1 Strikes occurred in Winnipeg in 1933–1934, in Saskatchewan in 1962, and in Quebec in 1970; limited job actions have also been undertaken at various times in different provinces during the negotiation of fee schedules. Only in the case of the strike of Quebec specialists over the introduction of medicare in that province in 1970 did the profession not gain significant concessions as a result—and the failure to do so in that case is arguably attributable to an exogenous factor, namely the political crisis surrounding the kidnappings of public officials by the Front de libération du Québec. See Naylor, C. David, Private Practice, Public Payment: Canadian Medicine and the Politics of Health Insurance, 1911–1966 (Montreal: McGill-Queen's University Press, 1986), 252–53;Google Scholar and Taylor, Malcolm G., Health Insurance and Canadian Public Policy (Montreal: McGill-Queen's University Press, 1978), chaps. 5, 7Google Scholar.

2 As described below, the dollar amount of extra-billing was estimated at the equivalent of 1.3 percent of total physician billings under medicare on a nation-wide basis; in no province did it exceed 3 per cent. Extra-billing physicians did tend to “cluster” in particular localities and specialties, but their billings were diffused in those areas across consumers who had no established countervailing group mechanism. It might also be argued that the costs of extra-billing came to be “concentrated” in provincial government budgets through the federal penalties imposed under the Canada Health Act (also discussed below)—but this was an artifact of policy part-way through the policy process, and in any event these penalties amounted to less than 1 per cent of provincial health budgets.

3 The following is a selection from an extensive literature. Olson, Mancur, The Logic of Collective Action (Cambridge: Harvard University Press, 1965);Google ScholarWilson, James Q., Political Organizations (New York: Basic Books, 1973);Google ScholarMoe, Terrence M., The Organization of Interests: Incentives and the Internal Dynamics of Interest Groups (Chicago: University of Chicago Press, 1980);Google ScholarTrebilcock, M. J., Hartle, D. G., Prichard, R. S., Dewees, D. N., The Choice of Governing Instrument, a study prepared for the Economic Council of Canada (Ottawa: Minister of Supply and Services, 1982), 8–10Google Scholar.

4 Edelman, Murray, The Symbolic Uses of Politics (Urbana: University of Illinois Press, 1964);Google ScholarTrebilcock, et al., The Choice of Governing Instrument, 55–61,67–71;Google ScholarFreeman, A. Myrick and Haveman, Robert H., “Clean Rhetoric, Dirty Water,” The Public Interest 28 (1972), 51–65;Google ScholarMcLean, Iain, Public Choice: An Introduction (Oxford: Basil Blackwell, 1987), 34–39Google Scholar.

5 See, for example, Wilson, , Political Organizations, chap. 16;Google Scholar and Stigler, George, “The Theory of Economic Regulation,” Bell Journal of Economics 2 (1971), 3–21CrossRefGoogle Scholar.

6 Derthick, Martha and Quirk, Paul J., The Politics of Deregulation (Washington: The Brookings Institution, 1985)Google Scholar.

7 Noll, Roger G. and Owen, Bruce M., “What Makes Reform Happen?” Regulation 7 (1983), 19–24Google Scholar.

8 Derthick, and Quirk, , The Politics of DeregulationGoogle Scholar.

9 Morone, James A. and Marmor, Theodore R., “Representing Consumer Interests: The Case of American Health Planning,” in Marmor, Theodore R. (ed.), Political Analysis and American Medical Care (Cambridge: Cambridge University Press, 1983), 76–95Google Scholar.

10 By “mix” is meant the labour and capital intensity of the procedures and services provided.

11 Schieber, George J., “Health Spending: Its Growth and Control,” OECD Observer 137 (November 1985);Google Scholar in addition, a 0.8 per cent annual increase was attributable to population growth.

12 Ibid.

13 Stone, Deborah, “Professionalism and Accountability: Controlling Health Services in the United States and West Germany,” Journal of Health Politics, Policy and Law 2 (1977), 38CrossRefGoogle Scholar.

14 Schwartz, William B. and Aaron, Henry J., “Rationing Hospital Care: Lessons from Britain,” New England Journal of Medicine 310 (1984), 52–56CrossRefGoogle Scholar. See also Enthoven, Alain, Reflections on Improving Efficiency in the National Health Service (London: Nuffield Provincial Hospitals Trust, 1985)Google Scholar.

15 Heidenheimer, Arnold J., Heclo, Hugh and Adams, Carolyn Teich, Comparative Public Policy (2nd ed.; New York: St. Martin's, 1983), 61Google Scholar.

