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Supporting the enactment of Bill C-14, Medical Assistance in Dying

https://policybase.cma.ca/en/permalink/policy13693
Last Reviewed
2019-03-03
Date
2016-05-02
Topics
Ethics and medical professionalism
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2019-03-03
Date
2016-05-02
Topics
Ethics and medical professionalism
Text
In this submission to the House of Commons Standing Committee on Justice and Human Rights, the CMA’s feedback is focused on three of the legislative objectives of Bill C-14, given their relevance to the CMA’s Principles-based Recommendations for a Canadian Approach to Assisted Dying. On behalf of its more than 83,000 members and the Canadian public, the CMA performs a wide variety of functions. Key functions include advocating for health promotion and disease/injury prevention policies and strategies, advocating for access to quality health care, facilitating change within the medical profession, and providing leadership and guidance to physicians to help them influence, manage and adapt to changes in health care delivery. i) Robust Safeguards First, the CMA supports the legislative objective of ensuring a system of robust safeguards to the provision of medical assistance in dying. The safeguards proposed by Bill C-14 include: patient eligibility criteria, process requirements to request medical assistance in dying, as well as monitoring and reporting requirements. The CMA is a voluntary professional organization representing the majority of Canada’s physicians and comprising 12 provincial and territorial divisions and over 60 national medical organizations. ii) Consistent, Pan-Canadian Framework Second, the CMA supports the legislative objective that a consistent framework for medical assistance in dying in Canada is desirable. In addition to robust safeguards, key measures proposed by Bill C-14 support the promulgation of a consistent framework across jurisdictions include legislating definitions for “medical assistance in dying” and “grievous and irremediable condition.” The CMA’s Principles-based Recommendations reflect on the subjective nature of what constitutes “enduring and intolerable suffering” and a “grievous and irremediable condition” as well as the physician’s role in making an eligibility determination. iii) End-of-Life Care Coordination System Thirdly, the CMA supports the objective to develop additional measures to support the provision of a full range of options for end-of-life care and to respect the personal convictions of health care providers. The fulfilment of these commitments with federal non-legislative measures will be integral to supporting the achievement of access to care, respecting the personal convictions of health care providers, and developing a consistent, pan-Canadian framework. The CMA encourages the federal government to rapidly advance its commitment to engage the provinces and territories in developing a pan-Canadian end-of-life care coordinating system. It will be essential for this system to be in place for June 6, 2016. At least one jurisdiction has made a system available to support connecting patients with willing providers. Until a pan-Canadian system is available, there will be a disparity of support for patients and practitioners across jurisdictions. iv) Respect Personal Convictions Finally, it is the CMA’s position that Bill C-14, to the extent constitutionally possible, must respect the personal convictions of health care providers. In the Carter decision, the Supreme Court of Canada emphasized that any regulatory or legislative response must seek to reconcile the Charter rights of patients wanting to access assisted dying and physicians who choose not to participate in medical assistance in dying on grounds of conscientious objection. The CMA’s Principles-based Recommendations achieves an appropriate balance between physicians’ freedom of conscience and the assurance of effective and timely patient access to a medical service. From the CMA’s significant consultation with our membership, it is clear that physicians who are comfortable providing referrals strongly believe it is necessary to ensure the system protects the conscience rights of physicians who are not. While the federal government has achieved this balance with Bill C-14, there is the potential for other regulatory bodies to implement approaches that may result in a patchwork system. The CMA’s position is that the federal government effectively mitigate this outcome by rapidly advancing the establishment of the pan-Canadian end-of-life care coordinating system. CMA Supports Cautious Approach for “Carter Plus” The CMA must emphasize the need for caution and careful study in consideration of “Carter Plus”, which includes: eligibility of mature minors, eligibility with respect to sole mental health conditions, and advance care directives. The CMA supports the federal government’s approach not to legislate these issues, rather to study them in greater detail. Word count: 750
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Review of Pan-Canadian health organizations

https://policybase.cma.ca/en/permalink/policy13737
Date
2017-11-24
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2017-11-24
Topics
Health systems, system funding and performance
Text
The Canadian Medical Association (CMA) welcomes this opportunity to provide input to the review of the Pan-Canadian health organizations (PCHOs). The CMA has had the opportunity to interact with all of them at one time or another. This review is timely, as there is a burning issue: Canada continues to languish near the bottom of the Commonwealth Fund's 11-country rankings, and the leading edge of the baby boom will reach age 75 in 2021, at which point per capita health care costs in Canada will escalate. We will discuss major unmet needs, make some general observations and offer two recommendations. References are provided in the bibliography. Unmet needs National focal point for quality: Our impression is that none of the PCHOs is pursuing a comprehensive approach to quality improvement (QI) consistent with the framework set out by the Institute of Medicine (IOM) in its 2001 report Crossing the Quality Chasm. The framework is built around the need for health care to be safe, effective, patient-centred, timely, efficient and equitable. To our knowledge Accreditation Canada is the only national organization that has adopted such a framework, but their QI mandate is to set standards and accredit health care organizations although it could potentially play an expanded role. The Canadian Patient Safety Institute has done an excellent job of highlighting the importance of patient safety, but that is only one of the six dimensions outlined in the IOM framework. Work needs to be done in Canada to address each of the other five dimensions. In terms of effective care, although the concept of evidence-based medicine was pioneered in Canada, we do not have a national developer of guidance to clinicians like the United Kingdom's National Institute for Health and Care Excellence (NICE). It is noted that there are some localized efforts in this area, such as Alberta's Toward Optimized Practice program, and the CMA Infobase maintained by CMA Joule contains some 1,200 clinical practice guidelines. Patient-centred care will be discussed below. Since the expiry of the 2004 Health Accord and the Wait Times Reduction Fund (WTRF), which the CMA spent years trying to get on the policy agenda, timely access to care has fallen out of the spotlight. The Wait Time Alliance did its best to promote the expansion and adoption of wait time benchmarks beyond the five treatments initially included in the WTRF, with very limited success. It is no surprise that according to the Commonwealth Fund's 2016 survey of 11 countries, Canadians faced the longest waiting times for a specialist appointment. In terms of efficiency there has been a rapid uptake of the Choosing Wisely Canada initiative by medical organizations, but the campaign could benefit from resources to conduct a thorough evaluation of its impact. The dimension of equitable care will be considered below as part of the discussion of social determinants of health. At least six provinces have established health quality councils, and if they had a national focal point for their efforts they could cross-pollinate their expertise and learnings with respect to all six of the Institute of Medicine's dimensions of care. National patient voice - While it is encouraging to see the emphasis on patient and family-centred care among the PCHOs, the lack of an organized national patient voice is a key gap. Previously the Consumers' Association of Canada provided an articulate patient/consumer voice on health issues, and indeed it was one of the seven charter members of the Health Action Lobby in 1991. However, the association's ability to speak in this capacity was greatly diminished after its federal funding dried up in the 1990s. At present there are various patient groups sponsored by health charities and industry but they tend to focus on specific interests. Patients Canada, an organization established in 2011, is showing promise, but with annual expenditures of just under $130,000 in 2014 it is insufficiently resourced to function as a national patient voice representing all regions of the country. There is a need for an independent go-to focal point that can speak on behalf of patients on national issues and that can help national health organizations with their advocacy and policy development initiatives. With better resources, Patients Canada might be able to play this role. Health equity - Given the impact of health inequalities in Canada they have a relatively low profile on the national scene, aside from the inequity between the health status of Canada's Indigenous Peoples and that of the general population. For example, Mackenbach and colleagues estimated that socio-economic inequalities accounted for 20% of health care costs in the European Union in 2004. There is little reason to imagine that the situation in Canada would be much different, but health inequalities have not been a preoccupation of the PCHOs. The Public Health Agency of Canada (PHAC) has done some good work in helping the federal government to meet its commitments in regard to the World Health Organization's 2011 Rio Political Declaration on Social Determinants of Health and it also funds the National Collaborating Centre for Determinants of Health, but these efforts have little profile outside of the public health community. The pronounced socio-economic gradient across virtually all causes of morbidity and mortality tends to be overlooked in the pursuit of strategies to address individual diseases. PHAC's Health Inequalities Data Tool shows that that the Canadian crude mortality rates for circulatory system disease and lung cancer in the lowest income quintile for census metropolitan areas are 1.6 and 1.7 times the rates in the highest income quintile, respectively. There are groups in Canada such as the Wellesley Institute and Health Providers Against Poverty that focus on health equity issues, and Canada should look at the leadership role being played by Sir Michael Marmot's Institute of Health Equity at University College London in England. Driving innovation - The Canadian Agency for Drugs and Technologies in Health is widely recognized for its work evaluating drugs and technologies but it is not in the business of promoting system-wide implementation. The Advisory Panel on Healthcare Innovation (David Naylor, Chair) recommended the establishment of a Healthcare Innovation Agency and a Healthcare Innovation Fund with the objective of effecting "sustainable and systemic changes in the delivery of health services to Canadians." More recently, the Standing Senate Committee on Social Affairs, Science and Technology called for a national conference on robotics, artificial intelligence and 3D printing that would give rise to working groups and a secretariat with a view to integrating these technologies into health care systems across Canada. One can cite examples where Canada has developed innovative technologies but has not made them mainstream. For example, telemedicine was pioneered by the late Dr. Maxwell House in Newfoundland in the mid-1970s. It is now being used regularly for clinical sessions, but the logical extension to telehome monitoring is barely in its infancy. According to the 2015 Canadian Telehealth Report there were 411,778 telehealth clinical sessions in 2014, but there were just 3,803 patients being monitored through telehomecare. Furthermore. the number of telehealth clinical sessions represents just 0.15% of the 270.3 million physician services reported by the Canadian Institute for Health Information (CIHI) in 2015-16. In contrast, Kaiser Permanente reported in 2016 that 52% of the 110 million physician-member interactions in the previous year took place through virtual means. One example of the use of a fund to bring about sustainable change was the two-step process that began with the establishment of the $150 million Health Transition Fund following the 1997 report of the National Forum on Health and the $800 million Primary Health Care Transition Fund that was part of the 2000 Health Accord. These resulted in the sustained adoption of new models of primary care delivery in Ontario and Alberta. It is noteworthy that the Canadian Foundation for Healthcare Improvement is doing interesting work in spreading and scaling up innovative treatment for patients with chronic obstructive pulmonary disease. The need for a dedicated entity to drive innovation is illustrated by the experience of the Health Care Innovation Working Group, which was struck by the premiers in 2012 and which included the unprecedented participation of professional associations including the CMA. The group released an ambitious report in the summer of 2012, but the effort was run by senior bureaucrats and association staff "off the sides of their desks" and has essentially stalled. Such a body could also play a role in sharing innovations across jurisdictions. Enhanced analytical capability - Since the demise of the Economic Council of Canada (ECC) in the 1990s Canada's national analytical capability in health care has diminished. The ECC employed health economists like the late Ludwig Auer who undertook detailed analysis of health sector data to examine issues like hospital productivity. CIHI does an excellent job of turning out reports such National Health Expenditure (NHEX) Trends in Canada, but these are not sufficient for an in-depth examination of a $242 billion industry. As journalist André Picard commented on the 2017 NHEX release, "We don't actually know how much we spend on administration, because it is hidden in places like hospital spending ... nor do we know the cost of labour ... we should certainly have a better idea of how much we spend on nurses, physician assistants, personal support workers, laboratory technologists and technicians and so on." Looking ahead, the widespread adoption of electronic medical records is going to present a major analytical opportunity and challenge. In 2008 PHAC provided a grant to the College of Family Physicians of Canada to establish the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) and subsequently provided additional funding until 2015. The goal of CPCSSN was to establish a database on eight chronic diseases and neurologic conditions by extracting de-identified patient information from electronic medical records. As of the last update, in October 2016, CPCSSN now includes 11 university-affiliated primary care research networks and almost 1,200 physicians contributing data from 1.5 million patients. A recent report concludes that CPCSSN's diagnostic algorithms show excellent sensitivity and specificity for hypertension, diabetes, epilepsy and parkinsonism. The CMA highlighted CPCSSN in its submission to the Advisory Panel on Healthcare Innovation as being worthy of ongoing federal support. General observations We would like to make three general observations. First, the future of the PHCOs should not be decided in isolation. Instead, we believe that the big picture of federal funding for the advancement of health and health care should be considered, including the investments that the federal government is making in the Canadian Institutes of Health Research and the Strategy for Patient-Oriented Research. Second, the CMA's engagement with the PCHOs has been haphazard. While we have had the opportunity to participate in consultations and technical and working groups with the PCHOs, these interactions have generally fallen short of what we would consider to be early, meaningful and ongoing engagement. Third, the PCHOs have developed considerable expertise within their mandates and spheres of activity. They could almost certainly harness their potential to mount a synergistic effort to successfully address pressing national issues that might otherwise seem almost impossible to confront, such as seniors care. Recommendations The CMA respectfully offers two recommendations: 1. That the government's implementation plan following the PCHO review include mechanisms to address the following needs: * for a national focal point that promotes a comprehensive approach to quality health care; * for a well-resourced national patient voice that advocates for patient- and family-centred health care; * for greater recognition of the importance of the social determinants of health and health equity; * for a national mechanism to drive the sustainable adoption of innovative technologies in health care across Canada; and * for advanced analytical capabilities to conduct in-depth assessments of funding mechanisms and advance the collection and analysis of data generated by electronic medical records. 2. That the federal government challenge the PCHOs and other federal agencies to work with the provincial/territorial governments and stakeholders to develop and implement a national action plan to address the health and health care of Canada's seniors. Bibliography Accreditation Canada. Client- and family-centred care in the Qmentum program. Ottawa: Accreditation Canada; 2015. Advisory Board. A milestone: Kaiser now interacts more with patients virtually than in-person. Washington, DC: Advisory Board; 2016 Oct 13. Available: www.advisory.com/daily-briefing/2016/10/13/kaiser-telehealth (accessed 2017 Nov 10). Advisory Panel on Healthcare Innovation. Unleashing innovation: excellent healthcare for Canada. Ottawa: Minister of Health; 2015. Available: http://healthycanadians.gc.ca/publications/health-system-systeme-sante/report-healthcare-innovation-rapport-soins/alt/report-healthcare-innovation-rapport-soins-eng.pdf (accessed 2017 Nov 10). Birtwhistle R. Update from CPCSSN. Can Fam Physician 2016;62(10):851. Canadian Institute for Health Information. National Physician Database. Table B.1 Number of services, by physician specialty, national groupin system strata and province/territory, 2015-2016. Ottawa: The Institute; 2017. Canadian Medical Association. CPG Infobase: clinical practice guidelines. Ottawa: The Association; 2017. Available: www.cma.ca/En/Pages/clinical-practice-guidelines.aspx (accessed 2017 Nov 10). Canadian Medical Association. Submission to Advisory Panel on Healthcare Innovation. Ottawa: The Association; 2014. Available: www.cma.ca/Assets/assets-library/document/en/advocacy/submissions/CMA-Submission-Adv-Panel-on-HC-Innovation.pdf (accessed 2017 Nov 10). Canada's Health Informatics Association. 2015 Canadian telehealth report. Toronto: The Association; 2015. Available: https://livecare.ca/sites/default/files/2015%20TeleHealth-Public-eBook-Final-10-9-15-secured.pdf (accessed 2017 Nov 10). Health Providers Against Poverty(HPAP). Canada: HPAP; 2017. Available: https://healthprovidersagainstpoverty.ca (accessed 2017 Nov 10). Institute of Health Equity. London: Institute of Health Equity; 2017. Available: www.instituteofhealthequity.org (accessed 2017 Nov 10). Mackenbach J, Meerding W, Kunst A. Economic costs of health inequalities in the European Union. J Epidemiol Community Health 2011;65(5):412-9. National Academy of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington DC: National Academies Press; 2001. The National Institute for Health and Care Excellence (NICE). Improving health and social care through evidence-based guidance. London: NICE; 2017. Available: https://www.nice.org.uk/ (Accessed 24 November 2017). Osborn R, Squires D, Doty M, Sarnak S, Schneider E. In new survey of eleven countries, US adults still struggle with access to and affordability of health care. Health Aff (Millwood) 2016;35(12):2327-6. Patients Canada. Toronto: Patients Canada, 2017. Available: www.patientscanada.ca/ (accessed 2017 Nov 10). Picard A. It's time for a data-driven approach to health care. Globe and Mail 2017 Nov 7. https://beta.theglobeandmail.com/opinion/its-time-for-a-data-driven-approach-to-health-care/article36858079/?ref=http://www.theglobeandmail.com& (accessed 2017 Nov 10). National Collaborating Centre for Determinants of Health (NCCDH). Antigonish, NS: NCCDH; 2017. Available: /www.nccdh.ca/ (accessed 2017 Nov 10). Public Health Agency of Canada. Health inequalities data tool - public health infobase. Ottawa: Public Health Agency of Canada; 2017. Available: https://infobase.phac-aspc.gc.ca/health-inequalities/ (accessed 2017 Nov 10). Schneider E, Sarnak D, Squires D, Shah A, Doty M. Mirror, mirror 2017: international comparison reflects flaws and opportunities for better U.S. health care. New York, NY: Commonwealth Fund; 2017. Available: www.commonwealthfund.org/~/media/files/publications/fund-report/2017/jul/schneider_mirror_mirror_2017.pdf (accessed 2017 Nov 13). Standing Senate Committee on Social Affairs, Science and Technology. Challenge ahead: integrating robotics, artificial intelligence and 3D printing technologies into Canada's healthcare systems. Ottawa: The Senate; 2017. Available: https://sencanada.ca/content/sen/committee/421/SOCI/reports/RoboticsAI3DFinal_Web_e.pdf (accessed 2017 Nov 10). Tinkham & Associates LLP. Financial statements of Patients Canada. Toronto: Tinkham & Associates LLP; 31 Dec 2014. Available: www.patientscanada.ca/site/patients_canada/assets/pdf/patientscanada-financialstatements-2014.pdf (accessed 2017 Nov 10). Toward Optimized Practice (TOP). Edmonton, AB: TOP; 2017. Available: www.topalbertadoctors.org/home/ (accessed 2017 Nov 13). Wellesley Institute. Toronto: Wellesley Institute; 2017. Available: www.wellesleyinstitute.com/about (accessed 2017 Nov 10). Williamson T, Green M, Birtwhistle R, Khan S, Garies S, Wong S, Natarajan N, Manca D, Drummond N. Validating the 8 CPCSSN case definitions for chronic disease surveillance in a primary care database of electronic health records. Ann Fam Med 2014;12(4):367-72. World Health Organization. Rio political declaration on social determinants of health. Geneva: The Organization; 2011. Available: www.who.int/sdhconference/declaration/Rio_political_declaration.pdf?ua=1 (accessed 2017 Nov 10).
