That the government create a one-time Health Care and Innovation Fund to resume health care services, bolster public health capacity and expand primary care teams, allowing Canadians wide-ranging access to health care.
That the government recognize and support the continued adoption of virtual care and address the inequitable access to digital health services by creating a Digi-Health Knowledge Bank and by expediting broadband access to all Canadians.
That the government act on our collective learned lessons regarding our approach to seniors care and create a national demographic top-up to the Canada Health Transfer and establish a Seniors Care Benefit.
That the government recognize the unique risks and financial burden experienced by physicians and front line health care workers by implementing the Frontline Gratitude Tax Deduction, by extending eligibility of the Memorial Grant and by addressing remaining administrative barriers to physician practices accessing critical federal economic relief programs.
Five months ago COVID-19 hit our shores. We were unprepared and unprotected. We were fallible and vulnerable. But, we responded swiftly.
The federal government initiated Canadians into a new routine rooted in public health guidance.
It struggled to outfit the front line workers. It anchored quick measures to ensure some financial stability.
Canadians tuned in to daily updates on the health crisis and the battle against its wrath.
Together, we flattened the curve… For now.
We have experienced the impact of the first wave of the pandemic. The initial wake has left Canadians, and those who care for them, feeling the insecurities in our health care system.
While the economy is opening in varied phases – an exhaustive list including patios, stores, office spaces, and schools – the health care system that struggled to care for those most impacted by the pandemic remains feeble, susceptible not only to the insurgence of the virus, but ill-prepared to equally defend the daily health needs of our citizens.
The window to maintain momentum and to accelerate solutions to existing systemic ailments that have challenged us for years is short. We cannot allow it to pass. The urgency is written on the faces of tomorrow’s patients.
Before the onset of the pandemic, the government announced intentions to ensure all Canadians would be able to access a primary care family doctor. We knew then that the health care system was failing.
The pandemic has highlighted the criticality of these recommendations brought forward by the Canadian Medical Association. They bolster our collective efforts to ensure that Canadians get timely access to the care and services they need. Too many patients are succumbing to the gaps in our abilities to care for them. Patients have signaled their thirst for a model of virtual care. The magnitude of our failure to meet the needs of our aging population is now blindingly obvious. Many of the front line health care workers, the very individuals who put themselves and their families at risk to care for the nation, are being stretched to the breaking point to compensate for a crumbling system.
The health of the country’s economy cannot exist without the health of Canadians.
Long wait times have strangled our nation’s health care system for too long. It was chronic before COVID-19. Now, for far too many, it has turned tragic.
At the beginning of the pandemic, a significant proportion of health care services came to a halt. As health services are resuming, health care systems are left to grapple with a significant spike in wait times. Facilities will need to adopt new guidance to adhere to physical distancing, increasing staff levels, and planning and executing infrastructure changes. Canada’s already financially atrophied health systems will face significant funding challenges at a time when provincial/territorial governments are concerned with resuscitating economies.
The CMA is strongly supportive of new federal funding to ensure Canada’s health systems are resourced to meet the care needs of Canadians as the pandemic and life continues. We need to invigorate our health care system’s fitness to ensure that all Canadians are confident that it can and will serve them.
Creating a new Health Care and Innovation Fund would focus on resuming the health care system, addressing the backlog, and bringing primary care, the backbone of our health care system, back to centre stage.
The CMA will provide the budget costing in follow-up as an addendum to this submission.
RECOMMENDATION 1 Creating a one-time Health Care and Innovation Fund
It took a global pandemic to accelerate a digital economy and spark a digital health revolution in Canada. In our efforts to seek medical advice while in isolation, Canadians prompted a punctuated shift in how we can access care, regardless of our location or socio-economic situation. We redefined the need for virtual care.
During the pandemic, nearly half of Canadians have used virtual care. An incredible 91% were satisfied with their experience. The CMA has learned that 43% of Canadians would prefer that their first point of medical contact be virtual.
The CMA welcomes the $240 million federal investment in virtual care and encourages the government to ensure it is linked to a model that ensures equitable access.
A gaping deficit remains in using virtual care. Recently the CMA, the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada established a Virtual Care Task Force to identify digital opportunities to improve health care delivery, including what regulatory changes are required across provincial/territorial boundaries. To take full advantage of digital health capabilities, it will be essential for the entire population, to have a functional level of digital health literacy and access to the internet.