16 Bjorkman, James Warner, “Who Governs the Health Sector?” Comparative Politics 17 (1985), 417Google Scholar.

17 Starr, Paul, The Social Transformation of American Medicine (New York: Basic Books, 1982), chap. 5Google Scholar. See also Relman, Arnold S., “The New Medical-Industrial Complex,” New England Journal of Medicine 303 (1980), 963–70;CrossRefGoogle Scholar and Fuchs, Victor R., “The Battle for the Control of Health Care,” Health Affairs 1 (1983), 5–13CrossRefGoogle Scholar.

18 Pattison, Robert V. and Katz, Hallie M., “Investor-owned and Not-for-profit Hospitals: A Comparison Based on California Data,” New England Journal of Medicine 309 (1983), 347–53;CrossRefGoogle Scholar and Lewin, Lawrence S., Derzon, Robert A. and Marguilies, Rhea, “Investor-owneds and Nonprofits Differ in Economic Performance,” Hospitals 55 (1981), 52–58Google Scholar.

19 Naylor, , Private Practice, Public Payment, 251;Google Scholar and Fuchs, “The Battle for the Control of Health Care.”

20 Tuohy, Carolyn, “Conflict and Accommodation in the Canadian Health System,” in Evans, Robert G. and Stoddart, Greg L. (eds.), Medicare at Maturity (Calgary: University of Calgary Press, 1986), 393–434.Google Scholar See also Gilb, Corinne Lathrop, Hidden Hierarchies: The Professions and Government (New York: Harper and Row, 1966);Google Scholar and Bjorkman, James Warner, “Professionalism in the Welfare State,” European Journal of Political Research 10 (1982), 422–23Google Scholar.

21 Tuohy, C. J., “Medical Politics After Medicare: The Ontario Case,” Canadian Public Policy 2 (1976), 192–210;CrossRefGoogle Scholar and Wolfson, A. D. and Tuohy, Carolyn J., Opting Out of Medicare: Private Medical Markets in Ontario (Toronto: University of Toronto Press, 1980), 11–14Google Scholar.

22 Barer, Morris L. and Evans, Robert G., “Riding North on a South-bound Horse? Expenditures, Prices, Utilization and Incomes in the Canadian Health System,” in Evans, and Stoddart, (eds.), Medicare at Maturity, 80Google Scholar.

23 Ibid., 88.

24 Tuohy, Carolyn, “Federalism and Canadian Health Policy,” in Chandler, William and Zollner, Christian (eds.), Challenges to Federalism in Canada and the Federal Republic of Germany (Kingston: Institute for Intergovernmental Relations, Queen's University, forthcoming);Google Scholarlnglehart, John K., “Canada's Health System: Addressing Problems of Physician Supply,” New England Journal of Medicine 315 (1986), 1623–28;Google ScholarLomas, Jonathan and Barer, Morris L.. “The Legacy of Canadian Health Manpower Policy,” in Evans, and Stoddart, (eds.), Medicare at Maturity, 258–59;Google Scholar Barer and Evans, “Riding North on a South-bound Horse?”

25 Barer, Morris L., “Regulating Physician Supply: The Evolution of British Columbia's Bill 41,” Journal of Health Politics, Policy and Law (forthcoming)Google Scholar.

26 Inglehart, “Canada's Health Care System,” 1628.

27 Wilson, P. R., Chappell, D. and Lincoln, R., “Policing Physician Abuse in British Columbia,” Canadian Public Policy 12 (1986), 236–44;CrossRefGoogle Scholar and Tuohy, Carolyn, “Does a Claims Monitoring System Influence High-volume Medical Practitioners? Attitudinal Data from Ontario,” Inquiry 19 (1982), 18–33Google Scholar.

28 Barer, and Evans, , “Riding North on a South-bound Horse?” 98–108Google Scholar.

29 Detsky, Alan S., Stacey, Sidney and Bombardier, Claire, “The Effectiveness of a Regulatory Strategy in Containing Hospital Costs,” New England Journal of Medicine 309 (1983), 151–59CrossRefGoogle Scholar.

30 This discussion of Canadian medical opinion is largely drawn from earlier analyses of data from two physician surveys in Ontario in the 1970s, reported in Wolfson, and Tuohy, , Opting Out of Medicare, and Tuohy, Carolyn J., “Smoke and Mirrors: Professional Ideology and Symbolism in Health Policy,” Proceedings of the Conference on Health in the ‘80s and ‘90s (Toronto: Council of Ontario Universities, 1982), 185–203Google Scholar. These findings are supplemented with reference to a 1983 five-province survey reported in Stevenson, H. M. and Williams, A. P., “Physicians and Medicare: Professional Ideology and Canadian Health Care Policy,” Canadian Public Policy 11 (1985), 504–21CrossRefGoogle Scholar: and a subsequent 1986 nation-wide survey reported in H. Michael Stevenson, Eugene Vaydaand A. Paul Williams, “Medical Politics After the Canada Health Act: Preliminary Results of the 1986 Physicians’ Survey,” paper delivered at the annual meeting of the Canadian Political Science Association, Hamilton, 1987.