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Advancing Inclusion and quality of life for seniors

https://policybase.cma.ca/en/permalink/policy13729
Date
2017-10-26
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2017-10-26
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Text
Canadians are living longer, healthier lives than ever before. The number of seniors expected to need help or care in the next 30 years will double, placing an unprecedented challenge on Canada’s health care system. That we face this challenge speaks to the immense success story that is modern medicine, but it doesn’t in any way minimize the task ahead. Publicly funded health care was created about 50 years ago when Canada’s population was just over 20 million and the average life expectancy was 71. Today, our population is over 36 million and the average life expectancy is 10 years longer. People 85 and older make up the fastest growing age group in our country, and the growth in the number of centenarians is also expected to continue. The Canadian Medical Association is pleased that the House of Commons Standing Committee on Human Resources, Skills and Social Development and the Status of Persons with Disabilities is studying ways Canada can respond to these challenges. Here, for your consideration, we present 15 comprehensive recommendations that would help our seniors remain active, contributing citizens of their communities while improving the quality of their lives. These range from increasing capital investment in residential care infrastructure, to enhancing assistance for caregivers, to improving the senior-friendliness of our neighbourhoods. The task faced by this committee, indeed the task faced by all of Canada, is daunting. That said, it is manageable and great advances can be made on behalf of seniors. By doing so, we will ultimately deliver both health and financial benefits to all Canadians. Dr. Laurent Marcoux, CMA President The Canadian Medical Association (CMA) is pleased to submit this brief to the Standing Committee on Human Resources, Skills and Social Development and the Status of Persons with Disabilities as part of its study regarding how the Government can support vulnerable seniors today while preparing for the diverse and growing seniors population of tomorrow. This brief directly addresses the three themes considered by this Committee:
How the Government can improve access to housing for seniors including aging in place and affordable and accessible housing;
How the Government can improve income security for vulnerable seniors; and
How the Government can improve the overall quality of life and well-being for seniors including community programming, social inclusivity, and social determinants of health. Improving access to housing for seniors As part of a new National Housing Strategy, the federal government announced in the 2017 Budget that it will invest more than $11.2 billion in a range of initiatives designed to build, renew, and repair Canada’s stock of affordable housing and help to ensure that Canadians have adequate and affordable housing that meets their needs. While a welcome step, physicians continue to see the problems facing seniors in relation to a lack of housing options and supports — problems that cascade across the entire health care system. A major hindrance to social equity in health care delivery and a serious cause of wait times is the inappropriate placement of patients, particularly seniors, in hospitals. Alternate level of care (ALC) beds are often used in acute care hospitals to accommodate patients — most of whom are medically stable seniors — waiting for appropriate levels of home care or access to a residential care home/facility. High rates of ALC patients in hospitals affect all patients by contributing to hospital overcrowding, lengthy waits in emergency departments, delayed hospital admissions, cancelled elective surgeries, and sidelined ambulance services waiting to offload new arrivals (often referred to as code gridlock).1 Moreover, unnecessarily long hospital stays can leave patients vulnerable to hospital-acquired illnesses and disabilities such as delirium, deconditioning, and falls. Daily costs - Ontario $842: acute care hospital, per patient $126: long-term care residence, per patient $42: home care, per patient # of acute care hospital beds = 18,571 14% waiting for placement = 2,600 beds Providing more cost-effective and appropriate solutions will optimize the use of health care resources. It has been estimated that it costs $842 per day for a hospital bed versus $126 per day for a long-term care bed and $42 per day for care at home.2 An investment in appropriate home or residential care, which can take many forms, will alleviate inappropriate hospital admissions and facilitate timely discharges. The residential care sector is facing significant challenges because of the rising numbers of older seniors with increasingly complex care needs. The demand for residential care will increase significantly over the next several years because of the growing number of frail elderly seniors requiring this service. New facilities will need to be constructed and existing facilities will need to be upgraded to comply with enhanced regulatory requirements and respond to residents’ higher care needs. The Conference Board of Canada has produced a residential care bed forecast tied to population growth of age cohorts. It is estimated that Canada will require an average of 10,500 new beds per year over the next 19 years, for a total of 199,000 new beds by 2035. This forecast does not include the investments needed to renovate and retrofit existing long-term care homes.3 A recent report by the Canadian Institute for Health Information indicated that residential care capacity must double over the next 20 years (assuming no change in how care is currently provided), necessitating a transformation in how seniors care is provided across the continuum of care.4 These findings provide a sense of the immense challenges Canada faces in addressing the residential care needs of older seniors. Investments in residential care infrastructure and continuing care will improve care for seniors while significantly reducing wait times in hospitals and across the system, benefiting all patients. Efforts to de-hospitalize the system and address the housing and residential care options for Canada’s aging population are key. The federal government can provide significant pan-Canadian assistance by investing in residential care infrastructure. RECOMMENDATION 1 The CMA recommends that the federal government include capital investment in residential care infrastructure, including retrofit and renovation, as part of its commitment to invest in social infrastructure. Improving income security for vulnerable seniors Income is a key factor impacting the health of individuals and communities. Higher income and social status are linked to better health.5 Adequate Income: Poverty among seniors in Canada dropped sharply in the 1970s and 1980s but it has been rising in recent years. In 2012, the incidence of low income among people aged 65 years and over was 12.1%. This rate was considerably higher for single seniors at 28.5%.6 Incidence of low income (2012) Seniors overall: 12.1% Single seniors: 28.5% Most older Canadians rely on Old Age Security (OAS), the Canada Pension Plan (CPP), and their personal pensions or investments to maintain their basic standard of living in retirement. Some seniors are also eligible for a Guaranteed Income Supplement (GIS) to improve their financial security. The CMA recognizes the federal government’s actions to strengthen these programs and initiatives to ensure their viability and to provide sustainable tax relief. These measures must continue and evolve to support aging Canadians so they can afford to live at home or in age-friendly communities as they get older. The government’s actions to ensure adequate income support will also assist aging Canadians to take care of their health, maintain independence, and continue living safely without the need for institutional care. On the topic of seniors’ income security, the financial abuse of seniors cannot be overlooked. Elder abuse can take many forms: financial, physical, psychological, sexual, and neglect. Often the abuser is a family member, friend, or other person in a position of trust. Researchers estimate that 4 to 10% of Canadian seniors experience abuse or neglect, but that only a small portion of this is reported. The CMA supports public awareness initiatives that bring attention to elder abuse, as well as programs to intervene with seniors who are abused and with their abusers. RECOMMENDATION 2 The CMA recommends that the federal government take steps to provide adequate income support for older Canadians, as well as education and protection from financial abuse. Improving the overall quality of life and well-being for seniors Improving how we support and care for Canada’s growing seniors population has been a priority for CMA over the past several years. For the first time in Canada’s history, persons aged 65 years and older outnumber those under the age of 15 years.7 Seniors are projected to represent over 20% of the population by 2024 and up to 25% of the population by 2036.8 People aged 85 years and over make up the fastest growing age group in Canada — this portion of the population grew by 127% between 1993 and 2013.9 Statistics Canada projects, on the basis of a medium-growth scenario, that there will be over 11,100 Canadians aged 100 years and older by 2021, 14,800 by 2026 and 20,300 by 2036.7 Though age does not automatically mean ill health or disability, the risk of both increases with age. Approximately 75 to 80% of Canadian seniors report having one or more chronic conditions.10 Because of increasing rates of disability and chronic disease, the demand for health services is expected to increase as Canada’s population ages. The Conference Board of Canada has estimated 2.4 million Canadians 65 years and older will need continuing care, both paid and unpaid, by 2026 — a 71% increase since 2011.11 When publicly funded health care was created about 50 years ago, Canada’s population was just over 20 million and the average life expectancy was 71. Today, our population is over 36 million and the average life expectancy is 10 years longer. The aging of our population is both a success story and a pressing health policy issue. National seniors strategy Canada needs a new approach to ensure that both our aging population and the rest of Canadians can get the care they need, when and where they need it. The CMA believes that the federal government should invest in seniors care now, guided by a pan-Canadian seniors strategy. In doing so, it can help aging Canadians be as productive as possible — at work, in their communities, and in their homes. The CMA is pleased with the June 2017 Report of the Standing Senate Committee on National Finance that called for the federal government to develop, in collaboration with the provinces and territories and Indigenous partners, a national seniors strategy in order to control spending growth while ensuring appropriate and accessible care.12 The CMA is also pleased that MP Marc Serré (Nickel Belt) secured support for his private members’ motion calling for the development of a national seniors strategy. Over 50,000 Canadians have already lent their support to this cause (see www.DemandaPlan.ca). RECOMMENDATION 3 The CMA recommends that the federal government provide targeted funding to support the development of a pan-Canadian seniors strategy to address the needs of the aging population. Improving assistance for home care and Canada’s caregivers Many of the services required by seniors, in particular home care and long-term care, are not covered by the Canada Health Act. Funding for these services varies widely from province to province. The disparity among the provinces in terms of their fiscal capacity in the current economic climate will mean improvements in seniors care will advance at an uneven pace. The funding and delivery of accessible home care services will help more aging Canadians to recover from illness, live at home longer, and contribute to their families and communities. Multi-year funding arrangements to reinforce commitment to and financial investment in home care should be carefully considered.13 The development of innovative partnerships and models to help ensure services and resources for seniors’ seamless transition across the continuum of care are also important. RECOMMENDATION 4 The CMA recommends governments work with the health and social services sectors, and with private insurers, to develop a framework for the funding and delivery of accessible and sustainable home care and long-term care services. Family and friend caregivers are an extremely important part of the health care system. A 2012 Statistics Canada study found that 5.4 million Canadians provided care to a senior family member or friend, and 62% of caregivers helping seniors said that the care receiver lived in a private residence separate from their own.14 According to a report by Carers Canada, the Canadian Home Care Association, and the Canadian Cancer Action Network, caregivers provide an array of services including personal and medical care, housekeeping, advocacy, financial management, and social/emotional support. The report also indicated that caregivers contribute $25 billion in unpaid labour to our health system.15 Given their enormous contributions, Canada’s caregivers need support in the form of financial assistance, education, peer support, and respite care. A pan-Canadian caregiver strategy is needed to ensure caregivers are provided with the support they require.15 Caregivers provide... Personal and Medical Care Housekeeping worth $25 billion in Advocacy unpaid labour Financial Managemen Social-emo ional Suppor RECOMMENDATION 5 The CMA recommends that the federal government and other stakeholders work together to develop and implement a pan-Canadian caregiver strategy, and expand the support programs currently offered to informal caregivers. Canadians want governments to do more to help seniors and their family caregivers.16 The federal government’s new combined Canada Caregiver Credit (CCC) is a non-refundable credit to individuals caring for dependent relatives with infirmities (including persons with disabilities). The CCC will be more accessible and will extend tax relief to more caregivers by including dependent relatives who do not live with their caregivers and by increasing the income threshold. Making the new CCC a refundable tax credit for caregivers whose tax owing is less than the total credit would result in a refund payment to provide further financial support for low-income families. RECOMMENDATION 6 The CMA recommends that the federal government improve awareness of the new Canada Caregiver Credit and amend it to make it a refundable tax credit for caregivers. The federal government’s recent commitment to provide $6 billion over 10 years to the provinces and territories for home care, including support for caregivers, is a welcome step toward improving opportunities for seniors to remain in their homes. As with previous bilateral funding agreements, it is important to establish clear operating principles between the parties to oversee the funding implementation and for the development of clear metrics to measure performance. RECOMMENDATION 7 The CMA recommends that the federal government develop explicit operating principles for the home care funding that has been negotiated with the provinces and territories to recognize funding for caregivers and respite care as eligible areas of investment. The federal government’s recent funding investments in home care and mental health recognize the importance of these aspects of the health care system. They also signal that Canada has under-invested in home and community-based care to date. Other countries have more supportive systems and programs in place — systems and programs that Canada should consider. RECOMMENDATION 8 The CMA recommends the federal government convene an all-party parliamentary international study that includes stakeholders to examine the approaches taken to mitigate the inappropriate use of acute care for elderly persons and provide support for caregivers. Programs and supports to promote healthy aging The CMA believes that governments at all levels should invest in programs and supports to promote healthy aging, a comprehensive continuum of health services to provide optimal care and support to older Canadians, and an environment and society that is “age friendly”.17 The Public Health Agency of Canada (PHAC) defines healthy aging as “the process of optimizing opportunities for physical, social and mental health to enable seniors to take an active part in society without discrimination and to enjoy independence and quality of life.”18 It is believed that initiatives to promote healthy aging and enable older Canadians to maintain their health will help lower health care costs by reducing the overall burden of disability and chronic disease. Such initiatives should focus on physical activity, good nutrition, injury (e.g. falls) prevention, and seniors’ mental health (including depression). RECOMMENDATION 9 The CMA recommends that governments at all levels support programs to promote physical activity, nutrition, injury prevention, and mental health among older Canadians. For seniors who have multiple chronic diseases or disabilities, care needs can be complex, and they may vary greatly from one person to another and involve many health care providers. Complex care needs demand a flexible and responsive health system. The CMA believes that quality health care for older Canadians should be delivered on a continuum from community-based health care (e.g. primary health care, chronic disease management programs), to home care (e.g. visiting health care workers to give baths and foot care), to long-term care and palliative care. Ideally, this continuum should be managed so that the senior can remain at home and out of emergency departments, hospitals, and long-term care unless appropriate; easily access necessary care; and make a smooth transition from one level of care to another when necessary. RECOMMENDATION 10 The CMA recommends governments and other stakeholders work together to develop and implement models of integrated, interdisciplinary health service delivery for older Canadians. Every senior should have the opportunity to have a family physician or to be part of a family practice that serves as a medical home. This provides a central hub for the timely provision and coordination of the comprehensive menu of health and medical services. A medical home should provide patients with access to medical advice and the provision of, or direction to, needed care 24 hours a day, seven days a week, 365 days a year. Research in 2014 by the Commonwealth Fund found that the percentage of Canadian seniors who have a regular family physician or place of care is very high (98%); however, their ability to get timely access based on same-day or next-day appointments was among the lowest of 11 nations.19 Compared to seniors in most other countries surveyed, Canadian seniors were also more likely to use the emergency department and experience problems with care coordination. RECOMMENDATION 11 The CMA recommends governments continue efforts to ensure that older Canadians have access to a family physician, supported by specialized geriatric services as appropriate. Prescription drugs represent the fastest-growing item in the health budget and the second-largest category of health expenditure. As the population of seniors grows, there will be an ongoing need for detailed information regarding seniors’ drug use and expenditure to support the overall management of public drug programs.20 Despite some level of drug coverage for seniors in all provinces and territories, some seniors still skip doses or avoid filling prescriptions due to cost, and more research into the extent of this problem is required.21 The CMA supports the development of an equitable and comprehensive pan-Canadian pharmacare program. As a step toward comprehensive, universal coverage, the CMA has repeatedly called on the federal government to implement a system of catastrophic coverage for prescription medication to reduce cost barriers of treatment and ensure Canadians do not experience undue financial hardship. Moreover, with more drugs available to treat a large number of complex and chronic health conditions, the CMA supports the development of a coordinated national approach to reduce polypharmacy among the elderly. RECOMMENDATION 12 The CMA recommends governments and other stakeholders work together to develop and implement a pan-Canadian pharmaceutical strategy that addresses both comprehensive coverage of essential medicines for all Canadians, and programs to encourage optimal prescribing and drug therapy. Optimal care and support for older Canadians also depends on identifying, adapting, and implementing best practices in the care of seniors. PHAC’s Best Practices Portal22 is one noteworthy initiative, and the system needs to spread and scale best practices by leveraging and enhancing pan-Canadian resources that build capacity and improve performance in home care and other sectors.13 RECOMMENDATION 13 The CMA recommends that governments and other stakeholders support ongoing research to identify best practices in the care of seniors, and monitor the impact of various interventions on health outcomes and costs. An environment and society that is “age friendly” One of the primary goals of seniors policy in Canada is to promote the independence of older Canadians, avoiding costly institutionalization for as long as feasible. To help older Canadians successfully maintain their independence, governments and society must keep the social determinants of health in mind when developing and implementing policy that affects seniors. It is also important to eliminate discrimination against seniors and promote positive messaging around aging. An age-friendly society respects the experience, knowledge, and capabilities of its older members and accords them the same worth and dignity as it does other citizens. Employment is also important for seniors who need or desire it. Many seniors are choosing to remain active in the workplace for a variety of reasons, such as adding to their financial resources or staying connected to a social network.23 The CMA recognizes the federal government’s support for seniors who opt to continue working. And, while many employers encourage older workers and accommodate their needs, employment may be difficult to find in workplaces that are unwilling to hire older workers. RECOMMENDATION 14 The CMA recommends that governments at all levels and other partners give older Canadians access to opportunities for meaningful employment if they desire. The physical environment, including the built environment, can help to promote seniors’ independence and successful, healthy aging. The World Health Organization defines an “age-friendly environment” as one that fosters health and well-being and the participation of people as they age.24 Age-friendly environments are accessible, equitable, inclusive, safe and secure, and supportive. They promote health and prevent or delay the onset of disease and functional decline. They provide people-centered services and support to enable recovery or to compensate for the loss of function so that people can continue to do the things that are important to them.24 These factors should be taken into consideration by those who design and build communities. For example, buildings should be designed with entrance ramps and elevators; sidewalks could have sloping curbs for walkers and wheelchairs; and frequent, accessible public transportation should be provided in neighbourhoods with large concentrations of seniors. RECOMMENDATION 15 The CMA recommends that governments and communities take the needs of older Canadians into account when designing buildings, walkways, transportation systems, and other aspects of the built environment. Conclusion The CMA recognizes the federal government’s commitment to support vulnerable seniors today while preparing for the diverse and growing seniors’ population of tomorrow. The CMA’s recommendations in this submission can assist the government as it seeks to improve access to housing for seniors, enhance income security for vulnerable seniors, and improve the overall quality of life for seniors in ways that will help to advance inclusion, well-being, and the health of Canada’s aging population. To maximize the health and well-being of older Canadians, and ensure their active engagement and independence for as long as possible, the CMA believes that the health care system, governments, and society should work with older Canadians to promote healthy aging, provide quality patient-centred health care and support services, and build communities that value Canadians of all ages. References 1 Simpson C. Code Gridlock: Why Canada needs a national seniors strategy. Address to the Canadian Club of Ottawa by Dr. Christopher Simpson, President, Canadian Medical Association; 2014 Nov. 18; Ottawa, Ontario. Available: https://www.cma.ca/En/Lists/Medias/Code_Gridlock_final. pdf#search=code%20gridlock (accessed 2016 Sep 22). 