The continued adoption of virtual care is reliant on our ability to educate patients on how to access it. It will be further contingent on consistent and equitable access to broadband internet service.
Create a Digi-Health Knowledge Bank
Virtual care can’t just happen. It requires knowledge on how to access and effectively deliver it, from patients and health care providers respectively. It is crucial to understand and promote digital health literacy across Canada. What the federal government has done for financial literacy, with the appointment of the Financial Literacy Leader within the Financial Consumer Agency of Canada, can serve as a template for digital health literacy.
We recommend that the federal government establish a Digi-Health Knowledge Bank to develop indicators and measure the digital health of Canadians, create tools patients and health care providers can use to enhance digital health literacy, continually monitor the changing digital divide that exists among some population segments.
Pan-Canadian broadband expansion
It is critical to bridge the broadband divide by ensuring all those in Canada have equitable access to affordable, reliable and sustainable internet connectivity. Those in rural, remote, Northern and Indigenous communities are presently seriously disadvantaged in this way. With the rise in virtual care, a lack of access to broadband exacerbates inequalities in access to care. This issue needs to be expedited before we can have pride in any other achievement.
RECOMMENDATION 2 Embedding virtual care in our nation’s health care system
Some groups have been disproportionately affected by the COVID-19 crisis. Woefully inadequate care of seniors and residents of long-term care homes has left a shameful and intensely painful mark on our record. Our health care system has failed to meet the needs of our aging population for too long.
The following two recommendations, combined with a focus on improving access to health care services, will make a critical difference for Canadian seniors.
A demographic top-up to the Canada Health Transfer
The Canada Health Transfer (CHT) is the single largest federal transfer to the provinces and territories. It is critical in supporting provincial and territorial health programs in Canada. As an equal per-capita-based transfer, it does not currently address the imbalance in population segments like seniors.
The CMA, hand-in-hand with the Organizations for Health Action (HEAL), recommends that a demographic top-up be transferred to provinces and territories based on the projected increase in health care spending associated with an aging population, with the federal contribution set to the current share of the CHT as a percentage of provincial-territorial health spending. A top-up has been calculated at 1.7 billion for 2021. Additional funding would be worth a total of $21.1 billion to the provinces and territories over the next decade.
Seniors care benefit
Rising out-of-pocket expenses associated with seniors care could extend from 9 billion to 23 billion by 2035. A Seniors Care Benefits program would directly support seniors and those who care for them. Like the Child Care Benefit program, it would offset the high out-of-pocket health costs that burden caregivers and patients.
RECOMMENDATION 3 Ensuring that better care is secured for our seniors
The federal government has made great strides to mitigate the health and economic impacts of COVID-19. Amidst the task of providing stability, there has been a grand oversight: measures to support our front line health care workers and their financial burden have fallen short.
The CMA recommends the following measures:
1. Despite the significant contribution of physicians’ offices to Canada’s GDP, many physician practices have not been eligible for critical economic programs. The CMA welcomes the remedies implemented by Bill C-20 and recommends the federal government address remaining administrative barriers to physicians accessing federal economic relief program.
2. We recommend that the government implement the Frontline Gratitude Tax Deduction, an income tax deduction for frontline health care workers put at risk during the COVID-19 pandemic. In person patient care providers would be eligible to deduct a predetermined amount against income earned during the pandemic. The Canadian Armed Forces already employs this model for its members serving in hazardous missions.
3. It is a devastating reality that front line health care workers have died as a result of COVID-19. Extending eligibility for the Memorial Grant to families of front line health care workers who mourn the loss of a family member because of COVID-19, as a direct result of responding to the pandemic or as a result of an occupational illness or psychological impairment related to their work will relieve any unnecessary additional hardship experienced. The same grant should extend to cases in which their work contributes to the death of a family member.
RECOMMENDATION 4 Cementing financial stabilization measures for our front line health care workers
Those impacted by COVID-19 deserve our care. The health of our nation’s economy is contingent on the health standards for its people. We must assert the right to decent quality of life for those who are most vulnerable: those whose incomes have been dramatically impacted by the pandemic, those living in poverty, those living in marginalized communities, and those doubly plagued by experiencing racism and the pandemic. We are not speaking solely for physicians. This is about equitable care for every Canadian impacted by the pandemic.