31 Only a minority, for example, would support private for-profit management of hospitals, or a return to voluntary and commercial control of the health sector. See Stevenson, Vayda and Williams, “Medical Politics After the Canada Health Act,” 12.

32 This strategic minority is composed largely, though not exclusively, of academically-based physicians (Tuohy, “Smoke and Mirrors,” 190–95). The linkages between the medical schools and the regulatory colleges are both functional (deriving from a common interest in entry standards to the profession) and structural (deriving from the representation of medical schools on the governing councils of the colleges).

33 Wolfson, and Tuohy, , Opting Out of Medicare, 45–46, 134Google Scholar. In Ontario, it was necessary to formally “opt out” of participation in the governmental insurance plan in order to bill patients directly and to extra-bill.

34 Stevenson, and Williams, , “Physicians and Medicare,” 513Google Scholar.

35 Barer, and Evans, , “Riding North on a South-bound Horse?” 78Google Scholar.

36 These calculations are based on data provided in Health and Welfare Canada, Canada Health Act Annual Report, 1984/85 (Ottawa: Minister of Supply and Services, 1986)Google Scholar. Estimates of extra-billing in Nova Scotia are not available using this measure, since Nova Scotia's legislative ban on the practice coincided with the coming into force of the Canada Health Act and federal penalties were never imposed. Estimates are approximate, given slight variations in provincial practices for reporting total billings for insured medical services.

37 Government of Canada, Preserving Universal Medicare (Ottawa: Minister of National Health and Welfare, 1983), 12Google Scholar.

38 Beck, R. G., “The Effects of Co-payment on the Poor,” Journal of Human Resources 9 (1974), 129–42CrossRefGoogle Scholar.

39 G. L. Stoddart and C. A. Woodward, “The Effect of Physician Extra-billing on Patient's Access to Care and Attitudes Toward the Ontario Health System,” Department of Clinical Epidemiology and Biostatistics, McMaster University, 1980 (mimeo).

40 Plain, Richard, “Charging the Sick—Observations on the Economic Aspects of Medical-Social Policy Reform,” in Medicare: The Decisive Year, Proceedings of the CCPA Conference on Medicare (Ottawa: Canadian Centre for Policy Alternatives, 1984), 54Google Scholar.

41 Wolfson, and Tuohy, , Opting Out of MedicareGoogle Scholar.

42 See, for example, Barer, M. L., Evans, R. G. and Stoddart, G. L., Controlling Health Care Costs by Direct Charges to Patients (Toronto: Ontario Economic Council, 1979);Google Scholar and Stoddart, Greg L. and Labelle, Robert J., Privatization in the Canadian Health Care System (Ottawa: Minister of National Health and Welfare, 1985)Google Scholar. Much of the evidence is also reviewed in Pran Manga, The Political Economy of Extra-billing (Ottawa: Canadian Council on Social Development, 1983)Google Scholar.

43 Parliamentary Task Force on Federal-Provincial Arrangements, Fiscal Federalism in Canada (Ottawa: Minister of Supply and Services, 1981)Google Scholar. For a discussion of the Task Force's work, see Taylor, Malcolm G., “The Canadian Health Care System 1974–1984,” in Evans, and Stoddart, (eds.), Medicare at Maturity, 21–25Google Scholar.

44 Derthick, and Quirk, , The Politics of Deregulation, 13Google Scholar.

45 Edelman, , The Symbolic Uses of PoliticsGoogle Scholar.

46 Hall, Hon. Emmett M., Canada's National-Provincial Health Program for the 1980's (Ottawa: Department of National Health and Welfare, 1980)Google Scholar. See also Taylor, , “The Canadian Health Care System 1974–1984,” 16–20Google Scholar.

47 Ward, Bruce, “Survey Shows Bégin Backed on Medicare,” Toronto Star, August 27, 1983Google Scholar.

48 CCH Canada, Ottawa Letter 16:38 (September 1983).

49 CCH Canada, Ottawa Letter 16:101 (December 1984).

50 Government of Canada, Preserving Universal Medicare, 7–8Google Scholar.

51 Unless one assumes that the threat of an increase in extra-billing constituted a bargaining chip in the negotiation of the fee schedule under the governmental insurance plans. But one could on the contrary assume that the “safety valve” of extra-billing released pressure for fee schedule increases and held fee schedules down.

52 Wolfson, and Tuohy, , Opting Out of Medicare, 44Google Scholar.

53 Stevenson, and Williams, , “Physicians and Medicare,” 513, 520–21Google Scholar.

54 Ibid., 514.

55 Gusfield, Joseph R., Symbolic Crusade (Urbana: University of Illinois Press, 1963), 7Google Scholar.

56 The budgetary implications of these penalties for provincial governments were relatively small. In Ontario, the province in which these penalties constituted the largest share of the health budget, that proportion was still only 0.6 per cent in the fiscal year 1984–1985.

