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Medical Reform Group of Ontario (MRG)The Medical Reform Group of Ontario (MRG) was a physicians’ organization formed in 1978 to act as a voice for progressive doctors who were dissatisfied with the conservatism and self-interest of the established medical profession. The MRG played a significant role in shaping public opinion around health care and health policy in Ontario and Canada for the next several decades, until the group’s eventual dissolution in 2014. The impetus for the MRG’s founding came in 1978 when two young members of the house staff at Toronto Western Hospital, Fred Freedman and Gordon Guyatt, discovered that they shared concerns about two-tier health care, as exemplified by the fact that patients – as long as they were willing and able to pay an additional fee – could bypass the waiting list for seeing specialists at the hospital by making appointments to see the same specialists at their private offices across the street. The fact that the established medical organizations defended these kinds of arrangements rather than stand up for equity of access led Freedman and Guyatt to circulate a letter to other house staff proposing the creation of an organization that would represent progressive, socially conscious physicians. Ten to fifteen of their colleagues expressed an interest, and this core group, plus some new recruits, began to meet on a regular basis and work out a set of principles and priorities. The group’s first public statements, in early 1979, said that “We believe that the most rational way to organize health care is around the community clinic. Such a clinic would financed by global budget and all employees, including physicians, would be paid salary.” A general meeting to officially found the Medical Reform Group of Ontario, with 58 people present, was held at Hart House at the University of Toronto on May 26, 1979. At that meeting, the three founding principles of the MRG were adopted. They were: 1. The universal access of every person to high quality, appropriate health care must be guaranteed. The health care system must be administered in a manner which precludes any monetary or other deterrent to equal care. 2. Health care workers, including physicians, should seek out and recognize the social, economic, occupational, and environmental causes of disease, and be directly involved in their eradication. 3. The health care system should be structured in a manner in which the equally valuable contribution of all health workers is recognized. Both the public and health care workers should have a direct say in resource allocation and in determining the setting in which health care is provided. Key themes discussed at the May 1979 founding meeting included opting out and cutbacks; advocacy of extending health insurance to cover dental care, drugs and other services; education of physicians; decolonization of medicine; and occupational and environmental causes of illness. A second general meeting, on October 14, 1979, adopted a constitution, elected a steering committee, and discussed policies and priorities. A working groups on occupational health reported on its work, as did another on economic issues, especially health care cutbacks and physicians ‘opting out’ of public health insurance and engaging in extra-billing. Additional working groups on women’s health and community health centres were subsequently created. It was decided to keep the MRG as an Ontario organization: interested physicians in other provinces were admitted as affiliate members, with the hope that groups similar to the MRG would emerge in those provinces. It was also decided to restrict membership to physicians and medical students so that the group could position itself as an alternative voice to the mainstream medical organizations. Other health care providers, such as nurses, dentists, and pharmacists, were able to join, and take part in MRG meetings, as associate members. The MRG announced its existence to the media on November 1, 1979, and received favourable coverage from the mainstream media, including the Globe and Mail, and the Toronto Star, which carried a front-page headline proclaiming “125 MDs Break Ranks with the OMA.” A spokesperson for the Ontario Medical Association predictably dismissed the MRG as “a rump group of the medical profession.” The early period of the MRG’s existence was marked by intense activity. Joe Clark’s short-lived federal government had appointed a commission, headed by Justice Emmett Hall, on the state of medical care in Canada. Hall had headed an earlier Royal Commission in 1961-1964 which had recommended that Saskatchewan’s system of medicare be adopted nationally, and expanded, and many of his key recommendations had been adopted by the Liberal government of Lester Pearson. This second Hall Commission was seen as potentially pivotal to the future of medicare in Canada, and the MRG prepared a well-researched and comprehensive brief to the Commission. The MRG’s brief included important recommendations that were highlighted in the Hall Commission’s final report, including ending user fees and health care premiums. The MRG’s early period was also characterized by high profile educational work around occupational health with unions in both Toronto and Hamilton. In the latter city, a group of MRG members, including Ken Burgess, Annalee Yassi, Clyde Hertzman, John Chong, and Ted Haines, were instrumental in the formation of the first workers’ occupational health clinic in Canada. As the group grew, the administrative burden became difficult for volunteer steering committee members to carry, and in October 1981 the group’s first part-time executive secretary was hired. The early 1980s were a time of significant upheaval in health care. The Ontario Medical Association (OMA) began a series of rotating strikes to support their monetary demands. The MRG issued a statement of condemnation, and its position criticizing the OMA’s actions was widely publicized. 