2 North East Local Health Integration Network. HOME First shifts care of seniors to HOME. LHINfo Minute, Northeastern Ontario Health Care Update. Sudbury: The Network; 2011. Cited by Home Care Ontario. Facts & figures - publicly funded home care. Hamilton: Home Care Ontario; 2017 Jun. Available: http://www.homecareontario.ca/home-care-services/facts-figures/publiclyfundedhomecare (accessed 2016 Sep 22). 3 Conference Board of Canada. A cost-benefit analysis of meeting the demand for long-term care beds. Ottawa: Conference Board of Canada; Manuscript submitted for publication. 4 Canadian Institute for Health Information (CIHI). Seniors in transition: exploring pathways across the care continuum. Ottawa: The Institute; 2017. Available: https://www.cihi.ca/sites/default/files/document/seniors-in-transition-report-2017-en.pdf (accessed 2017 Jun 30). 5 World Health Organization. Health Impact Assessment (HIA). The determinants of health. Available: http://www.who.int/hia/evidence/doh/en/ (accessed 2017 Oct 23). 6 Statistics Canada. Persons in low income (after-tax low income measure), 2012. The Daily. Ottawa: Statistics Canada; 2014 Dec 10. Available: http://www.statcan.gc.ca/daily-quotidien/141210/t141210a003-eng.htm (accessed 2017 Oct 17). 7 Statistics Canada. Population projections: Canada, the provinces and territories, 2013 to 2063. The Daily. Ottawa: Statistics Canada; 2014 Sep 17. Available: http://www.statcan.gc.ca/daily-quotidien/140917/dq140917a-eng.pdf (accessed 2016 Sep 19). 8 Statistics Canada. Canada Year Book 2012, seniors. Ottawa: Statistics Canada; 2012. Available: https://www.statcan.gc.ca/pub/11­ 402-x/2012000/chap/seniors-aines/seniors-aines-eng.htm (accessed 2017 Oct 18). 9 Public Health Agency of Canada. The Chief Public Health Officer’s report on the state of public health in Canada, 2014: public health in the future. Ottawa: Public Health Agency of Canada; 2014. Available: https://www.canada.ca/content/dam/phac-aspc/migration/phac-aspc/ cphorsphc-respcacsp/2014/assets/pdf/2014-eng.pdf (accessed 2016 Sep 19). 10 Canadian Institute for Health Information (CIHI). Health Care in Canada, 2011: A Focus on Seniors and Aging. Ottawa: The Institute; 2014 Nov. Available: https://secure.cihi.ca/free_products/HCIC_2011_seniors_report_en.pdf (accessed 2016 Sept 19). 11 Stonebridge C, Hermus G, Edenhoffer K. Future care for Canadian seniors: a status quo forecast. Ottawa: Conference Board of Canada; 2015. Available: http://www.conferenceboard.ca/e-library/abstract.aspx?did=7374 (accessed 2016 Sep 20). 12 Report of the Standing Senate Committee on National Finance. Getting ready: For a new generation of active seniors. Ottawa: The Committee; 2017 Jun. Available: https://sencanada.ca/content/sen/committee/421/NFFN/Reports/NFFN_Final19th_Aging_e.pdf (accessed 2017 Oct 18). 13 Canadian Home Care Association, The College of Family Physicians of Canada, Canadian Nurses Association. Better Home Care in Canada: A National Action Plan. 2016. Ottawa: Canadian Home Care Association, The College of Family Physicians of Canada, Canadian Nurses Association; 2016. Available: http://www.thehomecareplan.ca/wp-content/uploads/2016/10/Better-Home-Care-Report-Oct-web.pdf (accessed 2017 Oct 23). 14 Turcotte M, Sawaya C. Senior care: differences by type of housing. Insights on Canadian society. Cat. No. 75-006-X. Ottawa: Statistics Canada; 2015 Feb 25. Available: http://www.statcan.gc.ca/pub/75-006-x/2015001/article/14142-eng.pdf (accessed 2016 Sep 22). 15 Carers Canada, Canadian Home Care Association, Canadian Cancer Action Network. Advancing Collective Priorities: A Canadian Carer Strategy. 2017. Mississauga: Canadian Home Care Association, Canadian Cancer Action Network; 2017. Available: http://www.cdnhomecare.ca/media. php?mid=4918 (accessed 2017 Oct 23). 16 Ipsos Public Affairs, HealthCareCAN, Canadian College of Health Leaders. National Health Leadership Conference report. Toronto: Ipsos Public Affairs; 2016 Jun 6. Available: http://www.nhlc-cnls.ca/assets/2016%20Ottawa/NHLCIpsosReportJune1.pdf (accessed 2016 Jun 06). 17 Canadian Medical Association. Health and Health Care for an Aging Population. Ottawa: The Association; December 2013. Available: https:// www.cma.ca/Assets/assets-library/document/en/advocacy/policy-research/CMA_Policy_Health_and_Health_Care_for_an_Aging-Population_ PD14-03-e.pdf (accessed 2017 Oct 20). 18 Government of Canada. The Chief Public Health Officer’s Report on the State of Public Health in Canada 2010 – Canada’s experience in setting the stage for healthy aging. Ottawa: Government of Canada; 2014. Available: https://www.canada.ca/en/public-health/corporate/publications/ chief-public-health-officer-reports-state-public-health-canada/annual-report-on-state-public-health-canada-2010/chapter-2.html (accessed 2017 Oct 23). 19 Commonwealth Fund. 2014 International Health Policy Survey of Older Adults in Eleven Countries. 2014. New York: Commonweath Fund; 2014. Available: http://www.commonwealthfund.org/~/media/files/publications/in-the-literature/2014/nov/pdf_1787_commonwealth_fund_2014_intl_ survey_chartpack.pdf (accessed 2017 Oct 23). 20 Canadian Institute for Health Information. Drug Use among Seniors on Public Drug Programs in Canada, 2002 to 2008. (2010). Ottawa: The Institute; 2010. Available: https://secure.cihi.ca/free_products/drug_use_in_seniors_2002-2008_e.pdf (accessed 2017 Oct 23). 21 Law MR, Cheng L, Dhalla IA, Heard D, Morgan SG. The effect of cost on adherence to prescription medications in Canada. CMAJ. 2012 Feb21;184(3):297-302. Available: http://www.cmaj.ca/content/184/3/297.short. (accessed 2017 Oct 23). 22 Public Health Agency of Canada. Canadian Best Practices Portal. Ottawa: Public Health Agency of Canada; 2016. Available: http://cbpp-pcpe. phac-aspc.gc.ca/public-health-topics/seniors/ (accessed 2017 Oct 23). 23 Government of Canada. Action for Seniors report. 2014. Ottawa: Government of Canada; 2014. Available: https://www.canada.ca/en/ employment-social-development/programs/seniors-action-report.html (accessed 2017 Oct 23). 24 World Health Organization (WHO). Age-friendly environments. Geneva: WHO; 2017. Available: http://www.who.int/ageing/projects/age­ friendly-environments/en/ (accessed 2017 Oct 23).
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A medical industry perspective – supporting small business, the economic engine of Canada

https://policybase.cma.ca/en/permalink/policy13731
Date
2017-10-02
Topics
Physician practice/ compensation/ forms
  1 document  
Policy Type
Parliamentary submission
Date
2017-10-02
Topics
Physician practice/ compensation/ forms
Text
The changes announced on July 18, 2017, are the most significant change to the private corporation tax structure in 45 years and will have a negative impact on doctors and also convenience store operators, electrical contractors and family farmers. In short, these proposals will negatively affect all small business owners, most of whom are squarely in the middle class and are the engine of the Canadian economy. We believe a 75-day consultation is inadequate to assess the scope of these changes and the ramifications for not only our members but also the 1.1 million other small business operators as well as the impacts of the proposals on Canada's prospects for future economic growth. The Canadian Medical Association (CMA) strongly urges the federal government to: 1) suspend the current proposals; 2) conduct a comprehensive review of these proposals to ensure that legislation can meet policy objectives without significant unintended consequences; and 3) engage all Canadians in a comprehensive review of the tax system considering unique aspects of all sectors, including safety net provisions. Economic considerations of the tax proposals: Small business in Canada Most Canadian businesses are small. As of December 2015, there were 1.17 million employer businesses in the Canadian economy. Of these, 1.14 million (97.9%) were small-sized businesses, 21,415 (1.8%) were medium-sized businesses and 2,933 (0.3%) were large-sized businesses. Small- and medium-sized enterprise s (SMEs) are critical contributors to the Canadian economy. They generate the majority of Canadian jobs. Across the country, an estimated 10.6 million people (66.8% of the labour force) work in small-sized businesses and another 3.3 million (20.4%) are employed in medium-sized businesses. Only 2.0 million (12.8%) work in large-sized businesses. In addition to generating jobs, SMEs make a significant contribution to gross domestic product (GDP). Notably, small businesses with fewer than 50 employees will contribute on average 30% to national GDP. SMEs also make sizable contributions to research and development. Between 2011 and 2013, SMEs accounted for 27% of the research and development expenditures in this country. Medical industry Physicians' offices are an important component of the Canadian economy, employing people and supporting suppliers in their communities. The majority of physicians (66% or 54,000) own and operate a private corporation. The direct GDP contribution produced by physicians' offices in Canada in 2016 was $22.3 billion. They paid $6.2 billion in wages and salaries, employed 137,000 people and contributed $643 million in tax revenues to governments. Including the supply chain and induced effects of this economic activity, the total GDP supported by the economic footprint of physicians' offices was $33.4 billion and the total number of jobs supported was 250,000. Physicians' medical practices, in addition to providing essential health care services to Canadians, also provide a noticeable contribution to Canada's economy. The total economic footprint of physicians' practices in 2016 - directly, through their supply chain and through induced effects - accounted for 1.6% of Canada's total GDP in 2016. Making Canada an attractive place to practise medicine Physicians and small business owners across the country believe that the proposals are complex and will ultimately lead to unintended consequences that will affect all Canadians. With so many underserviced regions of Canada and 5.3 million orphan patients, it behooves government to establish conditions that facilitate recruitment and retention of highly skilled professionals, such as physicians. Physicians are more mobile than many other small business owners. Between 2014 and 2015, for instance, approximately 740 physicians (about 1% of all physicians) moved from one province or territory to another. In the CMA's recent member survey, 22% of practising physicians stated they would consider relocating their practice to another country as a result of the proposed federal tax changes. Of the medical residents who participated in the survey, 39% would consider moving their practice to another country if the proposed federal tax changes are implemented. The experience of the 1990s provides evidence that this is a real possibility. In 1992, health ministers agreed to reduce medical school enrolment, and shortly afterward provincial governments began to put restrictions in place, such as a two-year moratorium on new billing numbers in Ontario for physicians who had not completed their undergraduate or postgraduate training there. These measures sent a clear message that doctors were not welcome in Canada and it was no surprise that they left in large numbers. From 1995 to 1997 Canada experienced an annual average net loss of 454 physicians to migration, the equivalent of four medical school classes. The United States continues to face a shortage of physicians, and it may be an attractive alternative for Canadian physicians to practise. Projections released earlier this year for the American Association of Medical Colleges indicate that the United States will have a shortage of between 40,800 and 104,900 physicians by 2030. The path to becoming a physician is a long one, which includes 10 or more years of postsecondary education. As a result, physicians start their careers later than other workers. Average student debt ranges from $160,000 to $180,000. This represents a large personal investment of time and money. We want to ensure that Canada establishes the public policy conditions necessary to retain and attract the next generation of physicians. Thriving medical practices are the best medicine for patients Public policy should strive to promote economic growth, innovation and quality of life for all Canadians. Thriving medical practices are a key ingredient in ensuring that Canadians have access to medical care when and where they need it. Any changes to the existing tax regimen can have the unintended consequences of forcing owners of medical practices to curtail their operations, reduce availability of care and stifle expansions of much-needed medical services. The CMA asked physicians whether they would consider reducing the number of hours they worked if the government eliminated any or all of the benefits of incorporation. Over half of the practising physicians who responded to the survey (54%) indicated they would consider reducing their number of hours worked, and 24% indicated they would consider retirement. In addition, 31% of the respondents stated they would consider closing their practice and moving to another practice setting (such as a hospital-based or salaried position). Of particular note, 64% of the medical residents who responded to the survey indicated that they would avoid independent practice. If fewer physicians opt to stay in or enter into independent practice there could be important implications for physician supply and patient accessibility. This may be particularly important in rural and remote regions, where independent practice is the most common means for delivery of physician services. In some rural and remote communities across Canada, there is already a shortage of physicians. According to Statistics Canada, about 19% of the Canadian population lives in rural and remote communities, but only about 14% of family physicians and 2% of specialists practise in such communities. The ratio of physicians to patients is also much lower in rural than in urban Canada (0.8 versus 2.1 per 1,000 in 2013). Some of the challenges in recruiting and retaining physicians to rural and especially to remote communities include the reality that physicians in these regions often have to work long hours, have a high level of on-call responsibilities and need additional competencies to meet their community's needs. Unlike most physicians working in urban environments, they may also experience insufficient backup or a total absence of backup from other physicians, nurses and complementary services. There are typically fewer professional education opportunities in rural and remote communities. Finally, physicians sometimes find it difficult to travel long distances to visit their families in urban regions or to convince their spouses and children to relocate from urban to rural and remote communities because of limited job prospects and educational opportunities for their families. Promoting gender equality in small- and medium-sized businesses and in medical practices The current federal government has advanced a feminist agenda with a view to ensuring that all public policy aligns with and supports gender equality. It is therefore perplexing to see the tax proposals being considered, as these may further deter women from entering the medical profession. It is worth noting that female physicians now account for 40% of all Canadian physicians and they represent 60% of physicians under the age of 35. This statistic represents a significant achievement in promoting gender equality in the profession. While the potential indirect effects of the federal tax proposals apply to all physicians regardless of gender, female physicians will likely see an incrementally larger decrease in income at all career stages and particularly as they start a family. This is coupled with the fact that there are already fewer female physicians over the age of 50. Many female physicians may choose to stay at home if the current financial and entrepreneurial incentives are no longer available. In addition to the direct impact of the proposed tax measures on female physicians, any practice consolidations or closures resulting from these measures will also impact women currently employed in physician practices, including nurses and administrative support staff. This is significant for occupations such as medical administrative assistants and other health services support staff; 98% and 80% of total employees in these occupations are women, respectively. Inspiring innovation as the cornerstone of Canada's future A significant portion of medical research in Canada is funded by physician donations of cash and unpaid physician labour. This is especially true for physicians working in academic health science centres (AHSCs). AHSCs are vital to ensuring that leading-edge medical research continues in Canada. Since most AHSCs are structured as partnerships of incorporated physicians, they will also be affected by the federal tax proposals, and donations to fund medical research will be compromised as physicians make financial decisions to reduce their spending to make up for their increased tax burden. This is significant, as the CMA estimates that physicians provide $340 million from their gross earnings to fund medical research and teaching in AHSCs. Furthermore, if physicians are facing a reduction in after-tax income from their practices, they will likely favour paid labour over unpaid labour to offset the reduction, which would result in fewer physician hours spent on medical research. There would be little financial incentive for physicians to continue with medical research, which would significantly impede medical innovation in Canada. Technical considerations of the proposals: In reviewing the specifics of the proposals, the CMA wishes to provide its perspective on several of the elements being considered, including fairness, complexity, passive income of a small business corporation, anti-avoidance rules and income splitting. Fairness The tax rules for private corporations are available to everyone should they wish to start and run their own business. They have been supported and even promoted by various governments to encourage entrepreneurship and those who are willing to take the risk of starting up a small business, entering independent practice or taking over the family business. Seeking to compare a salaried employee to someone who works through a private corporation where the corporation earns an equivalent amount of income fails to take into account all the factors necessary to operate a successful business through a corporate structure. For example, private corporations reinvest in the business and save funds to weather adverse economic events and to offset the lack of employment provisions and benefits. Physicians start their medical practice with significant debt and enter their career in their 30s. Private corporations in different sectors face their own unique set of challenges and the existing policies provide certainty that enables them to make plans. The CMA is aware that in 2011 an Employment Insurance (EI) program was established for self-employed individuals whereby they could register and pay for benefits including maternity and parental leave. We understand that there has been low uptake; we suspect that is because many self-employed people cannot take a full year off for maternity/parental leave and therefore do not receive the full value of what they put into the program. Other considerations include the fact that the program is not topped up by an employer, the program does not factor in expenses related to replacement costs, and there is loss of flexibility to cover lifestyle costs. Although well-intentioned, it seems that the enhancements to the EI program may not address the realities of running a business (regardless of incorporation) and that is why we need a more comprehensive review of the tax system that considers unique sector conditions and safety net provisions. Corporations are legitimate business vehicles that facilitate compliance and administration, and they have been sanctioned and encouraged by successive governments for decades. Changing the rules now will be highly destabilizing for small business owners who have chosen to organize their affairs in this way, many of whom also do not have the resources to adjust to these changes. In some cases, provisions for physician incorporation have been part of a negotiated settlement with provincial governments. The proposed changes will drive up medical costs, increase pressure on provincial and territorial governments and worsen fee-schedule negotiations between physicians and their provincial and territorial governments, causing yet more unnecessary disruption. The use of corporations has to a certain extent kept the underground economy at bay because of mandatory reporting requirements and registration both for income tax and GST/HST purposes and for corporate governance. Complexity