Public awareness and support have never been stronger. We are not facing the end of the pandemic; we are confronting an ebb in our journey. Hope and optimism will remain elusive until we can be confident in our health care system.
During these unprecedented times, Canada’s physicians, along with all front-line health care workers (FLHCWs), have not only put themselves at risk but have made enormous personal sacrifices while fulfilling a critical role in life-threatening circumstances.
The CMA recognizes and strongly supports the measures the federal government has taken to date to mitigate the health and economic impacts of COVID-19 on Canadians. However, given the unique circumstances that Canada’s FLHCWs face, additional measures are required to acknowledge their role, the risks to themselves and their families, and the financial burden they have taken on through it all.
To gain a better understanding of this issue, the CMA commissioned MNP LLP (MNP) to conduct a thorough economic impact study. They assessed the effects of the COVID-19 pandemic on physician practices in Canada and identified policy options to mitigate these effects.
This brief summarizes the findings, provides an overview of the impact of the COVID-19 pandemic on physician practices across the country and highlights targeted federal measures that can significantly mitigate the evident challenges physicians are experiencing. It is important to note that the recommended measured were developed through the lens of recognizing the important contribution of Canada’s FLHCWs.
UNDERSTANDING HOW THE PANDEMIC
IS IMPACTING PHYSICIAN PRACTICES
Canada’s physicians are highly skilled professionals, providing an important public service and making a significant contribution to the health of Canadians, our nation’s health infrastructure and our knowledge economy. In light of the design of Canada’s health care system, the vast majority of physicians are self-employed professionals operating medical practices as small business owners. Like most small businesses in Canada, physician practices have been negatively impacted by the necessary measures governments have established to contain this pandemic.
Under the circumstances of the pandemic, the provinces postponed non-emergent procedures and surgeries, indefinitely. According to data from the 2019 Physician Workforce Survey conducted by the CMA, approximately 75% of physicians reported practising in settings that would be expected to experience a reduction in patient volumes as a result of COVID-19 measures. This suggests “the vast majority of physicians in Canada anticipate declines in earnings as a result of COVID-19 restrictions.”
Physician practices include a variety of structures, which relate to the practice setting or type. In their economic impact study, MNP estimates that across the range of practice settings, the after-tax monthly earnings of physician practices are estimated to decline between 15% and 100% in the low-impact scenario, and between 25% and 267% in the high-impact scenario. These two scenarios are in comparison to a baseline scenario, prior to the pandemic. The low-impact scenario is based on the reduction of physician services reported during the 2003 experience with the Severe Acute Respiratory Syndrome (SARS) while the high-impact scenario estimates more significant impacts, being approximately double those observed during SARS.
Unlike salaried public sector professionals, such as teachers, nurses or public servants, most physicians operate as small business owners who are solely responsible for the management of their practices. They employ staff, rent office space and have numerous other overhead costs related to running a small business, which they are still responsible for regardless of decreased earnings. According to data published by Statistics Canada in 2019 there were 120,241 people employed in physician offices in Canada and an additional 28,054 employed in medical laboratories. Additionally, physicians manage significant overhead expenses that are unique to medical practice such as practice insurance, licence fees and continuing medical education. It’s important to understand that even hospital-based physicians may be responsible for significant overhead expenses, unlike other hospital staff. Like any small business owner grappling with drastic declines in revenue, physicians may be forced to reduce their staffing levels or even close their practices entirely in response to the COVID-19 pandemic.
ADDRESSING THE GAPS: ENSURING THAT FEDERAL ECONOMIC PROGRAMS CAPTURE PHYSICIAN PRACTICES
To reiterate, the CMA supports the federal government’s decisive and meaningful response to the pandemic, including delivering critical economic relief programs. However, more detailed analysis is revealing that segments of physician practices are not eligible for these critical economic programs, because of technicalities.