1984 saw the MRG play a major role in the debate over the Canada Health Act. The introduction and adoption of the Canada Health Act by Pierre Trudeau’s Liberal government, spearheaded by Health Minister Monique Begin, was a pivotal development in the history of health care in Canada. It established and enshrined in law the basic principles that continue to govern health care in Canada, including: While feeling that the Act may not have gone far enough (for example, pharmaceuticals and dental care are not included), the MRG was supportive of its content. MRG members spoke at a number of educational sessions sponsored by the Ontario Health Coalition, presented a submission to the House of Commons health care committee, and countered the misleading statements made by the OMA and the National Citizens Coalition concerning the Canada Health Act. MRG members debated representatives of groups such as the OMA and the Association of Independent Physicians in various public forums and in the media, over the Canada Health Act and the economics of health care in general. Monique Begin, the federal health minister who pushed the legislation forward, subsequently expressed her gratitude for the MRG’s strong support. The passing of the Act marked a major victory for advocates of medicare. Over this period other important MRG activities included major support of pro-choice activists in Toronto, work that was led by Miriam Garfinkle and Mimi Divinsky; submission of a brief to the Health Professions Review committee emphasizing the need for greater public input in monitoring the performance of the health professions which was prepared by Don Woodside, Paul Rosenberg, and Clyde Hertzman; and submission of an intensively researched brief prepared by Joel Lexchin and Bob Frankford to the Eastman Commission on the pharmaceutical industry. This last brief called on the government to abandon plans for legislation that would change the patent act in favour of the multinational sector of the pharmaceutical industry and contrary to the public interest. 1984 saw Ulli Diemer take over as the MRG’s executive secretary, a position he was to occupy until 1995. He was responsible for bringing about a number of changes, including a major upgrade and expansion of the MRG newsletter, which henceforth reported on important developments in health care in Ontario and beyond, and began soliciting more articles from members on their areas of expertise. Another intense period of activity began in 1985, when Ontario’s long-ruling Conservatives were ousted by a Liberal minority government headed by David Peterson, which needed the support of the New Democratic Party (NDP) to pass its legislative program. A crucial condition of NDP support was legislation to end extra billing by doctors, i.e. physicians charging patients additional fees on top of the payment they received from the public health care system. The legislation was introduced in December 1985, and the official doctors’ organization, the Ontario Medical Association (OMA), was vehement in its opposition. The OMA refused to meet with the government to discuss implementation, and called a series of rotating strikes. The MRG was extremely effective in countering the OMA. Its spokespersons received widespread media coverage, and played a major role in turning public opinion against the OMA and its actions. The OMA called off its strikes in July, effectively acknowledging that its tactics had failed and that it had lost the battle. Victory in the battle against extra billing and opting out was a high point for the MRG, but it also led to a certain loss of focus. Working groups continued to be active on issues such as access to abortion, which the MRG strongly supported; licensing of midwifery, which the MRG similarly supported; and opposing increased pharmaceutical patent protection, as proposed (and eventually implement) by the federal Mulroney government which took office in 1984. However, with one of the key issues which had united the group resolved, some members drifted away because they saw less need for the MRG, while differences emerged around resource allocation issues in the health care system. While the battle over the Canada Health Act led to an influx of new members into the MRG, a paradoxical result of the victory on extra-billing in the longer term was that, as a sop to the OMA, the government agreed to recognize the OMA as the bargaining agent for physicians over payment, and to require all doctors in the province to pay membership fees to the OMA. Faced with having to pay a substantial fee to belong to the OMA, along with the perception that the battle had been won, some members allowed their MRG memberships to lapse. At this time, with politicians of all stripes jumping on