The Canadian tax system and in particular the rules governing both big and small corporations are complex, and successive governments have strived to simplify them over time. The proposed tax changes have a level of complexity that is counter to what the present government has been promoting by eliminating boutique tax provisions. The proposals create a bigger disparity between small business corporations eligible for the small business deduction and small public corporations that provide many of the same benefits to family shareholders. Passive investments Passive income is already taxed at higher levels than active business income. Working capital is just as necessary in a small business corporation as it is in a public corporation. Investing passively in a private corporation has been a legitimate practice for many generations of Canadian business owners. The method of taxing passive income has been in effect since 1972. Investing passively within a corporation accommodates business owners who assume risk and responsibility not otherwise assumed by employees. A few important accommodations are noted below: * Investing passively provides a business owner with efficient access to capital so that opportunities can be seized, creating growth and employment for our economy. * Business owners are more likely to accept the risk associated with making investments if they have access to more capital. * Investing passively allows a business owner to manage risks assumed when one goes into business for oneself. These risks are not otherwise assumed by employees. * Investing passively allows a business owner to diversify risk by investing in assets that are very different than private corporation shares. * Investing passively allows a business owner to provide for retirement and unforeseen circumstances that may need to be self-funded. Physicians, like other small business owners, retain capital in their corporations to weather the financial ups and downs that are inherent in self-employment. Because physicians do not have employer-sponsored pension plans or health, disability or maternity benefits or statutory vacation leave, they rely on retained earnings and make passive investments to build up the capital to fund these eventualities. Similar to other businesses, medical practices have to respond to the ups and downs of the business cycle - in the medical practice context, provincial and territorial governments will implement expenditure caps and cuts that will affect the medical practice's bottom line. Fair, simple and efficient tax system As noted by CPA Canada, fairness in our tax system is an essential principle and it is doubtful that the recent proposals will improve this. Investing passively in a private corporation has in some cases been a mechanism available to business owners of all sizes since 1972. It will be important to consider the fact that many small business owners have legitimately organized their affairs by investing passively in their corporation and have not contributed to registered retirement savings plans (RRSPs), tax free savings accounts (TFSAs) and registered education savings plans (RESPs). Fundamentally changing the tax system will in some cases require physicians to: * work for more years to save for retirement with after tax dollars; * evaluate whether Canada's tax system is competitive with that of other economies; and * alter practice decisions, such as opting to retire completely versus easing into retirement or reducing hours of work in favour of other career pursuits. Applying a 50% permanent income tax rate in the corporation to passive income assumes that all small business owners are high-rate taxpayers. This is not the case, and this assumption would inadvertently punish many small business owners who are not subject to the highest rates of income tax. In some cases, applying a high rate of personal income tax to corporate income that has already been subject to tax at 50% will result in a combined income tax rate of approximately 71%. Canada's tax system is already complex and the proposed methods of accounting for passive income will in all cases add further complexity, reducing taxpayer compliance. Tracking and pooling sources of income to account for investments will be both time consuming and costly. There will need to be simple mechanisms for both grandfathered investments and those impacted by the new rules. Lastly, making significant changes to legitimate tax structures that have been in use for 45 years requires careful consideration, material stakeholder involvement, carefully considered grandfathering provisions and the appropriate amount of time to plan and implement. The proposals concerning passive income in a private corporation represent a significant change in tax policy. If implemented as proposed by the government, the changes could act as a disincentive for those looking to invest in small business, decreasing job creation. Furthermore, the tax policy changes as proposed could make it difficult for Canada to attract, recruit and retain highly skilled professionals, which will significantly impact the quality and availability of health care in the short and long term. For consideration - prescribed allowable assets for passive investment A fair tax system accommodates taxpayers who assume different levels of risk and is flexible enough to allow taxpayers to manage various circumstances. From a policy perspective, there are many examples of accommodation or incentive, such as the lifetime capital gains exemption (LCGE) and the small business deduction (SBD), which accommodate a self-employed individual's realities when compared with an employee. In the CMA's view, passive income is already taxed at rates of almost 50% to discourage investing passively in a corporation, and when passive income is distributed to individual shareholders, investment income is appropriately taxed. Existing passive assets and any income or related capital gain thereon should not be impacted by any new system that is implemented. Regarding a transition, a taxpayer should have the ability to elect to have existing or substituted assets and the related income or capital gains taxed under the current regime resulting in no change. On a prospective basis, passive assets accumulated over and above a prescribed threshold could be subject to new investment income rules. The prescribed threshold would allow business owners to accumulate passive assets commensurate with the amount of risk they accept or assume. Alternatively, the prescribed threshold would allow a taxpayer to opt out of the onerous and costly rules that are not conducive to small business. Business owners have raised the concern that they need to retain capital in their corporations for valid business purposes. These include saving for economic downturns, future growth and contingencies such as an illness of the principal business owner. Allowing a prescribed amount of passive investments to be held by private corporations will permit them to save for these valid business reasons without facing excessive tax rates, while still meeting the government's policy objective of preventing individuals from using corporations to save beyond government tolerance. A prescribed threshold provides greater certainty for planning and ease of administration. These ideas are worth exploring but require time and the engagement of small businesses to ensure that the changes do not produce unintended consequences while meeting public policy objectives. Converting income to capital Anti-tax avoidance rules We are in support of targeted measures to curtail abuse. Non-arm's length manipulations of cost base to reduce or eliminate capital gains are not appropriate, and such abuses should be curtailed. Use of mechanisms to avoid double taxation such as the so-called pipeline strategy that has been accepted by the Canada Revenue Agency (CRA) to avoid double taxation should be encouraged, not legislated against. Estate planning CRA has issued numerous favourable advanced income tax rulings with respect to pipeline planning. The proposed changes in ITA section 84.1 are especially troublesome for those nearing retirement and those who have planned for their final estate tax liability under the current income tax regime. For example, assume an owner of a private corporation dies in Ontario and the shares are not inherited by a spouse. If the private company shares have a fair market value of $2,000,000 with minimal adjusted cost base, the estate's final income tax liability will increase by approximately $360,000 if the fair market value of the private corporation must be realized as a dividend rather than as a capital gain, as contemplated by proposed subsection 84.1(2). In addition, there would be limited opportunities for retired or near-retirement business owners to acquire life insurance or otherwise reorganize their affairs. Lastly, the proposed changes would effectively require each estate to wind up the affairs of a private corporation within a very short period of time (12 months) to avoid double taxation. For consideration Subsection 164(6) of the Act should be extended to coincide with the graduated rate estate rules that were recently introduced. On this basis, an estate would have three years to properly wind up the affairs of a private company, realize a capital loss and carry it back to the terminal return of the shareholder to avoid paying income tax twice. Income sprinkling The practice of income sprinkling within the use of a professional corporation has been supported by judgments issued by the Supreme Court of Canada. It is also true that in some cases provincial governments have amended legislation governing professionals to allow a professional to introduce family members as shareholders of their professional corporations. Such amendments were made in the context of negotiating contracts for service deliverables and remuneration and in recognition of the family involvement in running a small business, such as a medical office in the case of physicians. Upon incorporation the entity that has been created in support of a specific business activity has nominal value. The corporation builds and expands through bank borrowing, expenditures and the sweat capital of spouses/partners. The value of that sweat capital is difficult to quantify but in many respects is no different than the sweat capital provided by unrelated entrepreneurs in developing a high technology idea into a working venture. The proposed changes could result in more stringent requirements for a family shareholder to demonstrate their contribution of capital or value to an entity than would be required of a non-family member shareholder. Spouses/partners are integral to the risk and development of a business enterprise that, as a family, they have an interest in: pension income splitting recognizes the family unit and similar considerations apply here. Tax policy reflected in the ITA has always permitted a certain level of income based on the personal amount and the dividend tax credit to be received without tax cost. In 2017 the amount was approximately $32,000.00. There is no abuse in using those provisions just as there is no abuse in pension income splitting to share the tax obligation within a family. Subjectivity of reasonability criteria Regarding the application of tax on split income (TOSI) and the "reasonableness test," the CMA is concerned that in practice, the proposed rules will result in inconsistent application, as the reasonableness test requires a subjective self-assessment after considering labour and capital contributions. Consider the practical difficulties that will arise in the following situations: * Both spouses are involved in the business on a regular and continuous basis. However, at different points during their life, their involvement is limited because of health or maternity reasons. * All family members (adult children and parents) are involved on a regular and continuous basis in the business. Similar to the example above, each family member has differing levels of involvement at different times and each family member makes unique contributions. * In some cases, a household will be required to decide on the division of labour. The division of labour would consider both inside and outside duties, resulting in one family member being less active in the business for a period of time or permanently because he/she is directly supporting inside duties so that the other spouse's involvement can exceed what would normally be required of an employee. . When assessing the reasonability of a dividend paid, both the taxpayer and CRA are required to evaluate a proper rate of return and assess the risk assumed. Independent data or proxies are not readily available when assessing risk assumed with respect to a private company investment. In the case where a spouse and/or all family members are involved with the business on a regular and continuous basis, practical difficulty will constantly arise when attempting to ascertain with any degree of precision or certainty reasonable compensation in the circumstances. In some cases, a physician's spouse will deliberately choose not to enter the workforce as a second income earner because it is not economically viable to do so given the day-to-day realities of managing a business, raising a family and planning for the future. Constraining income splitting will in some cases cause hardship for families who have organized their division of labour so that the family can fully support the professional's activities. This translates into physicians being more available to grow their practice and to care for patients. If the economics concerning the division of labour within and outside of the household are seriously altered, many small business owners could be motivated to work less and refocus their division of labour. For consideration - prescribed threshold on income sprinkling Dividends are paid to shareholders as a return on their investment in the corporation. Since the distribution of the dividend is not determined by the quantum of a shareholder's contribution to the corporation, it is illogical to use contribution or labour as the criterion that determines when dividend income will be subject to TOSI. A small business is dynamic, and contributions to a family business are required at different times by different people and entail different amounts of effort. Documenting and measuring the many different contributions will undoubtedly create problems because a business owner and their spouse are often inextricably linked when it comes to valuing their contributions to a business. Because of the complexity that the proposed changes would cause, the TOSI income rules should not consider a small business owner's spouse or common-law partner. In the alternative, a threshold should be contemplated that would recognize various contributions and eliminate the uncertainty and judgment required when applying the proposed rules. The implementation of a prescribed threshold of allowable dividends to be paid to family members would alleviate many of the issues with the current reasonableness test. The primary concern with the current wording of the reasonableness tests is the inherent uncertainty because of the difficulty in determining the value of contributions made by family members. A threshold of allowable dividends would inherently acknowledge that family members contribute value and assume risk with respect to a family business. This would eliminate the uncertainty about these amounts paid to family members, allowing small businesses to recognize the contributions of family members without fear of future reassessments at the top marginal rate of tax. This would also shift the focus of the proposals to higher income earners. Dividends above the prescribed threshold would still be subject to the proposed reasonableness test, preventing excessive amounts from being paid to family members where their contributions do not warrant these distributions. These ideas are worthy of consideration but require the engagement of the small business community to ensure that the changes do not produce unintended consequences while achieving their public policy objectives. Conclusion Canada's doctors are fully committed to improving health and health care by helping families, youth and women, growing the economy and ensuring we have thriving communities from coast to coast to coast. We know that these values are shared by governments. As health care providers and as owners of small businesses, Canada's doctors have been committed to these goals for decades. While the full impact of the proposed taxation changes is currently being assessed, every indication points to significant negative ramifications for frontline health care workers and the Canadian economy. Physician medical practices contribute significantly to the local and national economy by directly employing 137,000 Canadians and providing needed medical infrastructure. These entrepreneurs are also responsible for providing a self-funded safety net. These factors have, to a significant degree, been taken into account in settling fee structures for the medical professional on an overall after-tax basis. If those provisions cannot be relied on in the future, fairness would dictate that time be given for those in the relevant provinces to renegotiate their fee structures so that new factors can be taken into account. Fairness would also dictate that other self-funded safety net provisions, such as retirement savings vehicles, be adjusted or created to cover planned and unplanned events. The July 18, 2017, proposals represent the most significant tax changes since 1972. The CMA is concerned that the government may not be aware of the potential for far-reaching unintended consequences of the proposals and therefore strongly urges the government to: 1. suspend the current proposals; 2. conduct a comprehensive review of these proposals to ensure that legislation can meet policy objectives without significant unintended consequences; and 3. engage all Canadians in a comprehensive review of the tax system considering unique aspects of all sectors, including safety net provisions. Appendix A: Unintended consequences There are several potential mitigating measures physicians may apply to offset reductions in net revenue, including the following: * Physicians may decide to operate their practices on a leaner basis, offsetting their loss in net income by reducing practice spending. They may reduce their individual spending on staff and other costs, or they may elect to consolidate several practices into one. * Physicians may decide to reduce their hours worked, or change their practice setting in response to the reduction in net income. Scenario 1 provides an example. Scenario 1: Private practice Background Dr. Johns operates a private practice in rural Ontario. Understanding that there is a significant shortage of physicians in rural communities across Canada, Dr. Johns and her husband moved to their current rural community 10 years ago. Dr. Johns' husband, a teacher by trade, has been unable to secure full-time employment because of the limited number of jobs available in their community. Instead, he helps Dr. Johns by dealing with all operational matters for her clinics. This includes negotiating leases, buying equipment and hiring staff so that Dr. Johns can focus on delivering medical services. The children are involved too; they developed and maintain the clinic website. Over the last 10 years, he has also handled all matters related to the household, including raising their two children. Dr. Johns' children are now 18 and 19 years old and are both starting university in 2018. Dr. Johns, Mr. Johns and their children are shareholders of the medical professional corporation. Outcome Because of the new changes, Dr. Johns worries that she will not be able to help her children pay for university. Dr. and Mr. Johns are now trying to decide if they should close the rural practice and move back to the city, where Mr. Johns could find employment to help pay for their children's education. Scenario 2 illustrates how the proposed tax changes would affect a female pediatrician operating her practice through a corporation. Scenario 2: Retirement Background Dr. Grey is a 55-year-old pediatrician who operates her practice through a corporation. She is married and has two adult children. Her husband is a shareholder in the corporation. Her children are not. After finishing medical school and her residency, she started practising when she was 30. She spent the next three years making minimum payments on her student loans so that she could save enough to finance her maternity leave. Between ages 33 and 35, she had two children and was unable to work. When she returned to work, her husband stopped working to raise the children and manage the household. By age 40 she had finally paid off her medical school debt, but she spent the next 15 years saving to pay for her children's education and supporting the family. As a result, Dr. Grey has not been able to save any money for retirement before now. Outcome Dr. Grey has heard that her plans may be significantly impacted by the changes to both income splitting and passive investments. She has heard that existing portfolios of passive investments will be grandfathered, but she does not see how that will help her because she is only starting to save for retirement now. As Dr. Grey's fees are set by the province she cannot increase the fees she charges to her patients and will therefore have to reduce costs, including staffing costs. Otherwise, she may never be able to retire comfortably. Scenario 3: Married physician at an academic health science centre Background Dr. Ritchie is an incorporated cardiologist working in an academic health science centre. Because of her sporadic schedule her husband is not able to work a traditional job. Instead, he manages the household, and when needed he helps with any administrative activities required for managing Dr. Ritchie's corporation. As Dr. Ritchie understands that medical research is not well funded in Canada, she donates $25,000 per year to her local research institute. Dr. Ritchie currently takes an annual dividend of $135,000 out of her corporation and pays a dividend of $35,000 to her husband. Outcome Under the proposed changes to income splitting, it is unclear what would be considered a "reasonable amount" that can be paid to Dr. Ritchie's husband for his contributions; therefore, Dr. Ritchie will have to take out all funds herself. If the $35,000 typically paid to Dr. Ritchie's husband is now paid to her, the family tax liability will increase by $13,016/year. This means that if the family wants to have the same after-tax cash under the new rules, they will have to draw an additional $23,400 out of the corporation as dividends, increasing total dividends to $193,400. To fund this additional outflow while still saving for retirement, Dr. Ritchie will have to reduce her practice's expenditures by an amount roughly equal to her annual medical research donation. She is strongly considering not making donations to medical research so that she can support her family.