At this time, the CMA has identified three key segments of physician practice models who may
not currently be eligible for the economic relief programs because of technicalities. These are:
1. hospital-based specialists
2. physician practices that operate as a small business but may not meet technical criteria
3. physicians delivering locum medical care
These technical factors reflect the complexity of the health system infrastructure in Canada. Although hospital-based specialists may receive some form of salary, they may still be structured as a small business and be responsible for paying overhead fees to the hospital. Many physicians may operate as a small business and remit a statement of self-employment, and they may not have a business number or a business bank account. As is common amongst other self-employed professionals, many physicians operate practices within cost-sharing structures. The CMA is deeply concerned that these structures are presently being excluded for the federal government’s critical economic relief programs. As a result, this exclusion is affecting the many employees of practices structured as cost-sharing arrangements. Finally, physicians providing care in other communities, known as locum practice, would also be responsible for overhead expenses.
It is the CMA’s understanding that the federal government is seeking to be inclusive in delivering economic relief programs to mitigate the impacts of the pandemic, such as closures or unemployment. For physician practices, eligibility for federal economic relief programs would extend the reach of these mitigation measures to maintaining Canada’s critical health resources and services, as physician practices are responsible for a
significant portion of health system infrastructure.
As such, the CMA respectfully recommends that the federal government ensure that these critical economic programs be made available to all segments of physician practices.
To this end, the CMA recommends that
the federal government expand eligibility
for the federal economic relief program to:
1. Include hospital-based specialists paying fees for overhead expenses to the hospitals
(e.g., staff, equipment, space);
2. capture physician-owned medical practices using a “personal” banking account as well
as those in cost-sharing structures to access programs; and,
3. include physicians who provide locum medical care.
NEW FEDERAL TAX MEASURES TO SUPPORT AND RECOGNIZE FRONT-LINE HEALTH CARE WORKERS
It is also important to note that the impact of COVID-19 on FLHCWs goes well beyond the financial impacts.
All FLHCWs face numerous challenges trying to carry out their work during these difficult times. They put their health and the health of their families at risk. They make enormous sacrifices, sometimes separating themselves from their families to protect them. These risks and sacrifices can strain an individual’s mental health, especially when coupled with anxiety over the lack of proper personal protective equipment (PPE). A survey conducted by the CMA at the end of April showed that almost 75% of physicians who responded to the survey indicated feeling very or somewhat anxious about the lack of PPE. FLHCWs deserve to be recognized for their unique role during
Given the enormous sacrifices and risks that FLHCWs are making every day, the federal government should enact measures to recognize their significant contributions during these unprecedented times.
The CMA recommends that the federal government implement the following
new measures for all FLHCWs:
1. An income tax deduction for FLHCWs put at risk during the COVID-19 pandemic,
in recognition of their heroic efforts. All FLHCWs providing in-person patient care during the pandemic would be eligible to deduct a designated amount against their income earned. This would be modelled on the deduction provided to members
of the Canadian Armed Forces serving in moderate- and high-risk missions.
2. A non-taxable grant to support the families of FLHCWs who die in the course of responding to the COVID-19 pandemic or who die as a result of an occupational illness or psychological impairment related to this work. The grant would also apply to cases in which the death of an FLHCW’s family member is attributable to the FLHCW’s work in responding to the pandemic. The CMA is recommending that access to the Memorial Grant program, or a similar measure, be granted to FLHCWs and
their family member(s).
3. A temporary emergency accommodation tax deduction for FLHCWs who incur additional accommodation costs as well as a home renovation credit in recognition of the need for FLHCWs to adhere to social distancing to prevent the spread of COVID-19 to their family members. The CMA recommends all FLHCWs earning income while working at a health care facility or in a capacity related thereto
(e.g., paramedics or janitorial staff) be eligible for the deduction and credit.
4. Provide additional child-care relief to FLHCWs by doubling the child-care deduction.
The CMA recommends the individuals listed above be eligible for the enhanced deduction.
It is important that any measures enacted be simple for the government to implement and administer as well as simple for FLHCWs to understand and access. The recommendations above will ensure that relief applies to a wide range of Canada’s FLHCWs who are battling COVID-19.
More details on these recommendations are provided in Appendix A to this brief.
