With this series, the editorial team goes back to the sources of a Quebec model that is struggling in the hope of rekindling its first sparks, those that allowed our nation to distinguish itself from others. Today: its public health system.
In his monologue Moneyin the late 1960s, Yvon Deschamps had found a wonderful formula to convey the painful relationship that Quebecers had with illness. “It is better to be rich and healthy than poor and sick,” he observed. At a time that those under 55 cannot know, more than half the population lived without insurance. When illness struck, the afflicted drew on their savings or relied on Christian charity or social assistance.
It was at this time that the Quebec nation realized that the future belonged to the nations that best cared for their people. From 1966 to 1972, the Castonguay-Nepveu Commission considered ways to provide Quebec with a health system worthy of the modernity to which it aspired. Very quickly, its commissioners concluded that it was necessary to establish “a complete and universal health insurance plan” to complement the deconfessionalization of hospitals and the establishment of a hospital insurance plan in 1961.
Let us recall that in 1957, Ottawa had offered to cover half the cost of such a plan to the provinces before doing it again in 1966 with a similar formula for medical services. Created in 1969, the Régie de l’assurance maladie du Québec (RAMQ) would administer the universal health insurance plan established in 1970. In 1971, the Act respecting health services and social services, which provided for the general organization of services, was assented to.
Our public system was born, and this, without abusing forceps. This pride will have aroused a rare unanimity in homes, which will unfortunately be disillusioned. Incapable of choosing between more coordination and more competition, our governments will succeed one another without managing to break with two sins that have become capital: tug-of-war and compromise.
While the federal government’s outstretched hand has accelerated our shift toward universal care, it has not made its implementation any easier. Under Ottawa’s velvet glove lies a hand that loves arm wrestling. The arguments over health transfers will quickly become a rule that the provinces will repeatedly encounter. Often to gain too little, as evidenced by the latest Pyrrhic victory snatched by the Legault government.
These sterile disputes add to a host of pressures that have become colossal. Medicine in the 1970s mainly treated acute episodes with limited resources. Today’s medicine has a much more elaborate arsenal to treat chronic illnesses that require a lot of human, technical and financial resources. Quebec is not alone in facing an explosion in costs and waiting times combined with impoverishing shortages. It is global. But it has made choices that weigh it down more than others.
The mother of all shaky tinkering, the Quebec compromise was felt from day 1, by granting doctors the status of self-employed workers, in addition to reserving them a fee-for-service remuneration that unfairly benefits them. Our inability to cut to the chase will also have fueled a hospital-centrism that has become insatiable to the point of underfunding all other programs. We are thinking here of the front line, mental health, home care, public health, social services, all in a serious state of deprivation today.
However, the best models – whether from Japan, the Netherlands or Switzerland – are precisely those which have been able to avoid or reverse this infernal spiral of “poor financing”.
A defender of “good care, by the right person, at the right time,” the man who has been dubbed the father of health insurance prescribed several remedies for our ills in 2008. Claude Castonguay’s analysis still holds in 2024: the system urgently needs to be rebalanced toward the front line, its structures streamlined, and our basket of services, which has gone into freewheeling mode, needs to be thoroughly revised.
The overhaul of Health Minister Christian Dubé shares some of the objectives mentioned above, but is overly centralized. It also avoids tackling head-on the disorderly proliferation of breaches in the private sector. The result: in 2024, we have a two-tier system that is well established and… perfectly dysfunctional. The question is: do we want to cut it short? If so, can we still do so, and how?
Health is a chain; all its links are important. Yes, we must promote joint and local work, coordinate it better, break down silos and restore healthy structures to this damaged environment, at human level, both for caregivers and for patients, who too often seek a soul in vain.
The big challenge in the coming years will be to determine what we mean by “universal care” today, and what efforts we are prepared to make to preserve the fairness of a system that was once our pride.