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Social equity and increasing productivity

https://policybase.cma.ca/en/permalink/policy13725
Date
2017-09-21
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2017-09-21
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Text
Canadians are living longer, healthier lives than ever before. This is due in large part to Canada’s health care system, the people working in it, research and medical school excellence, public and private investments and the many advances that have been made over the decades in medicine. However, the Canadian Medical Association (CMA) is deeply concerned that Canada’s health care system isn’t keeping up with the health care needs of older Canadians. When publicly funded health care was created about 50 years ago, Canada’s population was just over 20 million and the average life expectancy was 71. Today, our population is over 30 million and the average life expectancy is 10 years longer. The aging of our population is both an immense success story and the most pressing policy imperative of our time. Our submission and recommendations focus on seniors care. We believe the ability of our country to meet the health care needs of this segment of our population is indeed of such high priority that we have come to these consultations with this single issue in mind. While daunting, the task ahead is by no means impossible and will ultimately result in numerous health and financial benefits. By providing the means to expand long-term care and home care capacity, the Government of Canada will improve health care for seniors and others, create new jobs and add billions of dollars annually to the Gross Domestic Product. Furtherbed demand will vary over this period, peaking in 2032 and beginning to decline thereafter. The five-year projection for beds is as follows: Table 1: Projected shortage in long-term care beds, 2017–2021 Number of additional Year beds required 2017 15,740* 2018 6,940 2019 6,450 2020 6,620 2021 7,140 Projected 42,890 five-year shortage *Note: the figure for additional beds required in 2017 includes 8,420 beds’ worth of demand that is currently unmet, in the form of patients in alternate level of care beds in hospitals. The Conference Board estimated the cost to construct 10,500 beds (the average number of new beds required per year from 2017 to 2035) at $3.4 billion per year and $63.7 billion in total, on the basis of a cost estimate of $320,000 per bed (all figures in 2017 dollars). These figures include both public and private spending. This forecast does not include the significant investments required to renovate and retrofit the existing stock of residential facilities. The average number of new long-term care beds needed in Canada every year up to 2035 is 10,500. The Conference Board of Canada estimates the cost of this to be $3.4 billion per year, for a total public and private expenditure of $63.7 billion. This forecast does not include the investments needed to renovate and retrofit existing long-term care homes. Construction of new residential care models and renovation/retrofitting of existing facilities will provide significant economic opportunities for many communities across Canada. The construction and maintenance of 10,500 new residential care beds will yield direct economic benefits that include a $1.4 billion annual average contribution to GDP supporting 14,600 jobs yearly during the capital investment phase and a $5.3 billion annual average contribution to GDP supporting an average of 58,300 jobs annually during the facility operation phase. By comparison, nursing homes and residential care facilities employed about 412,000 people in 2016. These investments would also close the significant gap between the projected residential care bed shortages and currently planned investment. When indirect economic contributions are included, the average estimated annual contribution to Canada’s GDP from the construction and operation of the new beds reaches $12.4 billion, supporting an average of 130,000 jobs annually between 2017 and 2035 (in construction, care provision and other sectors). This bed projection provides a sense of the immense challenge Canada faces in addressing the needs of a vulnerable segment of its population of older seniors. A recent report by the Canadian Institute for Health Information indicated that residential care capacity will need to double over the next 20 years (assuming no change in how care is currently provided), necessitating a transformation in how seniors care is provided in Canada across the continuum of care.13 Efforts to de-hospitalize the system and deal with Canada’s aging population should be part of an overall national seniors strategy. Such a strategy was called for previously by the CMA, other organizations (e.g., the National Association of Federal Retirees), the Standing Senate Committee on National Finance14 and over 50,000 Canadians.15 Fixing seniors care will contribute to the renewal of the entire health system and will improve the productivity of health care delivery across the country. The differing fiscal capacities of the provinces in the current economic climate will mean that improvements in seniors care will advance at an uneven pace. The federal government can provide significant pan-Canadian assistance by investing in residential care infrastructure models. GDP # of jobs contributions Capitalinvestment phase Operation phase 14,600 58,300 $1.4 billion $5.3 billion With indirect contributions 130,000 $12.4 billion RECOMMENDATIONS: The CMA recommends that the federal government provide targeted funding to support the development of a pan-Canadian seniors strategy to address the needs of the aging population. The CMA recommends that the federal government include capital investment in residential care infrastructure, including retrofit and renovation, as part of its commitment to invest in social infrastructure. Caregivers are the backbone of any care system. A 2012 Statistics Canada study found that 5.4 million Canadians provided care to a senior family member or friend. While this care was most often received by a senior in their own residence, 62% of caregivers said the care recipients lived in a home separate from the caregiver’s home.16 Age-related needs are the most common reason for care requirements.17 Caregivers are of all ages; for instance, 27% of caregivers were between the ages of 15 and 29 years.18 One study has forecast that the number of Canadians requiring care will double over the next 30 years.19 Caregiver costs Work $5.5 in lost absence: productivity billion Personal upwards of or more out-of-a yearpocket: $2,000 A Statistics Canada study found that 56% of caregivers living with the care recipient provided at least 10 hours of care a week. Approximately 22% of caregivers helping a resident in a care facility also provided at least 10 hours of care a week. The chief condition for which care was provided was dementia or Alzheimer’s disease (25%).16 The cost to employers in lost productivity because of caregiving-related absenteeism is estimated at $5.5 billion annually.20 Caregivers also report high out-of-pocket expenses. This is especially true for those living with the care recipient: over 25% spend at least $2,000 annually on out-of-pocket expenses.16 Caregivers require a range of supports including education/training, peer support, respite care and financial assistance. Canadians want governments to do more to help seniors and their family caregivers.21 The federal government’s new combined Canada Caregiver Credit (CCC) is a non­refundable credit to individuals caring for dependent relatives with infirmities (including persons with disabilities). The CCC will be more accessible and will extend tax relief to more caregivers by including dependent relatives who do not live with their caregivers and by increasing the income threshold. Notwithstanding these changes and the greater flexibility for caregivers to use Employment Insurance benefits, caregivers will require more support. The CMA recommends making the new CCC a refundable tax credit for caregivers whose tax owing is less than the total credit, resulting in a refund payment to provide further financial support for low-income families. RECOMMENDATION: The CMA recommends that the federal government improve awareness of the new Canada Caregiver Credit and amend it to make it a refundable tax credit for caregivers. The federal government’s commitment to provide $6 billion over 10 years to the provinces and territories for home care, including support for caregivers, is a welcomed step toward improving opportunities for seniors to remain in their homes. As with previous bilateral funding agreements, it will be important to establish clear operating principles between the parties to oversee the funding implementation including support for caregivers. RECOMMENDATION: RECOMMENDATION: The CMA recommends that the federal government develop explicit operating principles for the home care funding that has been negotiated with the provinces and territories to recognize funding for caregivers and respite care as eligible areas of investment. The federal government’s recent funding investment in home care and mental health is a recognition that Canada has under-invested in home and community-based care to date. Other countries have more supportive systems and programs in place — systems and programs that Canada should consider. 5 The CMA recommends the federal government convene an all-party parliamentary international study that includes stakeholders to examine the approaches taken to mitigate the inappropriate use of acute care for elderly persons and provide support for caregivers. T he CMA recognizes the federal government’s commitment to help Canadians be as productive as possible in their workplaces and in their communities. Implementing these recommendations as an integrated package is essential to stitching together the elements of community-based and residential care for seniors. In addition to making a meaningful contribution to meeting the future care needs of Canada’s aging population, these recommendations will mitigate the impacts of economic pressures on individuals as well as jurisdictions. The CMA would welcome the opportunity to provide further information and its rationale for each recommendation. 1 Simpson C. Code Gridlock: Why Canada needs a national seniors strategy. Address to the Canadian Club of Ottawa by Dr. Christopher Simpson, President, Canadian Medical Association; 2014 Nov. 18; Ottawa, Ontario. Available: https://www.cma.ca/En/Lists/Medias/Code_Gridlock_ final.pdf (accessed 2016 Sep 22). 2 Canadian Institute for Health Information. Seniors and alternate level of care: building on our knowledge. Ottawa: The Institute; 2012 Nov. Available: https://secure.cihi.ca/ free_products/ALC_AIB_EN.pdf (accessed 2016 Sep 22). 3 Access to Care, Cancer Care Ontario. Alternate level of care (ALC) [Prepared for the Ontario Hospital Association]. Toronto: Ontario Hospital Association (OHA); 2016 May. 4 McCloskey R, Jarrett P, Stewart C, et al. Alternate level of care patients in hospitals: What does dementia have to do with this? Can Geriatr J. 2014 Sep 5;17(3):88–94. 5 North East Local Health Integration Network. HOME First shifts care of seniors to HOME. LHINfo Minute, Northeastern Ontario Health Care Update. Sudbury: The Network; 2011. Cited by Home Care Ontario. Facts & figures - publicly funded home care. Hamilton: Home Care Ontario; 2017 Jun. Available: http://www. homecareontario.ca/home-care-services/facts-figures/ publiclyfundedhomecare (accessed 2016 Sep 22). 6 Sponagle J. Nunavut struggles to care for elders closer to home. CBC News. 2017 Jun 5. Available: http://www.cbc. ca/news/canada/north/nunavut-seniors-plan-1.4145757 (accessed 2017 Jun 30). 7 Health Quality Ontario. Wait times for long-term care homes. Toronto: Health Quality Ontario; 2017. Available: http://www.hqontario.ca/System-Performance/Long­ Term-Care-Home-Performance/Wait-Times (accessed 2017 Jun 22). 8 Alzheimer Society Canada. The Canadian Alzheimer’s Disease and Dementia Partnership: a collective vision for a national dementia strategy for Canada. Toronto: Alzheimer Society Canada; undated. Available: http:// www.alzheimer.ca/~/media/Files/national/Advocacy/ CADDP_Strategic_Objectives_e.pdf (accessed 2016 Sep 22). 9 Public Health Agency of Canada. The Chief Public Health Officer’s report on the state of public health in Canada, 2014: public health in the future. Ottawa: Public Health Agency of Canada; 2014. Available: https://www.canada. ca/content/dam/phac-aspc/migration/phac-aspc/ cphorsphc-respcacsp/2014/assets/pdf/2014-eng.pdf (accessed 2016 Sep 19). 10 Statistics Canada. Population projections: Canada, the provinces and territories, 2013 to 2063. The Daily. Ottawa: Statistics Canada; 2014 Sep 17. Available: http://www.statcan.gc.ca/daily-quotidien/140917/ dq140917a-eng.htm (accessed 2016 Sep 19). 11 The Conference Board of Canada. A cost-benefit analysis of meeting the demand for long-term care beds. Ottawa: Conference Board of Canada; forthcoming. 12 Lazurko M, Hearn B. Canadian continuing care scenarios 1999–2041. KPMG final project report to FPT Advisory Committee on Health Services. Ottawa: KPMG; 2000. Cited by Canadian Healthcare Association. New directions for facility-based long-term care. Ottawa: The Association; 2009. Available: https://www.advantageontario.ca/ oanhssdocs/Issue_Positions/External_Resources/ Sept2009_New_Directions_for_Facility_Based_LTC.pdf (accessed 2017 Jun 30). 13 Canadian Institute for Health Information. Seniors in transition: exploring pathways across the care continuum. Ottawa: The Institute; 2017. Available: https://www.cihi. ca/sites/default/files/document/seniors-in-transition­ report-2017-en.pdf (accessed 2017 Jun 30). 14 Standing Senate Committee on National Finance. Getting ready: for a new generation of active seniors. First interim report. Ottawa: The Senate; 2017 Jun. Available: https:// sencanada.ca/content/sen/committee/421/NFFN/Reports/ NFFN_Final19th_Aging_e.pdf (accessed 2017 Jun 30). 15 Canadian Medical Association. Demand a plan. Ottawa: The Association; 2017. Available: http://www.demandaplan.ca/ (accessed 2017 Jun 30). 16 Turcotte M, Sawaya C. Senior care: differences by type of housing. Insights on Canadian society. Cat. No. 75-006­ X. Ottawa: Statistics Canada; 2015 Feb 25. Available: http://www.statcan.gc.ca/pub/75-006-x/2015001/ article/14142-eng.pdf (accessed 2016 Sep 22). 17 Sinha M. Portrait of caregivers, 2012. Spotlight on Canadians: results from the General Social Survey. Cat. No. 89-652-X – No. 001. Ottawa: Statistics Canada; 2013 Sep. Available: http://www.statcan.gc.ca/pub/89-652­ x/89-652-x2013001-eng.htm (accessed 2016 Sep 22). 18 Bleakney A. Young Canadians providing care. Spotlight on Canadians: results from the General Social Survey. Cat. No. 89-652-X – No. 003. Ottawa: Statistics Canada; 2014 Sep. Available: http://www.statcan.gc.ca/pub/89-652­ x/89-652-x2014003-eng.htm (accessed 2017 Jun 30). 19 Carrière Y, Keefe J, Légaré J, et al. Projecting the future availability of the informal support network of the elderly population and assessing its impact on home care services. Demography Division Research Paper Cat. No. 91F0015M – No. 009. Ottawa: Statistics Canada; 2008. Available: http://publications.gc.ca/collections/collection_2009/ statcan/91F0015M/91f0015m2008009-eng.pdf (accessed 2017 Jun 30). 20 Ceridian Canada. Double duty: the caregiving crisis in the workplace [Blog post]. Ottawa: Ceridian Canada, 2015 Nov 5. Available: http://www.ceridian.ca/blog/2015/11/ double-duty-the-caregiving-crisis-in-the-workplace/ (accessed 2016 Sep 22). 21 Ipsos Public Affairs, HealthCareCAN, National Health Leadership Conference. National Health Leadership Conference report. Toronto: Ipsos Public Affairs; 2016 Jun 6. Available: http://www.nhlc-cnls.ca/assets/2016%20 Ottawa/NHLCIpsosReportJune1.pdf (accessed 2016 Jun 6).
