clear.  There was no diversion of federal  funds.  Extra billing by doctors was unacceptable.  Equally unacceptable were the premiums charged by three of the provinces, and user fees in most provinces.  At the same time Justice Hall opened three new fronts: in case of a stalemate in negotiations between doctors and their provincial government, binding arbitration should be instituted.  Immediate action should be taken to reduce the enrollment of faculties of medicine, as there were too many doctors and finally the poorer provinces especially the four Atlantic provinces should receive extra money from the federal government.

Begin’s was very pleased with the report along and her department officials were pleased as well.  They decided to hold a federal-provincial conference with Justice Emmet Hall as the special guest.  The meeting was set for September 29 in Winnipeg, where the provincial Ministers already were having their annual conference.  However, three weeks prior to the event Begin felt very uneasy sensing that the upcoming conference would be the  most unpleasant federal-provincial conference she had ever attended matched only by her experience at the Halifax conference in 1983.

In the days leading up to the conference provincial ministers, national and provincial medical associations, and individual physicians from across the country kept giving partisan interviews for and against making warlike statements and threats.  On the whole, however, the response was rather confusing for Begin.  Yet she maintained that they would come to an agreement once they’d gather together in camera because “we were all in it together; we had all been singled out in the report.  The future of medicare was what counted now.”

The meeting lasted barely half of the day, and the only scenario Begin had not envision, to her surprise, actually happened.  Justice Hall was ridiculed, several ministers laughed in his face completely rejecting his report and recommendations.  They would not be the only ones.  Later the Ottawa Citizen reported that some doctors had answered the report saying: “This country does not need to listen to the report of a man with one foot in the grave.” Several provincial ministers attacked Begin outright.  The meeting poisoned relationships right off the bat! In general, health professionals other than physicians – nurses, hospital administrators and others were satisfied with Justice Hall’s report.  As for the CMA, it had begun a study of the possibility of the unionization of doctors.  Its outgoing president.  Dr. Larry Wilson condemned Hall’s report, while the new president Dr. W. Thomas encouraged doctors to take overt political action.  War had be declared by organized medicine!

The timing of this was rather poor – it could not have come at a worse time for Begin and the Liberals.  They were doing well in the polls hovering at 50%.  The 1980 Quebec Referendum had just been won by the federal forces and the idea of repatriating the Canadian Constitution had created a climate of good faith and generosity throughout the country.  For Trudeau, repatriation was the only issue that counted. For Trudeau it was truly the dream of his life.  The resolution for repatriating the Constitution was tabled one month after the Justice Hall’s report was released and the dreadful conference in Winnipeg.  On October 6, 1980, with its own ups and downs, successes and dramas, this fundamental question for a nation together with the Charter of Rights and Freedoms, would stay in the limelight until Queen Elizabeth II signed the documents in Ottawa two years later on April 17, 1982.

Queen Elizabeth II signs Canada’s constitutional proclamation in Ottawa on April 17, 1982 as Prime Minister Pierre Trudeau looks on. Star photo Ron Bull Apr 17 1982.
Begin’s soon would find herself alone to handle problems with medicare, the file wasn’t on the government’s agenda at that point for it too was competing for attention with a busy agenda and turned to totally different questions, starting with the constitutional dossiers.  More dossiers had been given  priority, for example, Marc Lalond’s national energy program, the Federal Budget and the issue of private pension planned reform pushed by Finance and supported by Privy Council that Begin Co-Chaired with Allan MacEachen.

Two long years would pass, yet the issue on medicare would not disappear thanks to the NDP, some Liberals members from several provinces, committed reporters in the media and groups that had submitted briefs to the Justice Hall’s hearings kept the matter at the forefront.  Begin couldn’t discuss the medicare file with her peers due to a rigid government system.  Collegian exchanges between colleagues simply could not be tolerated.  The prime minister told them that he didn’t want a few ministers meeting among themselves.  Begin could not be political with the file or assess political situations with her senior department nor civil servants and other as it would have been viewed as conspiracy, a power plot or worse.  As such from the outside it looked as if the Health dossier was going no where and the Federal Minister was either uninterested or totally indecisive.

