Doctors’ aggressive opposition to a more equitable tax code reflects a capitalist ethos that’s often been at odds with public health.
The Canadian Medical Association, Coalition of Ontario Doctors, Ontario Association of Radiologists, Canadian Association of Radiologists and Ontario Medical Association all joined the newly formed Coalition for Small Businesss Tax Fairness. The Canadian Chamber of Commerce, Canadian Taxpayers Federation and Canadian Federation of Independent Business are also part of this large coalition established to scuttle a government initiative to lessen tax advantages for wealthy small business owners and remove loopholes that incentivize incorporation for high paid professionals (two thirds of doctors have a corporation to reduce their taxes).
The government’s proposal would restrict business owners’ ability to lower their tax rate by sprinkling income to family members — who do no work for the firm — in lower tax brackets. The changes would also limit certain companies’ investments in stocks and real estate and the ability to convert a corporation’s regular income into capital gains, which are taxed at a lower rate. The government says the proposed changes would have almost no impact on anyone making under $150,000 a year, but doctors often make $300,000, $500,000 or more and the higher the income the greater the savings under the current rules. According to a summary of the 2014-15 fiscal year, 500 Ontario doctors received over $1 million from the provincial government with the top-biller claiming $6.6 million.
Currently high paid doctors and other professionals often pay lower taxes rates than nurses. That injustice and the Ontario Medical Association president’s claim the proposed tax changes would harm patient care prompted the Canadian Nurses Association to endorse the government’s tax plan. The CNA noted, “should the proposed changes pass, provincial and territorial governments should see an increase in revenues which can be invested in strengthening our publicly-funded health services, which in themselves employ thousands of salaried, highly-skilled professionals who pay their fair share of personal income taxes.”
While nurses defend public health care, doctors have long promoted a capitalist model of medicine that maximizes their wealth and power. In 1962 doctors in Saskatchewan, the birthplace of Canada’s universal health care system, went on strike for 23 days to block Medicare and other health reforms that weakened their power over medicine. After working to stymie the Co-operative Commonwealth Federation’s proposed health reforms for two years, in July 1962 doctors withdrew their services and launched a massive public relations campaign when the government introduced its long promised health improvements.
As part of the research for The Year We Became Us: A Novel About the Saskatchewan Doctors Strike, Gary Engler examined the Moose Jaw Times Herald‘s coverage of the work stoppage. The rhetoric was over the top. One editorial was headlined “Legal Profession Next to be Socialized” and another “The Day That Freedom Died In Saskatchewan.” That story claimed, “the people of Saskatchewan are now awakening and find that their province has been slowly, and in recent months much more rapidly transformed from a free democracy into a totalitarian state, ruled by men drunk with power.”
The Saskatchewan doctors’ fight against Medicare was assisted financially by the American Medical Association, which has long been a major obstacle to public health insurance in the U.S. According to Stan Rands in Privilege and Policy: A History of Community clinics in Saskatchewan, “by 1920 the American Medical Association, fearing that public financing would lead to public control of medical practice, had opposed health insurance regulation by any state or federal government. The AMA saw health insurance as a threat to its independence and, like the CMA, proposed that health insurance be carried through private companies.”
Fortunately, the CCF (NDP predecessor) government remained steadfast and the doctors lost their battle against universal health insurance, which was extended to the rest of the nation a few years later. But, the Saskatchewan doctors won a number of concessions, notably fee-for-service billing. Unlike Britain where most doctors are salaried employees of the National Health Service, Canadian doctors are overwhelmingly paid per visit/x-ray/operation. Remunerated based upon the number of clients they see, doctors have a financial self-interest in treating rather than preventing ill health.
Careful consideration of the efficacy of every test or treatment, which should underpin all medical evaluations, is too often overlooked when financial benefits are to be had. In fact, one reason drugs are overprescribed is that doctors are generally paid the same whether they stay with a patient for two or twenty minutes. While a prescription can be written in seconds, it takes time to fully understand an individual’s health history and to offer them ways to avoid illness.
Doctors draw their income and prestige largely from curative medicine, but advances in life expectancy and overall health have largely been shaped by improved public health measures such as sanitation, pollution controls, workplace safety regulations, infection control standards, etc. Further improvements will most likely come through broader sociological dynamics such as reductions in inequality and poverty, or improvements in education, healthier food systems, exercise-oriented urban planning, etc.
In Betrayal of Trust: The Collapse of Global Public Health Laurie Garrett estimates that “86 per cent of increased life expectancy was due to decreases in infectious diseases. The same can be said for the United States, where less than 4 per cent of the total improvement in life expectancy since the 1700s can be credited to twentieth century advances in medical care.” While Garrett may be overstating her case, public health measures that seek to prevent illness are what works.
By aligning with corporate lobbyists opposed to a more equitable tax code, doctor associations have provided an opening to those who believe a mistake was made at the dawn of Medicare. Like almost everyone whose income comes from public funds, doctors should be paid a salary. This would better align their interests with Medicare, public pensions and many other social programs that have improved overall health as well as working class Canadians who overwhelmingly support a fair tax system to pay for improved government services.