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Bill C-45: The Cannabis Act

https://policybase.cma.ca/en/permalink/policy13723
Date
2017-08-18
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Parliamentary submission
Date
2017-08-18
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
The CMA is pleased to provide this submission to the House of Commons Standing Committee on Health on Bill C-45, the Cannabis Act. The CMA has long-standing concerns about the health risks associated with consuming cannabis,i particularly in its smoked form.1,2 Children and youth are especially at risk for cannabis-related harms, given their brains are undergoing rapid and extensive development. i The term cannabis is used, as in Bill C-45: that is, referring to the cannabis plant or any substance or mixture that contains any part of the plant. ii The plant contains at least 750 chemicals, of which there are over 100 different cannabinoids. Madras BK. Update of cannabis and its medical use. Agenda item 6.2. 37th Meeting of the Expert Committee on 1 Canadian Medical Association. Health risks and harms associated with the use of marijuana. CMA submission to the House of Commons Standing Committee on Health. Ottawa: The Association; 27 May 2014. Available: www.cma.ca/Assets/assets-library/document/en/advocacy/Brief-Marijuana-Health_Committee_May27-2014-FINAL.pdf (accessed 2017 Jul 27). 2 Canadian Medical Association. A public health perspective on cannabis and other illegal drugs. CMA submission to the Special Senate Committee on Illegal Drugs. Ottawa: The Association; 11 Mar 2002. Available: http://policybase.cma.ca/dbtw-wpd/BriefPDF/BR2002-08.pdf (accessed 2017 Jul 27). 3 Canadian Medical Association. Bill C-2 An Act to Amend the Controlled Drugs and Substances Act (Respect for Communities Act). CMA submission to the House of Commons Standing Committee on Public Safety and National Security. Ottawa: The Association; 28 Oct 2014. Available: www.cma.ca/Assets/assets-library/document/en/advocacy/submissions/CMA_Brief_C-2_Respect%C3%A9-for_Communities_Act-English.pdf (accessed 2017 Jul 27). 4 Harm Reduction International. What is harm reduction? A position statement from Harm Reduction International. London, UK: Harm Reduction International; 2017. Available: www.hri.global/what-is-harm-reduction (accessed 2017 Jul 27). 5 Riley D, O’Hare P. Harm reduction: history, definition and practice. In: Inciardi JA, Harrison LD, editors. Harm reduction: national and international perspectives. Thousand Oaks, CA: Sage Publications; 2000. 6 Fischer B, Russel C, Sabioni P, et al. Lower-risk cannabis use guidelines: a comprehensive update of evidence and recommendations. Am J Public Health 2017;107(8):e1–e12. 7 Canadian Medical Association. Legalization, regulation and restriction of access to marijuana. CMA submission to the Government of Canada – Task Force on Cannabis Legalization and Regulation. Ottawa: The Association; 2016 Aug 29. Available: www.cma.ca/Assets/assets-library/document/en/advocacy/submissions/2016-aug-29-cma-submission-legalization-and-regulation-of-marijuana-e.pdf (accessed 2017 Jul 27). 8 Government of Canada. Canadian Tobacco, Alcohol and Drugs Survey (CTADS): 2015 summary. Ottawa: Government of Canada; 2017. Available: www.canada.ca/en/health-canada/services/canadian-tobacco-alcohol-drugs-survey/2015-summary.html (accessed 2017 Jul 27). 9 Health Canada. Canadian Alcohol and Drug Use Monitoring Survey (CADUMS): summary of results for 2012. Ottawa: Health Canada; 2014. Available: www.canada.ca/en/health-canada/services/health-concerns/drug-prevention-treatment/drug-alcohol-use-statistics/canadian-alcohol-drug-use-monitoring-survey-summary-results-2012.html (accessed 2017 Jul 27). 10 World Health Organization. The health and social effects of nonmedical cannabis use. Geneva: World Health Organization; 2016. Available: http://apps.who.int/iris/bitstream/10665/251056/1/9789241510240-eng.pdf?ua=1 (accessed 2017 Jul 27). 11 Task Force on Cannabis Legalization and Regulation. A framework for the legalization and regulation of cannabis in Canada: final report. Ottawa: Health Canada; 2016. 12 Government of Canada. Legislative background: an Act respecting cannabis and to amend the Controlled Drugs and Substances Act, the Criminal Code and other Acts (Bill C-45). Ottawa: Government of Canada; 2017. 13 An Act respecting cannabis and to amend the Controlled Drugs and Substances Act, the Criminal Code and other Acts, Bill C-45, First Reading 2017 Apr 13. 14 Crean RD, Crane NA, Mason BJ. An evidence based review of acute and long-term effects of cannabis use on executive cognitive functions. J Addict Med 2011;5(1):1–8. The CMA’s approach to cannabis is grounded in broad public health policy. It includes promotion of health and prevention of drug dependence and addiction; access to assessment, counselling and treatment services; and a harm reduction perspective. The CMA believes that harm reduction encompasses policies, goals, strategies and programs directed at decreasing adverse health, social and economic consequences of drug use for the individual, the community and the society while allowing the user to continue to use drugs, not precluding abstinence.3,4 Specifically, the CMA recommends a multi-faceted cannabis public health strategy that prioritizes impactful and realistic goals before, and certainly no later than, any legalization of cannabis.5 We propose that the first goal should be to develop educational interventions for children, teenagers and young adults. Other goals relate to data collection; monitoring and surveillance; ensuring a proportionate balance between enforcement harms and the direct and indirect harms caused by cannabis use; and research. There is an ongoing need for research into the medicinal and harmful effects of cannabis use. As noted by the Lower-Risk Cannabis Use Guidelines, 6 there is limited evidence on such subjects as synthetic cannabinoids; practices like “deep inhalation” to increase the psychoactive effects of cannabis; and the combination of risky behaviours, like early-onset and frequent use, associated with experiencing acute or chronic health problems.6 Since 2002, the CMA has taken a public health perspective regarding cannabis and other illegal drugs. More recently, the CMA endorsed the Lower-Risk Cannabis Use Guidelines, and we submitted 22 recommendations to the Task Force on Cannabis Legalization and Regulation (“the Task Force”).7 Overview According to the recent Canadian Tobacco, Alcohol and Drugs Survey, cannabis is the most used illicit drug in Canada.8 In particular, 25%–30% of adolescents or youth report past-year cannabis use.9 This concerns the CMA. The increasing rate of high usage, despite the fact that non-medical use of cannabis is illegal, coupled with cannabis’ increased potency (from 2% in 1980 to 20% in 2015 in the United States),10 the complexity and versatility of the cannabis plant,ii the variable quality of the end product, and variations in the frequency, age of initiation Drug Dependence, Department of Essential Medicines and Health Products, World Health Organization; 2015. Available: www.who.int/medicines/access/controlled-substances/6_2_cannabis_update.pdf (accessed 2017 Jul 27). and method of use make it difficult to study the full health impacts and produce replicable, reliable scientific results. The CMA submits, therefore, that any legalization of cannabis for non-medical use must be guided by a comprehensive cannabis public health strategy and include a strong legal-regulatory framework emphasizing harm reduction principles. Given that the Task Force employed a minimizing of harms approach11 and given how the proposed legislation aligns with the Task Force’s recommendations,12 the bill addresses several aspects of a legal-regulatory framework “to provide legal access to cannabis and to control and regulate its production, distribution and sale.”13 This work provides the starting point for creating a national cannabis public health strategy. The CMA has long called for a comprehensive drug strategy that addresses addiction, prevention, treatment, enforcement and harm reduction.3 There are, however, key public health initiatives that the Canadian government has not adequately addressed and should be implemented before, or no later than, the implementation of legislation. One such initiative is education. Education is required to develop awareness among Canadians of the health, social and economic harms of cannabis use especially in young people. Supporting a Legal-Regulatory Framework that Advances Public Health and Protection of Children and Youth From a health perspective, allowing any use of cannabis by people under 25 years of age, and certainly those under 21 years of age, is challenging for physicians given the effects on the developing brain.1,3,14 The neurotoxic effect of cannabis, especially with persistent use, on the adolescent brain is more severe than on the adult brain.15,16 15 Meier MH, Caspi A, Ambler A, et al. Persistent cannabis users show neuropsychological decline from childhood to midlife. Proc Natl Acad Sci USA 2012;109(40):E2657–64 16 Crépault JF, Rehm J, Fischer B. The cannabis policy framework by the Centre for Addiction and Mental Health: a proposal for a public health approach to cannabis policy in Canada. Int J Drug Policy 2016;34:1–4. 17 Pope HG Jr, Gruber AJ, Hudson JI, et al. Early-onset cannabis use and cognitive deficits: What is the nature of the association? Drug Alcohol Depend 2003;69(3):303–310. 18 Gruber SA, Sagar KA, Dahlgren MK, et al. Age of onset of marijuana use and executive function. Psychol Addict Behav 2011;26(3):496–506. 19 National Academies of Sciences, Engineering, and Medicine. The health effects of cannabis and cannabinoids: the current state of evidence and recommendations for research. Washington (DC): The National Academies Press; 2017. 20 Canadian Cancer Society. 2017 federal pre-budget submission. Canadian Cancer Society submission to the Standing Committee on Finance. 2014 Aug. Available: www.ourcommons.ca/Content/Committee/421/FINA/Brief/BR8398102/br-external/CanadianCancerSociety-e.pdf (accessed 2017 Jul 27). 21 Health Canada. Backgrounder: legalizing and strictly regulating cannabis: the facts. Ottawa: Health Canada; 2017. Available: www.canada.ca/en/health-canada/news/2017/04/backgrounder_legalizingandstrictlyregulatingcannabisthefacts.html (accessed 2017 Jul 27) 22 Hall W, Degenhardt L. Adverse health effects of non-medical cannabis use. Lancet 2009;374(9698):1383–91. 23 Statistics Canada. Canadian Community Health Survey: Mental Health, 2012. The Daily. 2013 Sep 18. Statistics Canada cat. No. 11-001-X. Available: www.statcan.gc.ca/daily-quotidien/130918/dq130918a-eng.htm (accessed 2017 Jul 27). 24 Miech RA, Johnston LD, O’Malley PM, Bachman JG, Schulenberg, JE. Monitoring the future national survey results on drug use, 1975–2010. Vol 1: Secondary students. Ann Arbor: Institute for Social Research, University of Michigan; 2011. 25 Spithoff S, Kahan M. Cannabis and Canadian youth: evidence, not ideology. Can Fam Physician 2014;60(9):785–7. 26 Health Canada. Strong foundation, renewed focus: an overview of Canada’s Federal Tobacco Control Strategy 2012–2017. Ottawa: Health Canada; 2012. Available: www.canada.ca/content/dam/canada/health-canada/migration/healthy-canadians/publications/healthy-living-vie-saine/tobacco-strategy-2012-2017-strategie-tabagisme/alt/tobacco-strategy-2012-2017-strategie-tabagisme-eng.pdf (accessed 2017 Jul 27). 27 Controlled Drugs and Substances Act, SC 1996, c 19, s 9. Further, neurological studies have shown that adolescent-onset cannabis use produces greater deficits in executive functioning and verbal IQ and greater impairment of learning and memory than adult-onset use.17,18 This underscores the importance of protecting the brain during development. Since current scientific evidence indicates that brain development is not completed until about 25 years of age,19 this would be the ideal minimum age for legal cannabis use. Youth and young adults are among the highest users of cannabis in Canada. Despite non-medical use of cannabis being illegal in Canada since 1923, usage has increased over the past few decades. The CMA recognizes that a blanket prohibition of possession for teenagers and young adults would not reflect current reality or a harm reduction approach.3 Harm reduction is not one of polarities rather it is about ensuring the quality and integrity of human life and acknowledging where the individual is at within his/her community and society at large.5 The possibility that a young person might incur a lifelong criminal record for periodic use or possession of small amounts of cannabis for personal use means that the long-term social and economic harms of cannabis use can be disproportionate to the drug’s physiological harm. The Canadian government has recognized this disproportionality for over 15 years. Since 2001, there have been two parliamentary committee reportsiii and two billsiv introduced to decriminalize possession of small amounts of cannabis (30 g). It was recommended that small amounts of cannabis possession be a “ticketable” offence rather than a criminal one. iii House of Commons Special Committee on the Non-Medical Use of Drugs (2001) and the Senate Special Committee on Illegal Drugs (2002). iv An Act to amend the Contraventions Act and the Controlled Drugs and Substances Act (Bill C-38), which later was reintroduced as Bill C-10 in 2003. v For example, the Substance Use and Addictions Program (SUAP), a federal contributions program, is delivered by Health Canada to strengthen responses to drug and substance use issues in Canada. See Government of Canada. Substance Use and Addictions Program. Ottawa: Health Canada; 2017. Available: www.canada.ca/en/services/health/campaigns/canadian-drugs-substances-strategy/funding/substance-abuse-addictions-program.html (accessed 2017 Jul 27). Given all of the above, the CMA recommends that the age of legalization should be 21 years of age and that the quantities and the potency of cannabis be more restricted to those under age 25. Supporting a Comprehensive Cannabis Public Health Strategy with a Strong, Effective Education Component The CMA recognizes that Bill C-45 repeals the prohibition against simple possession while increasing penalties against the distribution and sale of cannabis to young people, but this is not enough to support a harm reduction approach. We note that the Federal Tobacco Control Strategy, with its $38 million budget, is intended to help reduce smoking rates and change Canadians’ perceptions toward tobacco.20 Similarly, there are extensive education programs concerning the dangers of alcohol, particularly for young people.v The government of Canada has proposed a modest commitment of $9.6 million to a public awareness campaign to inform Canadians, especially youth, of the risks of cannabis consumption, and to surveillance activities.21 A harm reduction strategy should include a hierarchy of goals with an immediate focus on groups with pressing needs. The CMA submits that young people should be targeted first with education. The lifetime risk of dependence to cannabis is estimated at 9%, increasing to almost 17% in those who initiate use in adolescence.22 In 2012, about 1.3% of people aged 15 years and over met the criteria for cannabis abuse or dependence — double the rate for any other drug — because of the high prevalence of cannabis use.23 The strategy should include the development of educational interventions, including skills-based training programs, social marketing interventions and mass media campaigns. Education should focus not only on cannabis’ general risks but also on its special risks for the young and its harmful effects on them. This is critical given that for many, the perception is that (i) legalization of possession for both adults and young people translates into normalization of use and (ii) government control over the source of cannabis for sale translates into safety of use. Complicating this has been the fear-mongering messaging associated with illegal drugs. The evidence shows that fewer adolescents today believe that cannabis use has any serious health risks24 and that enforcement policies have not been a deterrent.25 Having an appropriate education strategy rolled out before legalization of possession would reduce the numbers of uninformed young recreational users. It would also provide time to engage in meaningful research on the impact of the drug on youth. Such strategies have been successful in the past; for example, the long-termvi Federal Tobacco Control Strategy has been credited with helping reduce smoking rates to an all-time low in Canada.26 vi The Federal Tobacco Control Strategy was initiated in 2001 for 10 years and renewed in 2012 for another five years. The Lower-Risk Cannabis Use Guidelines were developed as a “science-based information tool for cannabis users to modify their use toward reducing at least some of the health risks.”6 The CMA urges the government to support the widespread dissemination of this tool and incorporation of its messages into educational efforts. Other strategies must include plain packaging and labelling with health information and health warnings. Supporting a One-System Approach. Alternatively, a Review of Legislation in Five Years The CMA believes that once the act is in force, there will be little need for two systems (i.e., one for medical and one for non-medical cannabis use). Cannabis will be available for those who wish to use it for medicinal purposes, either with or without medical authorization (some people may self-medicate with cannabis to alleviate symptoms but may be reluctant to raise the issue with their family physician for fear of being stigmatized), and for those who wish to use it for other purposes. The medical profession does not need to continue to be involved as a gatekeeper once cannabis is legal for all, especially given that cannabis has not undergone Health Canada’s usual pharmaceutical regulatory approval process. The Task Force’s discussion reflects the tension it heard between those who advocated for one system and those who did not. One concern raised by patients was about the stigma attached to entering retail outlets selling non-medical cannabis. The CMA submits that this concern would be alleviated if the federal government continued the online purchase and mail order system that is currently in place. Given that there is a lack of consensus and insufficient data to calculate how much of the demand for cannabis will be associated with medical authorization, the Task Force recommended that two systems be established, with an obligation to review — specifically, a program evaluation of the medical access framework in five years.11 If there are two systems, then in the alternative, the CMA recommends a review of the legislation within five years. This would allow time to ensure that the provisions of the act are meeting their intended purposes, as determined by research on the efficacy of educational efforts and other research. Five-year legislative reviews have been previously employed, especially where legislation must balance individual choice with protecting public health and public safety.vii For example, like Bill C-45, the purpose of the Controlled Drugs and Substances Act is to protect public health and public safety.27 Its review within five years is viewed as allowing for a thorough, evidence-based analysis to ensure that the provisions and operations of the act are meeting their intended purpose(s).viii Furthermore, a harm reduction approach lends itself to systematic evaluation of the approach’s short- and long-term impact on the reduction of harms.5 vii Several federal acts contain review provisions. Some examples include the Controlled Drugs and Substances Act, SC b1996, c 19, s 9 (five-year review); the Preclearance Act, SC 1999, c 20, s 39 (five-year review); the National Defence Act, RSC 1985, c N-5, s 273.601(1) (seven-year review); the Public Servants Disclosure Protection Act, SC 2005, c 46, s 54 (five-year review); and the Red Tape Reduction Act, SC 2015, c 12 (five-year review). viii The 2012 amendments to the Controlled Drugs and Substances Act were adopted from Bill S-10, which died on order papers in March 2011. The Senate Standing Committee on Legal and Constitutional Affairs reviewed Bill S-10 and recommended that the review period should be extended from two to five years as two years is not sufficient to allow for a comprehensive review. See Debates of the Senate, 40th Parliament, 3rd Session, No 147:66 (2010 Nov 17) at 1550; see also Senate Standing Committee on Legal and Constitutional Affairs, Eleventh Report: Bill S-10, An Act to Amend the Controlled Drugs and Substances Act and to Make Related and Consequential Amendments to Other Acts, with Amendments (2010 Nov 4). The CMA, therefore, submits that if a two-system approach is implemented when the legislation is enacted, the legislation should be amended to include the requirement for evaluation within five years of enactment. Criteria for evaluation may include the number of users in the medical system and the number of physicians authorizing medical cannabis use. The CMA would expect to be involved in the determination of such criteria and evaluation process. Conclusion Support has risen steadily in Canada and internationally for the removal of criminal sanctions for simple cannabis possession, as well as for the legalization and regulation of cannabis’ production, distribution and sale. The CMA has long-standing concerns about the health risks associated with consuming cannabis, especially by children and youth in its smoked form. Weighing societal trends against the health effects of cannabis, the CMA supports a broad legal-regulatory framework as part of a comprehensive and properly sequenced public health approach of harm reduction. Recommendations 1. The CMA recommends that the legalization age be amended to 21 years of age, to better protect the most vulnerable population, youth, from the developmental neurological harms associated with cannabis use. 2. The CMA recommends that a comprehensive cannabis public health strategy with a strong, effective health education component be implemented before, and no later than, the enactment of any legislation legalizing cannabis. 3a. The CMA recommends that there be only one regime for medical and non-medical use of cannabis, with provisions for the medical needs of those who would not be able to acquire cannabis in a legal manner (e.g., those below the minimum age). 3b. Alternatively, the CMA recommends that the legislation be amended to include a clause to review the legislation, including a review of having two regimes, within five years.