“Immediately after the Hall report was released, I received a letter from the prime minister reminding me of my budgetary restrictions and insisting that delivery of an integral health-care system are the provinces responsibility.  Through all my years in Cabinet,  I had never heard of a minister receiving such a letter.  Mandate letters such as those that Justin Trudeau’s ministers received in 2015 did not exist at the time.  It was obvious that the Privy Council, the “department” in charge of the government’s general direction, had informed the prime minister that there would be no way out for me if it was based on a request for more money.”

With no solution in sight Begin decided to participate in the annual meetings of Health Ministers of the World – The World Health Assembly conference was held every May in Geneva. In the last six months of 1981 through to 1982 medical associations continued with their ad attacks purchasing full page ads in daily newspapers trying to spread fear among Canadians terrifying the public with ridiculous statements such as “Civil servants will now decide what to do about your health problems and health treatments.  Don’t Let them!”  The CMA paid for what Begin called sickening radio ads she had to listen to on her drive in to Parliament Hill “As a practicing physician, I want you to know what Monique Begin is doing is dangerous for your health” along with the fable of civil servants taking

Monique Begin [Source: Toronto Star License – Toronto Public Reference Library (Digital Archives)]
Yet despite it all Begin’s personality and sense of human relations is what got her through most heated exchanges regardless of what disparaging pieces were written and said about her in the media. This speak to her strong sense of character and why Begin is respected and well liked by many.  You’d never hear Begin personally attack or insulted anyone publicly or behind closed doors, in camera, federal-provincial meetings, on medicare or on any other topic.  Begin return from a trip to China on a health delegation and entered into 1983 which was a turning point in the medicare saga. She had a small team to explore  legal actions while drafting an implementation strategy. As 1983 progressed so did the personal attacks Begin as a federal minister.  She received many letters that were sent opposing her work many were virulent, vulgar and sexist.  One doctor she writes sent her a letter on his letterhead (but sent it to the department’s official address, not even the House of Commons) with a prescription for hormones “to combat your menopause, as it is clear that you are crazy.”I personally enjoy here interactions with Pierre Trudeau.  You get the sense he had always respected Begin, available to her when she needed his advice and in turn he fully trusted her decisions and capabilities.  Here’s an excerpt: One day during question period, as soon as he was freed from questioning by the Opposition Leaders Begin walked over to Trudeau and asked for his advice:

“Boss I just don’t know where things are going with medicare anymore.”

“Who are the players and where do they stand on the Canada Health Act?” he asked

“The ten provinces are opposed: not just their ministers of health but their ministers of finance and  their premiers.  All of organized medicine is opposed.  All the official elites are opposed.” was my reply.”

“Where is the population in all of that?”

“In favour of the Bill.”

“That’s a sure win,” his stern answer, “Like the Constitution.” he added.  I always knew he trusted me completely, and his reassurance was extremely important: the information he was receiving from those around him kept telling him that the public’s support was neither assured nor obvious even, if it existed at all.”

Begin submitted three constitutional options for Justice to review and they agreed with all three approaches would be acceptable in the courts as a reasonable exercise of spending power.  A tabling bill was drafted that was short and an easy reading.  Bill C-3 would only have 13 short pages.  Begin added a fifth condition, clarifying the concept of “universality” with that of “accessibility”

Five key criteria for “complying” with provincial health insurance arrangements were:

Public Administration: requires that the administration and operation of the health-care insurance plan of a province be carried out on a non-profit basis by a public authority responsible to the provincial government.

Universality: requires that all residents of a province be entitled to public health-care insurance coverage.

Accessibility: requires reasonable access unimpeded by financial or other barriers to medically necessary hospital and physician services for residents, and reasonable compensation for both physician and hospitals.