INCREASING FEDERAL HEALTH FUNDING
TO SUPPORT SYSTEM CAPACITY
It is due to the action of the federal and provincial/territorial governments, together with Canadians, in adhering to public health guidance that our health systems have been able to manage the health needs of Canadians during the pandemic. However, as governments and public health experts consider how we may proceed in lifting certain restrictions, we are beginning to comprehend the enormity of the effort and investment required to resume health care services. During the pandemic, a significant proportion of health care services, such as surgeries, procedures and consults considered “non-essential” have been delayed. As health services begin to resume, health systems will be left to grapple with a significant spike in already lengthy waiting times. Further, all health care facilities will need to adopt new guidance to adhere to physical distancing, which may necessitate longer operating hours, increasing staff levels and/or physical renovations. Given these issues, the CMA is gravely concerned that Canada’s already financially struggling health systems will face significant funding challenges at a time when provincial/
territorial governments are grappling with recession economies. The CMA is strongly supportive of new
federal funding to ensure Canada’s health systems are resourced to meet the care needs of Canadians
as the pandemic continues.
As outlined in this brief, the overwhelming majority of Canada’s physician practices will be
negatively impacted financially by COVID-19. The indefinite postponement of numerous medical procedures, coupled with restrictions related to physical distancing resulting in reduced patient
visits, will have a material effect on physician practices, risking their future viability. As well,
all FLHCWs will be severely impacted by COVID-19 personally, through risks to themselves and their families. Many families of FLHCWs will also be impacted financially, from increased child-care costs
to, tragically, costs associated with the death of a loved one because of COVID-19.
In light of these substantial risks and sacrifices, the CMA urges the adoption of the above-mentioned recommendations designed to recognize the special contribution of Canada’s FLHCWs during these
It is with a sense of urgency that the Canadian Medical Association (CMA) submits
the recommendations herein for emergency federal measures that, taken together,
will ensure Canadians receive appropriate care and that supportive measures are
implemented for public health protection during the COVID-19 pandemic.
While Canada has made significant strides since SARS to establish and implement
effective public health infrastructure, resources and mechanisms, the significant
resource constraints across our health systems present a major challenge in our
current response. Federal emergency measures must be developed in the context
of the current state of health resources: hospitals across the country are already at
overcapacity, millions of Canadians lack access to a regular family doctor, countless
communities are grappling with health care shortages, virtual care is in its infancy,
and so on.
Another core concern is the chronic underfunding and ongoing budget cuts of
public health resources and programming. Public health capacity and leadership at
all levels is fundamental to preparedness to respond to an infectious disease threat,
particularly one of this magnitude.
It is in this context that the Canadian Medical Association recommends that the
following emergency measures be implemented by the federal government to
support the domestic response to the COVID-19 pandemic:
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1) FEDERAL RECOMMENDATION AND SUPPORT FOR SOCIAL DISTANCING
In this time of crisis, Canadians look to the federal government for leadership and guidance.
The single most important measure that can be implemented at this time is a consistent
national policy calling for social distancing. This recommendation by the federal government
must be paired with the resources necessary to ensure that no Canadian will be forced to choose
between financial hardship — whether by losing employment or not being able to pay rent —
and protecting their health.
The CMA strongly recommends that the federal government immediately communicate guidance
to Canadians to implement social distancing measures. The CMA further recommends that the
federal government deliver new financial support measures as well as employment protection
measures to ensure that all Canadians may engage in social distancing.
2) NEW FEDERAL EMERGENCY FUNDING TO BOOST PROVINCIAL/
TERRITORIAL CAPACITY AND ENSURE CONSISTENCY
It is the federal government’s role to ensure a coordinated and consistent national response across
jurisdictions and regions. This is by far the most important role for the federal government in
supporting an effective domestic response, that is, protecting the health and well-being of Canadians.
The CMA strongly recommends that the federal government deliver substantial emergency funding to
the provinces and territories to ensure health systems have the capacity to respond to the pandemic.
Across the OECD, countries are rapidly stepping up investment in measures to respond to COVID-19,
including significant investment targeting boosting health care capacity. In considering the
appropriate level of federal emergency funding to boost capacity in our provincial/territorial
systems, the CMA urges the federal government to recognize that our baseline is a position of deficit.
New emergency federal funding to boost capacity in provincial/territorial health systems should
be targeted to:
rapidly enabling the expansion and equitable delivery of virtual care;
establishing a centralized 24-hour national information hotline for health care workers to obtain
clear, timely and practical information on clinical guidelines, etc.;
expanding the capacity of and resources for emergency departments and intensive care units;
coordinating and disseminating information, monitoring and guidance within and across
rapidly delivering income stabilization for individuals and families under quarantine.