the bandwagon to cut government spending, cost control in the health care system was becoming a major priority of Ontario’s provincial government. Fee increases to physicians were essentially put on hold, and the OMA responded with a campaign that suggested that government funding constraints were compromising the quality of care. Episodes suggesting suboptimal care (patients waiting excessively long periods for cardiac surgery, an intensive care unit bed not being found for a woman who subsequently died) began appearing with increasing frequency in the media. While the issues were complex, some in the MRG leaned more to the position that health care funding was inadequate and should be increased, while others, notably Michael Rachlis, put their focus on improving the efficiency of the health care system. The MRG put considerable effort into developing nuanced, carefully researched, positions on these issue, but the complexity of the problems, along with differing views and emphases within the organization, made it difficult for the MRG to take clearcut public positions that could be packaged as media sound bites, and the group was consequently less visible in the media. Another issue which took up the MRG’s attention was the organization of, and methods of payment for, primary care. The alternative models of capitation/HSOs, and salaries/community health centres each had their advocates, though most agreed that fee-for-service was an undesirable model. The MRG eventually adopted a position supporting a major change in the structure of the current health-care system to one in which the primary mechanisms for reimbursement of primary health care delivery would be capitation and salary. The late 1980s and early 1990s saw a ferment in the American health care system predicated on the realization of huge inequalities and uncontrolled cost. By 1989 there was a great deal of interest among Americans about the Canadian health care system. Progressive groups in the United States looked for informed Canadian physicians to educate them, and their constituents, about how health care in Canada works. The MRG spent considerable energy filling this role. Gordon Guyatt and Haresh Kirpalani prepared a rigorously documented summary of the relative merits of the two systems with respect to coverage, patient satisfaction, physician satisfaction, health status, and costs. They prepared a slide show which was taken on the road by MRG speakers. MRG members participated in conferences on health care in Canada and the United States. The push for a publicly funded single-payer system in the U.S. eventually faltered in the face of the Clinton administration’s determination to leave private insurance companies in control of much of the health care system. 1995 saw a number of changes in the political context and the MRG’s activities. The NDP government headed by Bob Rae, which had governed the province since 1990, went down to defeat to Mike Harris’s hard-right Conservatives in June 1995. Whereas the NDP had been sympathetic to many of the MRG’s positions, albeit timid, inconsistent, and relatively ineffectual in acting on them, Harris’s Conservatives were focused on slashing the public sector, and ruthless in carrying out their program. The MRG once again found itself in combat mode, fighting to preserve the principles of medicare. The MRG’s executive secretary, Ulli Diemer, left in the spring of 1995, and was replaced later in the year by Janet Maher, who came to play central role in the organization for the next 19 years, including in allying the MRG with other groups that were also fighting the Conservatives' agenda. Headlines in the MRG’s newsletter reflect the group’s preoccupations in the period 1995 to 2003 (when the Conservatives were defeated by Dalton McGuinty’s Liberals): The 2000s saw another surge of energy into the MRG, with the creation of student chapters in Toronto and Hamilton, and the emergence of a new generation of steering committee members. In this period, acting on the social determinants of health (the focus of the MRG’s second founding principle) became a priority, with the MRG allying itself with groups such as Health Providers Against Poverty (HPAP), Health For All, and Canadian Doctors for Medicare. Former Saskatchewan Premier Roy Romanow was appointed as a one-person Royal Commission on the Future of Health Care in Canada. The MRG participated vigorously in the debate engendered by Romanow, whose conclusions in his 2002 report were consistent with MRG policy: that Canadians place a high value on equitable health care and that universal health care is not only necessary for equity, but is far more efficient than private health care alternatives. The MRG continued until 2014, when declining numbers and energy, and a feeling that the national group Canadian Doctors for Medicare, also committed to advancing the principles of medicare, was making the Medical Reform Group of Ontario somewhat redundant, led to a decision to wind down the MRG’s existence. References Medical Reform Group newsletter online archive Medical Reform Group of Ontario new releases 1979 - 1995 A Brief History of the Medical Reform Group (to 1994) Progressive doctors condemn opting out Making Medicare: The History of Health Care in Canada 1914 - 2007 (Canadian Museum of History) Subject headings
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