Portability: requires that coverage under public health care insurance be maintained when a resident moves or travels within Canada or travels outside the country (coverage outside Canada is restricted to the coverage the resident has in his or her own province)

Comprehensiveness: requires that all medically necessary services provided by hospitals and doctors be covered under the provincial health-care insurance plan.

Monique Begin speaking at Wilfrid Laurier University [Source: Ourontario.ca]

Here’s another interaction I like that Begin had with Trudeau.  It was to tell him, among other things that she was leaving politics – the same time as he was leaving politics:

“I requested a private meeting with the Prime Minister on June 22, 1983 and spent about thirty minutes with him as he was not good with small talk and I was not much better.  I started the conversation a bit abruptly, asking him politely if he was for or against the proposed Canada Health Act.  He looked at me a bit puzzled, and very much ‘a la Trudeau’, and replied simply, “The first Royal Assent that I signed as Prime Minister in 1968 was for the Medical Care Act.”  He said nothing more.  I thanked him immediately understanding that his last Royal Assent would be ” my” Act. Then I informed him of my plans to leave politics at the call of next election but asked him to keep it private as I still had lots of do and did not want to be seen as a ‘has been’.”

Begin continued with a media and promotion campaign to spread the word about Canada’s Health Act and everywhere Begin went to speak she was met with a fully packed meeting room.  Hundreds of thousands of promotional materials were distributed across the country. “The silent majority had a voice.”  Even Federal Ministers around the Cabinet table returned from their weekends at home where they had been told by their constituents to save medicare.  Publication of the federal government’s position paper in the summer of 1983 had given the project new legitimacy and the impending Canada Health Act was a compelling reason for all parties to get involved.  “The Provincial Minister’s strategy had been to invite me to their annual meeting in Halifax that September to try to stop the bill once and for all.”

Convincing the Provinces
The second dreadful experience for Begin was her meeting with the provinces in Halifax:

Begin arrived in Halifax on September 7th alone, “”invited” by my provincial counterparts.”  The meeting was behind closed doors, with provincial politicians and senior officials there in full force.  “It looked  as if all the reporters of the country were awaiting the outcome at the doors of the hotel.  I was feeling ill at ease.  I outlined my position, now the official federal position, again:  the reasons for our actions and our projected schedule.  I repeated that as soon as the Bill was fully drafted, they would be the first to get a copy.  Then we would begin the usual parliamentary process and contemplate eventual changes.  The atmosphere of attacks and jibes reached a peak.  Those in the meeting – one against ten, with me the only woman, an Ottawa “French power” francophone Quebecer – used all sorts of abusive arguments and personal remarks meant to humiliate me.  Luckily, I don’t cry easily, and I didn’t cry then.  After three hours of this very stressful exercise in which the dice were loaded against me, I returned to Ottawa. The media all agreed that with such unanimity from the provinces, I was the loser at the conference and this was a no-win situation.”

“December 12 – two days later, after caucus, in the middle of Question Period, Yvon Pinard suddenly came to my desk and whispered in my ear that the Progressive Conservative’s Health Critic, Jake Epp, had just announced to the media the Conservative caucus’s support for Bill C-3!  I had always predicted to those around me that this would happen after having studied their new leader, Brian Mulroney, but no one really believed me – except Trudeau, who reminded me afterwards.”

[Source: Toronto Public Reference Library – Digital Archives, Toronto Star License]

“The Opposition’s reactions ranged from sublime, with Mulroney stating that “medicare is a sacred trust that we will always preserve,” to the vulgar, with the Conservative MP from Calgary Centre, Harvie Andrew describing me to the Calgary Herald as “Begin, that disgusting woman!” The comment from the CMA president, Dr. Everett Coffin, was a gem: “Surely the Canada Health Act is a rape of the spirit, if not the legal stipulations of the Canadian Constitution.”  I’ll conclude with Medical Post’s repugnant comment: “Although I can’t for the life of me recall the source of the line, it’s something to the effect that if you’re going to be raped, you might as well lie back and enjoy it.”