57 Stevenson, , Williams, Vaydaand, “Medical Politics After the Canada Health Act,” 15Google Scholar.

58 For a discussion of the arrangements surrounding the banning of extra-billing in the various provinces, see Heiber, S. and Deber, R., “Banning Extra-billing in Canada: Just What the Doctor Didn't Order,” Canadian Public Policy 13 (1987), 62–74CrossRefGoogle Scholar.

59 Successive Progressive Conservative ministers of health used various rationales to defend the option to extra-bill. In 1979, Dennis Timbrell maintained that accessibility and universality were being maintained without having to “in effect put the doctors on the payroll...of the government and drive them out of Ontario” (Hansard, Official Report of Debates, Legislative Assembly of Ontario, December 19, 1979, 5740–41)Google Scholar. Larry Grossman in 1983 defended extra-billing on the grounds that, unlike the flat fee schedule, it can reward experience and expertise (Debates, April 18, 1983, 68). Keith Norton, in 1984, took a more “corporatist” approach, referring to the option to extra-bill as a “social contract” with the profession which could not be abruptly changed, and pointed to a 98 per cent success rate for the OM A in resolving individual “inequitable” cases of extra-billing (Debates, October 15, 1984, 3204).

60 Quoted in Joan Price Boase, “Public Policy and the Regulation of the Health Disciplines,” doctoral dissertation, York University, Toronto, Ontario, 1986, 180.

61 Reported in “Scott asks MD's to help with ban on extra-billing,” Globe and Mail, August 20, 1985.

62 Michael Adams, Donna Dasko and James Matsui, “49 per cent of decided voters back Peterson's Liberals,” Globe and Mail, June 27, 1986.

63 The OMA leadership, cognizant of the ongoing tension between general practitioners and specialists (and among specialists) over the distribution of fee schedule increases, was also wary of the internal tensions which would be generated in an attempt to distribute funds on the basis of “excellence” or other such measures. In this regard, it apparently read its members’ views well. A subsequent survey indicated that a majority of a sample of Ontario physicians opposed such a fund. See Stevenson, , Vayda, and Williams, , “Medical Politics After the Canada Health Act,” 15–16Google Scholar.

64 Edelman, , The Symbolic Uses of Politics, 47Google Scholar.

65 Elder, Charles D. and Cobb, Roger W., The Political Uses of Symbols (New York: Longman, 1983), 69–79Google Scholar.

66 Gusfield, , Symbolic Crusade, 183–88Google Scholar.

67 Naylor, , Private Practice, Public Payment, 250Google Scholar.

68 See, for example, Globe and Mail, July 17, 1986.

69 For a description of the College's role in this and other job actions, see Tuohy, Carolyn, “The Regulation of the Health Professions in Ontario,” in Desrosiers, Georges (ed.), Le systième de santé cte l'Ontario: enseignements pour le Québec (Montreal: Les éditions administration de la santé, 1987), 372–75Google Scholar.

70 The OMA executive also chose to join with the Canadian Medical Association in challenging the Canada Health Act and the Ontario legislation before the courts. For a discussion of these challenges, see R. Deber and S. Heiber, “Freedom, Equality and the Charter of Rights: Policy and Legal Aspects of Regulating Physician Reimbursement,” paper delivered at the annual meeting of the Canadian Political Science Association, Hamilton, 1987.

71 Calculated from data provided in Ontario Health Insurance Plan, Practitioner Care Statistics, 1985–86 (Toronto: Ministry of Health, 1986)Google Scholar and Ontario Health Insurance Plan, Practitioner Care Statistics, 1986–87 (Toronto: Ministry of Health, 1987)Google Scholar. Projected billings for June and July 1986 were estimated using June and July 1985 billings, adjusted for a 4 per cent fee schedule increase in January 1986, a 3 per cent fee increase in April 1986, a 4.75 per cent increase in the number of billing physicians, and assuming a 2 per cent “utilization” increase.

72 Debates, July 8, 1986, 2212.

73 Luft, Harold S., Health Maintenance Organizations: Dimensions of Performance (New York: Wiley, 1981);Google ScholarLomas, and Barer, , “The Legacy of Canadian Health Manpower Policy,” 261–63Google Scholar.

74 Stoddart, G. L., “Rationalizingthe Health Care System,” in , D. Conklin.Cookand, G.Courchene, T. (eds.), Ottawa and the Provinces: The Distribution of Money and Power (Toronto: Ontario Economic Council, 1985);Google Scholar and Lomas, and Barer, , “The Legacy of Canadian Health Manpower Policy,” 260–71Google Scholar.

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