Finally, the inconsistencies in the provision and implementation of guidance and adoption of
public health measures across and within and jurisdictions is highly concerning. The CMA strongly
encourages the federal government enable consistent adoption of pan-Canadian guidance and
measures to ensure the health and safety of all Canadians.
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3) ENSURING AN ADEQUATE SUPPLY OF PERSONAL PROTECTIVE
EQUIPMENT FOR CANADIAN HEALTH CARE WORKERS AND
ENSURING APPROPRIATE USAGE
The CMA is hearing significant concerns from front-line health care workers, including physicians,
about the supply and appropriate usage of personal protective equipment. It is the CMA’s
understanding that pan-Canadian efforts are underway to coordinate supply; however, additional
measures by the federal government to ensure adequate supply and appropriate usage are required.
Canada is at the outset of this public health crisis — supply issues at this stage may be exacerbated
as the situation progresses. As such, the CMA strongly recommends that the federal government
take additional measures to support the acquisition and distribution throughout health systems of
personal protective equipment, including taking a leadership role in ensuring our domestic supply via
international supply chains.
4) ESTABLISH EMERGENCY PAN-CANADIAN LICENSURE FOR
HEALTH CARE WORKERS
In this time of public health crisis, the federal government must ensure that regulatory barriers
do not prevent health care providers from delivering care to patients when and where they need
it. Many jurisdictions and regions in Canada are experiencing significant shortages in health
The CMA urges the federal government to support piloting a national licensure program so that
health care providers can opt to practice in regions experiencing higher infection rates or where
there is a shortage of providers. This can be accomplished by amending the Canadian Free Trade
Agreement (CFTA) to facilitate mobility of health care workers.
Specifically, that the following language be added to Article 705(3) of the CFTA:
(j) A regulatory authority of a Party* shall waive for a period of up to 100 days any condition of
certification found in 705(3)(a) - (f) for any regulated health care worker to work directly or
indirectly to address the Covid-19 pandemic or any health care emergency. Any disciplinary matter
emanating from work in any province shall be the responsibility of the regulatory authority of the
jurisdiction where the work is performed. Each Party shall instruct its regulatory authorities to set-up
a rapid check-in/check-out process for the worker.
*Party refers to a signatory of the CFTA
To further enable this measure, the CMA recommends that the federal government deliver targeted
funding to the regulatory colleges to implement this emergency measure as well as targeted funding
to support the provinces/territories in delivering expanded patient care.
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5) ESTABLISH AN EMERGENCY NATIONAL MENTAL HEALTH SUPPORT
SERVICE FOR HEALTH PROVIDERS
Health care providers may experience trauma and hardship in meeting the increasing health needs
and concerns of Canadians in this time of crisis. The CMA strongly recommends that the federal
government establish an emergency National Mental Health Support Services hotline for all health
care providers who are at the front lines of patient care during the pandemic. This critical resource
will ensure our health care providers have the help they may need as they care for patients,
including helping them to deal with an increasing patient load.
6) IMPLEMENT A TARGETED TAX CREDIT FOR HEALTH PROVIDERS
EXPERIENCING FINANCIAL LOSS DUE TO QUARANTINE
In addition to supporting income stabilization measures for all Canadians who may benefit from
support, the CMA recommends that the federal government establish a time-limited and targeted
tax credit for health providers who may experience financial loss due to quarantine.
Many health care providers operate independently and may face significant fixed expenses as part of
their care model. As health care providers may have an increased risk of contracting COVID-19, this
may result in significant financial loss. A time-limited tax credit to ease this loss may help ensure
the continued viability of their care model. Further, the CMA supports extending the federal tax
filing timeline in recognition of the fact that health care workers and all Canadians are focused
on emergency matters.
The CMA’s recommendations align with the OECD’s call to action: “Governments need to ensure
effective and well-resourced public health measures to prevent infection and contagion, and implement
well-targeted policies to support health care systems and workers, and protect the incomes of vulnerable
social groups and businesses during the virus outbreak.”
Now is the time to ensure that appropriate leadership continues and that targeted investments are
made to protect the health of Canadians.