Begin wasn’t out of the woods yet.  There were  few including Jean-Claude Deschenes and Pierre Marc Johnson who declared that the project was unconstitutional and accused Begin of breaking the “federal-provincial agreement signed between Begin and his predecessor, Denis Lazure.”  “He seemed genuinely angry – much angrier than when he had to challenge me publicly to satisfy the Quebec Ministry of Inter-Government Affairs.  “The Begin-Lazure Angreement?  What Agreement?” Then he’d start questioning this or that paragraph of the Bill and I saw at once that the French version had a few unfortunate and major translation errors.  I immediately apologized and promised necessary corrections.  The whole meeting was most unpleasant but I managed not to lose my patience.  My suspicion on the way back home from that unreal encounter was that Johnson’s theatrics was merely the dress rehearsal for the public show he would give over four weeks, culminating in his appearance with busloads of Quebec hospital elites – medical school deans, top civil servants, medical directors, and administrators of all major  hospitals, pressure groups – a total of some fort notables. He succeeded in the role of the ultra-nationalist shaking Ottawa’s constitutional confidence.  And he had misled me, assuring me that Quebec did not have user fees.  And here I had sworn to Marc Lalonde that there would be no penalty for Quebec, as they had no user fees!”

The file continued to with its hurdles and  major problems and then finally after an amended preamble for the better there was unanimous final passage of the Act on April 4, 1987 in the House of Commons and Royal Assent on April 17, 1984.  It was finally complete! Yet there still were some regrets and disappointments for example, not including nurses and only recognizing doctors and hospitals in the Bill.  “After the unpleasant and often painful last few months of the Canada Health Act showdowns and clashes, I welcomed a change of scene – a chance to decompress and relax and get some distance from the situation.  I wanted to participate in the first few days of my last WHO World Health Assembly.”

Monique Bégin. (Photograph by Chris Roussakis)

Yet it wasn’t over for Begin, during the 1984 general elections she had to impose the dollar-for-dollar financial penalties on seven provinces, totaling $9.5 million; Newfoundland, PEI and Nova Scotia had ended their financial surcharges before the Federal Election. Penalties were imposed in Quebec for their user fees every month up until Robert Bourassa’s election in 1985.  In fact, Quebec lost close to $800,000 in 1984 and when the Liberals took over they reluctantly abolished the user fees altogether.  Three years later,  in July 1987 penalties were imposed from the Canada Health Act totaling  close to “$250 million that the federal government had retained were fully reimbursed to the provinces as they had finally put ‘their houses in order’….Judith Erola, we both left the House of Commons after September 4, 1984 elections, she being defeated, me leaving politics of my own volition.”

Lessons Learned
Okay, now fast forward to 2019 and we’re still facing some critical issues with healthcare.  Our overall policy settings are sound, there’s no doubt about it – Medicare is sustainable –  the fundamentals of healthcare in Canada are right, we do not need “Big Bang” reforms.  There are, however, a host of changes required to respond better to emerging needs and to keep Medicare sustainable into the future and these changes can be done incrementally.  We are now managing a generational shift where the Baby Boomer generation are now reaching senior age and as such we will now have to add senior’s home care to the conversation among other issues  (i.e. Pharma-care/national drug plan).  Thankfully, this generation knows how to take better care of themselves than previous generations and are living longer because of it therefore the worry isn’t as high as the fear-mongering it once received.  However, keep in mind the rising number of chronic illnesses that puts a strain on our system, our fertility rates are down meaning less number of individuals entering the workforce which might affect the amount of disposable tax dollars to spend on the healthcare and with the shrinking workforce, it then gets even smaller when we are employing robots to do jobs that humans once occupied. Robots don’t pay taxes.

That said, healthcare is still sustainable.  Stephen Duckett wrote a few comprehensive books on Canada’s healthcare system and provided some excellent ideas in ways that in which we can answer the call to our ever changing times and demographics.  I like this one, for example from his book “Where to from here? Keeping Medicare Sustainable”, he says:  ” But  most of the change that is necessary will be in terms of the health systems, particularly how chronic care is managed and in terms of improving efficiency.” He provides a little mantra we should all get to know and think on how we can implement, he says:

Political leader and activist, Monique Begin, was the first woman from Quebec to be elected to the House of Commons, and served as Minister of National Health and Welfare under Prime Minister Pierre Elliot Trudeau. She was one of five women honoured by the Famous 5 Ottawa and the Governor General April 21, 2016. (JULIE OLIVER/POSTMEDIA)

“The right person enables the person enables the right care in the right setting, on time every time.”

Each of these words are important. Duckett provides a comprehensive breakdown of the sentence, I’ll try to paraphrase:

Right Person: to ensure that the full potential of all health workers is used, that all work to their full scope of practice, doctors do what doctors do, nurses do what nurses do, aides are used to full potential and so on. Benefit: from perspective of job satisfaction and economic perspective (I would add “safety” too).

Enables: health utilization is increasingly about managing chronic diseases. The health care discourse should recognize “co-production” the person with the disease is an important partner in care, therefore, the strategy should be about  informed demand.  What changes is the language of the role of the health care provider who is an “enabler” of care supporting the person (caregiver and family) with managing their chronic disease.

Right Care: This is about knowledge exchange about what is the best care as it is not always implemented in a clinical practice until about a decade or so after its first established.  identify best care, develop protocols to facilitate us in practice and benchmark the outcomes.  “”Right Care” also implies that the care is provided efficiently.”

Right Setting:  Sometimes getting the right care imposes travel and dislocation costs on patients and their families.  An important concept here is the “least restrictive alternative” with an emphasis on maintaining independence as much as possible for patient/resident seniors’ accommodation perhaps care at home , via telephone consults and in local and community settings.  that would mean an emphasis on primary care rather than secondary care, ambulatory care rather than inpatient care and an emphasis on getting patients home as quickly as possible.

On time:  Duckett says the phrasing of the Canada Health Act criterion of “reasonable access” explicitly addresses financial barriers to access, but long waits also impede access. For example, waits for a small list of elective procedures and diagnostic services, but the access agenda needs to be broadened to include waits to see a specialist, and waits in an emergency.  Timeliness of access across the whole continuum of care thus needs to be assured and demonstrated.

Every time:  Consistency, consistency, consistency! In terms of right care (in the right setting) and on time, thus linking to both timely access and good quality.  Safety and quality of care is equally important. “Every time” also connotes “for everybody,” emphasizing the importance of equity in access and provision.

[Source: Ottawa International Writers Festival]

There is much more to say about our Canada Health Act and how we can improve and expand on what was started by Tommy Douglas and Emmet Hall for which I will leave for an upcoming blog entry as this is a written piece to spot light a woman of influence and admiration.

Many Thanks Begin!
Reading just one chapter of Begin’s book about the Canada Health Act and learning all that she had to go through is emotionally exhausting! It seemed that bringing the Act to Royal Assent was supposed to be an easy job, nobody knew how difficult the file would turn out to be – man or woman – it was a fearsome ride.  But especially for Begin breaking the glass ceiling on many “firsts of…” in the world of politics, and having to forge the path for every female politician that came after her baring the brunt of unprofessional, unsavory and un-statesman behavior, I’d say we ladies, have much to thank Ms. Begin for her service.  She preferred to make peace and she did so by keeping her nose to the ground, focusing on outcomes, creating partnerships,  maintaining patience and a positive attitude, no bad talking, gossiping or game playing – she certainly showed us women how ‘curb the estrogen outbursts’ and focus on  getting “it done” when drowning in a sea of testosterone.   She certainly displayed all the characteristics required when searching for a female leader.  (See: Women’s Political Party – Female Leadership) She made allies rather than enemies, she kept her sense of humor, she looked for solutions rather than ‘throwing people under the bus’, she took breaks to care for her mental health and most heart warming of all she had a boss who supported and believed in her!