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CMA’s Support for Bill S-228: An Act to amend the Food and Drugs Act (prohibiting food and beverage marketing directed at children)

https://policybase.cma.ca/en/permalink/policy13645
Date
2017-06-14
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Date
2017-06-14
Topics
Population health/ health equity/ public health
Text
The Canadian Medical Association (CMA) is pleased to submit this brief to the Senate Standing Committee on Social Affairs, Science and Technology in support of Bill S-228, An Act to Amend the Food and Drugs Act (prohibiting food and beverage marketing directed at children). The CMA has over 85,000 physician-members; our mission is empowering and caring for patients and its vision is a vibrant profession and a healthy population. Overview The CMA is encouraged that the Senate is considering legislation that will protect children by prohibiting marketing of food and beverages directed to those under 13 years of age. We applaud Senator Nancy Greene Raine for sponsoring this important bill. Obesity rates among children and youth in Canada have nearly tripled in the last 30 years. Obesity is of particular concern to Canada’s physicians because it increases a person’s risk of developing a number of serious health problems: high blood pressure, high blood cholesterol, heart disease and stroke, type 2 diabetes, osteoarthritis, lower back pain and other musculoskeletal disorders, and many types of cancer. Type 2 diabetes, once found only in adults, is now being seen in children. Health advocates are concerned that because of obesity, today’s generation of children will have a shorter life expectancy than their parents. Children and youth who are obese are at higher risk of developing a range of health problems, and weight issues in childhood are likely to persist into adulthood. Diet-related chronic disease risk stems from long-term dietary patterns which start in childhood. Canadian statistics reveal children, consume too much fat, sodium and sugars (foods that cause chronic disease) and eat too little fiber, fruits and vegetables (foods that prevent chronic disease). The current generation of Canadian children is expected to live shorter less healthy lives as a result of unhealthy eating.1 CMA’s Cautions against Marketing Children and youth in Canada are exposed to a barrage of marketing and promotion of unhealthy foods and beverages through a variety of channels and techniques – tactics which undermine and contradict government, health care professional and scientific recommendations for healthy eating. Research undertaken for the Heart and Stroke Foundation found that kids see over 25 million food and beverage ads a year on their favourite websites and that over 90% of the food and beverage product ads viewed online are unhealthy.2 4 Unhealthy food and beverage advertising influences children’s food preferences, purchase requests, and consumption patterns and has been identified as a probable cause of childhood overweight and obesity by the World Health Organization.3 The CMA has long been calling on governments to explore ways to restrict the advertising and promotion of high-calorie, nutrient-poor foods. In 2006 CMA recommended that media advertising of high-calorie, nutrient-poor "junk" food in children's television programs be banned altogether. As the ways and means of advertising have expanded so too has our thinking, and in 2012 CMA adopted a policy on Restricting Marketing of Unhealthy Foods and Beverages to Children and Youth in Canada which called for the restriction of all marketing to children under 13 years of age of unhealthy foods and beverages. In 2014, CMA endorsed the Ottawa Principles and the Stop Marketing to Kids Coalition. The Ottawa Principles went further to help refine the definitions, scope and principles meant to guide marketing to kids (M2K) policy-making in Canada.4 They recommend the restriction of commercial marketing of all food and beverages to children and youth age 16 years and younger. Restrictions would include all forms of marketing with the exception of non-commercial marketing for public education. At present, Canada relies on voluntary industry codes to govern advertising and marketing practices. However, recent Canadian research into industry self-regulation has shown no reduction in children’s exposure to ads for unhealthy foods.5 The CMA believes that for maximum efficacy, regulatory measures are required to minimize the negative effect of food marketing on health. Only legally enforceable regulations have sufficient authority and power to ensure high-level protection of children from marketing and its persuasive influence over food preference and consumption. Not only health organizations are in favour of restrictions on the marketing to children. Recent public opinion polling from Heart and Stroke’s 2017 Report on the Health of Canadians highlights that 72% believe the food and beverage industry markets its products directly to children, 78% believe the food and beverages advertised to children are unhealthy and 70% feel that children are exposed to too much advertising by the food and beverage industry. In her introduction of Bill S-228, Senator Raine noted that this is not the first time that that legislation on this issue has come before the Canadian Parliament. The CMA sincerely believes that now is the time for action. We cannot delay any longer. Canadian children and parents need an environment free from the influence of food and beverage marketing in which to make health nutritious food choices. Conclusion 5 Childhood obesity and overweight are serious health problems in Canada, and as such are of great concern to the country’s physicians and to the Canadian Medical Association. The causes, CMA believes, are rooted mainly in changes in our environment and their effect on our eating and physical activity habits. The consequences are extremely serious, both for individual Canadians’ health and for the sustainability of Canada’s health care system. CMA believes that the way forward requires a number of different interventions, on many levels. The prohibition of the marketing of foods and beverages directed to children is one element of a wider healthy eating strategy that supports Canadians. Once again, CMA commends the Senate of Canada on conducting this study. We urge support of the Child Health Protection Act and believe that it can assist in creating a social environment that supports healthy eating and healthy weight. 1 Canadian Medical Association, Restricting Marketing Of Unhealthy Foods And Beverages To Children And Youth In Canada, A Canadian Health Care And Scientific Organization Consensus Policy Statement, December 2012 2 Heart & Stroke (2017). The kids are not alright. How the food and beverage industry is marketing our children and youth to death. 2017 Report on the Health of Canadians. 3 World Health Organization. Set of recommendations on the marketing of foods and non-alcoholic beverages to children. Geneva: World Health Organization, 2010. 4 The Ottawa Principles, Stop Marketing to Kids Coalition, accessed at https://foodsecurecanada.org/sites/foodsecurecanada.org/files/ottawaprinciples.pdf, June 7, 2017. 5 Heart & Stroke (2017). The kids are not alright. How the food and beverage industry is marketing our children and youth to death. 2017 Report on the Health of Canadians.
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CMA’s Recommendations for Bill S-5: An Act to amend the Tobacco Act and the Non-smokers’ Health Act and to make consequential amendments to other Acts

https://policybase.cma.ca/en/permalink/policy13641
Date
2017-04-07
Topics
Health care and patient safety
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Parliamentary submission
Date
2017-04-07
Topics
Health care and patient safety
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
CMA Submission: CMA’s Recommendations for Bill S-5: An Act to amend the Tobacco Act and the Non-smokers’ Health Act and to make consequential amendments to other Acts Submission to the Senate Standing Committee on Social Affairs, Science and Technology On behalf of its more than 85,000 members and the Canadian public, the CMA performs a wide variety of functions. Key functions include advocating for health promotion and disease/injury prevention policies and strategies, advocating for access to quality health care, facilitating change within the medical profession, and providing leadership and guidance to physicians to help them influence, manage and adapt to changes in health care delivery. April 7, 2017 The CMA is a voluntary professional organization representing the majority of Canada’s physicians and comprising 12 provincial and territorial divisions and over 60 national medical organizations. Introduction The Canadian Medical Association (CMA) is pleased to provide this submission to the Senate Social Affairs, Science and Technology Committee for its study of Bill S-5, An Act to amend the Tobacco Act and the Non-Smokers Health Act and to make consequential amendments to other Acts. We support the government’s effort to implement a new legislative and regulatory framework to address vaping products and related matters. Vaping products, such as electronic cigarettes (or e-cigarettes) replicate the act and taste of smoking but do not contain tobacco. We also recognize that the federal government is attempting to find a balance between regulating vaping devices and making them available to adults. Canada’s physicians, who see the devastating effects of tobacco use every day in their practices, have been working for decades toward the goal of a smoke-free Canada. The CMA issued its first public warning concerning the hazards of tobacco in 1954 and has continued to advocate for the strongest possible measures to control its use. The CMA has always supported strong, comprehensive tobacco control legislation, enacted and enforced by all levels of government, and we continue to do so. Our most recent efforts centred on our participation in the 2016 Endgame Summit, held late last year in Kingston, Ontario. This brief will focus on three areas: supporting population health; the importance of protecting youth; and, the promotion of vaping products. Overview Tobacco is an addictive and hazardous product, and a leading cause of preventable disease and death in Canada. Smoking has been on the decline in Canada the most recent Canadian Community Health Survey reports that 17.7% of the population aged 12 and older were current daily or occasional smokers in 2015 (5.3 million smokers); that is down from 18.1% in 2014.1 Many strong laws and regulations have already been enacted but some areas remain to be addressed and strengthened especially as the tobacco industry continues to evolve. Electronic cigarettes and vaping represents the next step in that evolution. 1 Statistics Canada. Smoking, 2015 Health Fact Sheets Canadian Community Health Survey, 2015 82-625-X March 22, 2017 While Canada is to be congratulated on its success to date, it needs to maintain an environment that encourages Canadians to remain tobacco-free if smoking prevalence is to be reduced further in Canada. The CMA believes it is incumbent on all levels of government in Canada to keep working on comprehensive, coordinated and effective tobacco control strategies, including vaping products, to achieve that goal. Supporting Population Health The arrival of vaping products in Canada placed them in a “grey zone” with respect to legislation and regulation. Clarification of their status is crucial from a public health perspective because of their growing popularity, particularly among youth.2 E-cigarettes have both defenders and opponents. Proponents say they are safer than tobacco cigarettes since they do not contain the tar and other toxic ingredients that are the cause of tobacco related disease. Indeed, some believe they serve a useful purpose as a harm reduction tool or cessation aid (though it is forbidden to market them as such since that claim has never been approved by Health Canada). 2 Czoli CD., Hammond D., White CM., Electronic cigarettes in Canada: Prevalence of use and perceptions among youth and young adults. Can J Public Health 2014;105(2):e97-e102 3 Filippos FT., Laverty AA., Gerovasili V, et al. Two-year trends and predictors of e-cigarette use in 27 European Union member states. Tob Control 2017;26:98-104 4 Malas M., van der Tempel J., Schwartz R., et al. Electronic cigarettes for smoking cessation: A systematic review. Nicotine & Tobacco Research 2016, 1-12 doi:10.1093/ntr/ntw119 5 Ibid 6 Ibid 7 Ibid Opponents are concerned that the nicotine delivered via e-cigarettes is addictive and that the cigarettes may contain other toxic ingredients such as nitrosamines. Also, they worry that acceptance of e-cigarettes will undermine efforts to de-normalize smoking, and that they may be a gateway to the use of tobacco by people who might otherwise have remained smoke-free. This issue will be addressed later in this brief. This difference of opinion certainly highlights the need for more research into the harms and benefits of vaping products and the factors that cause people to use them.3 Encouraging smokers to move from combustible tobacco products to a less harmful form of nicotine may be a positive step. However the current available evidence is not yet sufficient to establish them as a reliable cessation method. A systematic review published by M. Malas et al. (2016) concluded that while “a majority of studies demonstrate a positive relationship between e-cigarette use and smoking cessation, the evidence remains inconclusive due to the low quality of the research published to date.”4 Indeed, some are helped by these devices to quit smoking but “more carefully designed and scientifically sound studies are urgently needed to establish unequivocally the long-term cessation effects of e-cigarettes and to better understand how and when e-cigarettes may be helpful.”5 The authors found that the evidence examining e-cigarettes as an aid to quitting smoking was determined to be “very low to low.”6 A similar result was found for their use in reducing smoking; the quality of the evidence was revealed as being “very low to moderate.”7 This conclusion is supported by another review conducted by the University of Victoria (2017). It too indicates that there are not enough studies available to fully determine the efficacy of vaping devices as a tobacco cessation device.8 This review also noted that there is “encouraging evidence that vapour devices can be at least as effective as other nicotine replacements.”9 8 O’Leary R., MacDonald M., Stockwell T., & Reist D. (2017) Clearing the Air: A systematic review on the harms and benefits of e-cigarettes and vapour devices. Victoria, BC: Centre for Addiction Research for BC 9 Ibid 10 El Dib R. Suzumura EA., Akl EA, et al. Electronic nicotine delivery systems and/or electronic non-nicotine delivery systems for tobacco or reduction: A systematic review and meta-analysis. BMJ Open 2017;7: e012680. Doi10:1136/bmjopen-2016-012680 Another review by R. El Dib et al. (2017) reinforces these findings. Limited evidence was also found with respect to the impact of electronic devices to aide cessation. They also noted that the data available from randomized control trials are of “low certainty” and the “observational studies are of very low certainty.”10 The wide range of devices available makes it very difficult to test which are the most effective in helping cessation efforts. Many of the studies are on older devices so it is possible that as second-generation technology becomes available they will prove to be more successful. In view of this uncertainty, the CMA calls for more scientific research into the potential effectiveness and value of these devices as cessation aids. Physicians need to be confident that if they recommend such therapy to their patients it will have the desired outcome. To that end, we are pleased that Health Canada will continue to require manufacturers to apply for authorization under the Food and Drugs Act to sell products containing nicotine and make therapeutic claims. Risk and Safety In addition to the discussion concerning the usefulness of vaping devices as cessation devices, concerns from a public health standpoint involve the aerosol or vapour produced by heating the liquids used in these devices, and the nicotine some may contain. The tube of an e-cigarette contains heat-producing batteries and a chamber holding liquid. When heated, the liquid is turned into vapour which is drawn into the lungs. Ingredients vary by brand but many contain nicotine and/or flavourings that are intended to boost their appeal to young people. The CMA is concerned that not enough is known about the safety of the ingredients in the liquids being used in vaping devices. While it is the case that because e-cigarettes heat rather than burn the key constituent, they produce less harmful toxins and are much safer than conventional cigarettes. Research in the UK suggested that “long-term Nicotine Replacement Therapy (NRT)-only and e-cigarette-only use, but not dual-use of NRTs or e-cigarettes with combustible cigarettes, is associated with substantially reduced levels of measured carcinogens and toxins relative to smoking only combustible cigarettes.”11 However, this study has been criticized because “it only looked at a few toxins and didn’t test for any toxins that could be produced by e-cigarettes.”12 11 Shahab L, Goniewicz M., Blount B., et al. Nicotine, carcinogen, and toxin exposure in long-term e-cigarette and nicotine replacement therapy users. Annals of Internal Medicine doi:10.7326/M16-1107 7 February 2017 12 Collier R. E-cigs have lower levels of harmful toxins. CMAJ 2017 February 27;189:E331. doi: 10.1503/cmaj.1095396 13 Sleiman M., Logue J., Montesinos VN. et al. Emmissions from electronic cigarettes : Key parameters affecting the release of harmful chemicals. Environmental Science and Technology July 2016 doi:10.1021/acs.est.6b01741 14 Ibid 15 England LJ., Bunnell RE., et al. Nicotine and the developing human. Am J. Prev Med 2015 16 Editorial. Use of Electronic Cigarettes by Adolescents. Journal of Adolescent Health 57 (2015) 569-570 The variety of flavourings and delivery systems available make it imperative that the risks associated with these products be fully understood. As one study noted “analysis of e-liquids and vapours emitted by e-cigarettes led to the identification of several compounds of concern due to their potentially harmful effects on users and passively exposed non-users.”13 The study found that the emissions were associated with both cancer and non-cancer health impacts and required further study.14 There is another aspect of the public health question surrounding vaping devices. There is data to support the idea that “nicotine exposure during periods of developmental vulnerability (e.g., fetal through adolescent stages) has multiple adverse health consequences, including impaired fetal brain and lung development.”15 Therefore it is imperative that pregnant women and youth be protected. There is not enough known about the effects of long-term exposure to the nicotine inhaled through vaping devices at this time.16 Recommendations: 1) Given the scarcity of research on e-cigarettes the Canadian Medical Association calls for ongoing research into the potential harms of electronic cigarette use, including the use of flavourings and nicotine. 2) The CMA calls for more scientific research into the potential effectiveness and value of these devices as cessation aids.. 3) The Canadian Medical Association supports efforts to expand smoke-free policies to include a ban on the use of electronic cigarettes in areas where smoking is prohibited. Protecting Youth The CMA is encouraged by the government’s desire to protect youth from developing nicotine addiction and inducements to use tobacco products. Young people are particularly vulnerable to peer pressure, and to tobacco industry marketing tactics. The CMA supports continued health promotion and social marketing programs aimed at addressing the reasons why young people use tobacco and have been drawn to vaping devices, discouraging them from starting to use them and persuading them to quit, and raising their awareness of tobacco industry marketing tactics so that they can recognize and counteract them. These programs should be available continuously in schools and should begin in the earliest grades. The “cool/fun/new” factor that seems to have developed around vaping devices among youth make such programs all the more imperative.17 17 Khoury M., Manlhiot C., et al Reported electronic cigarette use among adolescents in the Niagara region of Ontario. CMAJ 2016 DOI:10.1503/cmaj.151169 18 U.S. National Cancer Institute and World Health Organization. The Economics of Tobacco and Tobacco Control. National Cancer Institute Tobacco Control Monograph 21. NIH Publication No. 16-CA-8029A. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute; and Geneva, CH: World Health Organization; 2016. The CMA recommends a ban on the sale of all electronic cigarettes to Canadians younger than the minimum age for tobacco consumption in their province or territory. We are pleased to see that Bill S-5 aims to restrict access to youth, including prohibiting the sale of both tobacco and vaping products in vending machines as well as prohibiting sales of quantities that do not comply with the regulations. In fact, the CMA recommends tightening the licensing system to limit the number of outlets where tobacco products, including vaping devices, can be purchased. The more restricted is availability, the easier it is to regulate. The CMA considers prohibiting the promotion of flavours in vaping products that may appeal to youth, such as soft drinks and cannabis, to be a positive step. A recent report published by the World Health Organization and the US National Cancer Institute indicated that websites dedicated to retailing e-cigarettes “contain themes that may appeal to young people, including images or claims of modernity, enhanced social status or social activity, romance, and the use of e-cigarettes by celebrities.”18 We are therefore pleased that sales of vaping products via the internet will be restricted through prohibiting the sending and delivering of such products to someone under the age of 18. This will be critical to limiting the tobacco industry’s reach with respect to youth. There have also been arguments around whether vaping products will serve as gateways to the use of combusted tobacco products. The University of Victoria (2017) paper suggests this isn’t the case; it notes that “there is no evidence of any gateway effect whereby youth who experiment with vapour devices are, as a result, more likely to take up tobacco use.”19 They base this on the decline in youth smoking while rates of the use of vaping devices rise.20 Others contend that vaping is indeed a gateway, saying it acts as a “one-way bridge to cigarette smoking among youth. Vaping as a risk factor for future smoking is a strong, scientifically-based rationale for restricting access to e-cigarettes.”21 Further, in a “national sample of US adolescents and young adults, use of e-cigarettes at baseline was associated with progression to traditional cigarette smoking. These findings support regulations to limit sales and decrease the appeal of e-cigarettes to adolescents and young adults.”22 19 Op cit. O’Leary R., MacDonald M., Stockwell T., & Reist D. (2017) Clearing the Air: A systematic review on the harms and benefits of e-cigarettes and vapour devices. 20 Ibid 21 Miech R., Patrick ME., O’Malley PM., et al E-cigarette use as a predictor of cigarette smoking: results from a 1-year follow-up of a national sample of 12th grade students. Tob. Control 2017;0:1-6. doi:10.1136/tobaccocontrol-2016-053291 22 Primack BA., Soneji S., Stoolmiller M., et al Progression to traditional cigarette smoking after electronic cigarette use among US adolescents and young adults. JAMA Pediatr. 2015;169(11): 1018-1023.doi:10.1001/jamapediatrics.2015.1742 23 Hoek J., Thrul J. Ling P. Qualitative analysis of young adult ENDS users’ expectations and experiences. BMJ Open 2017;7:e014990.doi:10 24 Ibid However, there may be a role for vaping products in relation to young users. A New Zealand study conducted among young adults that examined how electronic nicotine delivery systems (ENDS) were used to recreate or replace smoking habits. It found that study participants “used ENDS to construct rituals that recreated or replaced smoking attributes, and that varied in the emphasis given to device appearance.”23 Further, it was suggested that ascertaining how “ENDS users create new rituals and the components they privilege within these could help promote full transition from smoking to ENDS and identify those at greatest risk of dual use or relapse to cigarette smoking.”24 The CMA believes that further research is needed on the question of the use of vaping products as a gateway for youth into combustible tobacco products. Recommendations: 1) The Canadian Medical Association recommends a ban on the sale of all electronic cigarettes to Canadians younger than the minimum age for tobacco consumption in their province or territory. 2) The Canadian Medical Association calls for ongoing research into the potential harms and benefits of electronic cigarette use among youth. 3) The Canadian Medical Association recommends tightening the licensing system to limit the number of outlets where tobacco products, including vaping devices, can be purchased. Promotion of Vaping Products The CMA has been a leader in advocating for plain and standardized packaging for tobacco products for many years. We established our position in 1986 when we passed a resolution at our General Council in Vancouver recommending to the federal government “that all tobacco products be sold in plain packages of standard size with the words “this product is injurious to your health” printed in the same size lettering as the brand name, and that no extraneous information be printed on the package.” The CMA would like to see the proposed plain packing provisions for tobacco be extended to vaping products as well. The inclusion of the health warning messages on vaping products is a good first step but efforts should be made to ensure that they are of similar size and type as those on tobacco as soon as possible. The restrictions being applied to the promotion of vaping products is a positive step, especially those that could be aimed at youth, but they do not go far enough. The CMA believes the restrictions on promotion should be the same as those for tobacco products. As the WHO/U.S. National Cancer Institute has already demonstrated, e-cigarette retailers are very good at using social media to promote their products, relying on appeals to lifestyle changes to encourage the use of their products. The CMA is also concerned that e-cigarette advertising could appear in locations and on mediums popular with children and youth if they are not prohibited explicitly in the regulations. This would include television and radio advertisements during times and programs popular with children and youth, billboards near schools, hockey arenas, and on promotional products such as t-shirts and ball caps. As efforts continue to reduce the use of combustible tobacco products there is growing concern that the rising popularity of vaping products will lead to a “renormalization” of smoking. In fact, worry has been expressed that the manner they have been promoted “threaten(s) to reverse the successful, decades-long public health campaign to de-normalize smoking.”25 A recent US study indicated that students that use vaping products themselves, exposure to advertising of these devices, and living with other users of vaping products is “associated with acceptability of cigarette smoking, particularly among never smokers.”26 Further research is needed to explore these findings. 25 Fairchild AL., Bayer R., Colgrove J. The renormalization of smoking? E-cigarettes and the tobacco “endgame.” N Engl J Med 370:4 January 23, 2014 26 K. Choi et al. Electronic nicotine delivery systems and acceptability of adult smoking among Florida youth: Renormalization of Smoking? Journal of Adolescent Health (2016) 1-7 Recommendations: 1) The Canadian Medical Association recommends similar plain packaging provisions proposed for tobacco be extended to vaping products. 2) Health warning messages on vaping products should be of similar size and type as those on tobacco as soon as possible 3The Canadian Medical Association believes the restrictions on promotion of vaping products and devices should be the same as those for tobacco products. Conclusion Tobacco is an addictive and hazardous product, and a leading cause of preventable disease and death in Canada. Our members see the devastating effects of tobacco use every day in their practices and to that end the CMA has been working for decades toward the goal of a smoke-free Canada. The tobacco industry continues to evolve and vaping represents the next step in that evolution. The CMA believes it is incumbent on all levels of government in Canada to keep working on comprehensive, coordinated and effective tobacco control strategies, including vaping products, to achieve that goal. Bill S-5 is another step in that journey. Researchers have identified potential benefits as well as harms associated with these products that require much more scrutiny. The association of the tobacco industry with these products means that strong regulations, enforcement, and oversight are needed. Recommendations: 1) Given the scarcity of research on e-cigarettes the Canadian Medical Association calls for ongoing research into the potential harms of electronic cigarette use, including the use of flavourings and nicotine. 2) The CMA calls for more scientific research into the potential effectiveness and value of these devices as cessation aids.. 3) The Canadian Medical Association supports efforts to expand smoke-free policies to include a ban on the use of electronic cigarettes in areas where smoking is prohibited. 4) The Canadian Medical Association recommends a ban on the sale of all electronic cigarettes to Canadians younger than the minimum age for tobacco consumption in their province or territory. 5) The Canadian Medical Association calls for ongoing research into the potential harms and benefits of electronic cigarette use among youth. 6) The Canadian Medical Association recommends tightening the licensing system to limit the number of outlets where tobacco products, including vaping devices, can be purchased. 7) The Canadian Medical Association recommends similar plain packaging provisions proposed for tobacco be extended to vaping products. 8) Health warning messages on vaping products should be of similar size and type as those on tobacco as soon as possible9) The Canadian Medical Association believes the restrictions on promotion of vaping products and devices should be the same as those for tobacco products. 9) The Canadian Medical Association believes the restrictions on promotion of vaping products and devices should be the same as those for tobacco products.
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CMA submission to the study of Bill C-37

https://policybase.cma.ca/en/permalink/policy13617
Date
2017-04-06
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Parliamentary submission
Date
2017-04-06
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
The Canadian Medical Association (CMA) provides this brief for consideration as part of the Senate Committee on Legal and Constitutional Affairs’ study of Bill C-37, An Act to amend the Controlled Drugs and Substances Act and to make related amendments to other Acts.1 1 Bill C-37, An Act to amend the Controlled Drugs and Substances Act and to make related amendments to other Acts. Retrieved from: http://www.parl.gc.ca/HousePublications/Publication.aspx?Language=E&Mode=1&DocId=8769825 2 British Columbia Coroners Service. Coroners Report. Illicit Drug Overdose Deaths in BC: January 1, 2007 – February 28, 2017. Retrieved from: http://www2.gov.bc.ca/assets/gov/public-safety-and-emergency-services/death-investigation/statistical/illicit-drug.pdf 3 Health Canada “Government of Canada announces new comprehensive drug strategy supported by proposed legislative changes”. News release. December 12, 2016. Retrieved from: http://news.gc.ca/web/article-en.do?nid=1168519 4 Health Canada “Government of Canada announces new comprehensive drug strategy supported by proposed legislative changes”. News release. December 12, 2016. Retrieved from: http://news.gc.ca/web/article-en.do?nid=1168519 The CMA is deeply concerned with the opioid crisis in Canada, with unprecedented levels of harms, including overdose deaths. The crisis is taking a toll on individuals, families and communities, as well as first responders and health professionals at the front lines. The most recent BC Coroner’s Report indicates there were about 3.6 illicit drug overdose deaths per day in February 2017, an increase of 72.9% over the number of deaths in February of last year.2 Other provinces are also facing critical situations. The CMA welcomes the introduction of Bill C-37, proposed by the Minister of Health to address various portions of the Controlled Drugs and Substances Act (CDSA), among other changes. * We are particularly appreciative, given that this is part of a new federal strategy that promises to “replace the existing National Anti-Drug Strategy with a more balanced approach (…) and restores harm reduction as a core pillar of Canada’s drug policy, alongside prevention, treatment and enforcement and supports all pillars with a strong evidence base.3 This is necessary to ensure a public health approach to drug use and addiction. * For further discussion of CMA’s position on addiction, harm reduction and supervised consumption sites, as well as terminology, such as supervised consumption sites or supervised injection sites, see CMA’s submission to the Senate Standing Committee on Legal and Constitutional Affairs. Bill C-2 An Act to amend the Controlled Drugs and Substances Act (Respect for Communities Act). May 14, 2015. Retrieved from: https://www.cma.ca/Assets/assets-library/document/en/advocacy/submissions/cma-brief-c2-respect-for-communities-act-senate-committee-may-14-2015-english.pdf This proposed legislation includes various objectives, including “to prohibit the unregistered import of pill presses, and remove the exception currently placed on border officers to only open mail weighing more than 30 grams,” (…) to “make it a crime to possess or transport anything intended to be used to produce controlled substances, allow for temporary scheduling of new psychoactive substances, and support faster and safer disposal of seized chemicals and other dangerous substances.”4 CMA is supportive of actions by the federal government that advance the work at national, provincial and local levels to address the opioid crisis. Application for a Supervised Consumption Site The objective of Bill C-37 that CMA would like to provide recommendations for is the one that seeks to “simplify the process of applying for an exemption that would allow certain activities to take place at a supervised consumption site, as well as the process of applying for subsequent exemptions.5 5 Bill C-37, An Act to amend the Controlled Drugs and Substances Act and to make related amendments to other Acts. Legislative Summary. Retrieved from: http://www.parl.gc.ca/LegisInfo/BillDetails.aspx?billId=8689350&Language=E&Mode=1&View=8 6 Bill C-2, An Act to amend the Controlled Drugs and Substances Act. http://www.parl.gc.ca/HousePublications/Publication.aspx?DocId=8056955&Language=E&Mode=1&File=24#1 7 Bill C-2 An Act to amend the Controlled Drugs and Substances Act (Respect for Communities Act). CMA submission to the Senate Standing Committee on Legal and Constitutional Affairs. May 14, 2015. Retrieved from: https://www.cma.ca/Assets/assets-library/document/en/advocacy/submissions/cma-brief-c2-respect-for-communities-act-senate-committee-may-14-2015-english.pdf 8 Supreme Court of Canada (2011) Canada (A.G.) v. PHS Comm. Serv. Soc. Retrieved from: http://scc-csc.lexum.com/scc-csc/scc-csc/en/item/7960/index.do 9 Supreme Court of Canada (2011) Canada (A.G.) v. PHS Comm. Serv. Soc. supra. p.192-3 10 Vancouver Coastal Health. News release. Further overdose response action to include BC Mobile Medical Unit and new overdose prevention sites. December 8, 2016. Retrieved from: http://www.vch.ca/about-us/news/news-releases/further-overdose-response-action-to-include-bc-mobile-medical-unit-and-new-overdose-prevention-sites 11 CTV. ‘Pop–up’ injection sites aim to combat overdoses in Vancouver. November 20, 2016. Retrieved from: http://www.ctvnews.ca/health/pop-up-injection-sites-aim-to-combat-overdoses-in-vancouver-1.3169397 12 Woo, A. & Perreaux, L. Health Canada approves three supervised consumption sites for Montreal. Globe and Mail. February 6, 2017. Retrieved from: http://www.theglobeandmail.com/news/politics/federal-government-approves-three-supervised-injection-sites-in-montreal/article33914459/ 13 Supreme Court of Canada (2011) Canada (A.G.) v. PHS Comm. Serv. Soc. supra. p.192-3 14 Bill C-2 An Act to amend the Controlled Drugs and Substances Act (Respect for Communities Act). CMA submission to the Senate Standing Committee on Legal and Constitutional Affairs. May 14, 2015. Retrieved from: https://www.cma.ca/Assets/assets-library/document/en/advocacy/submissions/cma-brief-c2-respect-for-communities-act-senate-committee-may-14-2015-english.pdf 15 Schatz, E. & Nougier, M. (2012) Drug consumption rooms: evidence and practice. International Drug Policy Consortium Briefing Paper. (p.20) Retrieved from: http://www.drugsandalcohol.ie/17898/1/IDPC-Briefing-Paper_Drug-consumption-rooms.pdf 16 Bill C-2, An Act to amend the Controlled Drugs and Substances Act. http://www.parl.gc.ca/HousePublications/Publication.aspx?DocId=8056955&Language=E&Mode=1&File=24#1 The Bill proposes to repeal the 26 requirements to apply for an exemption to the CDSA, in Section 56.1, established by the Respect for Communities Act (former Bill C-26). The CMA supports the repeal, as we have repeatedly called for the withdrawal of the amendments made by former Bill C-2, and their replacement with “legislation that recognizes the unequivocal evidence of benefits of supervised consumption sites, that was accepted by the Supreme Court. Legislation would enhance access to health services, which include prevention, harm reduction and treatment services in communities where the evidence has shown they would benefit from such health services.”7 Bill C-37 proposes to replace those 26 requirements with the five elements cited in the 2011 Supreme Court of Canada unanimous ruling on Insite8, Vancouver’s supervised injection site. These elements are, “evidence, if any, on: . the impact of such a facility on crime rates, . the local conditions indicating a need for such a supervised injection site, . the regulatory structure in place to support the facility, . the resources available to support its maintenance and . expressions of community support or opposition.”9 These elements are proposed to reduce the unnecessary obstacles and burdens on local health departments and community organizations that would deter the creation of new supervised consumption sites, even when the health and safety benefits have been clearly established. Because of this cumbersome process, the BC Ministry of Health recently authorized the creation of “overdose prevention sites” in various locations where there are concerning numbers of overdose deaths, while the ministry “wait(s) for Health Canada approval of supervised consumption services”.10 This was after the creation of unsanctioned popup sites by community groups in the downtown eastside.11 Only Insite and the Dr Peter Centre operate with approved exemptions to date, with Montreal having recently received approval for three sites.12 Many other applications have been submitted for sites in Vancouver, Victoria, Toronto and Ottawa, and others are in preparation. Although a welcome reduction to only five elements, the CMA believes that these elements require more clarity, as they can be subject to interpretation, and undue influence, and could still demand unnecessary and significant time and resources on the part of provincial and local agencies. As well, the present crisis would require an expedited process that would not delay local responses to the crisis. Hence, our first recommendation is that there be provisions for an expedited review, at the request of provincial or territorial ministries of health, for situations in which there is an immediate need for such sites. Further, CMA recommends that the elements required for an application for opening a supervised consumption site proposed in Bill C-37 be more clearly defined and simplified in order not to require unnecessary and extensive resources and funding by local public health authorities and community agencies. The central element to be considered is that of “the local conditions indicating a need for such a supervised injection site”. Local health authorities and community organizations struggle with the issues related to drug use, including rising rates of infections, overdoses and deaths, and this is the fundamental reason to open a supervised consumption site. The regulatory structure and the resources available to support a supervised consumption site’s maintenance are issues that local health authorities deal with regularly for any health service, given the need to provide care with reduced risk of liability. The impact of a facility on crime rates is difficult to quantify before such a site is created. Further, the government must consider the experience of the many sites both in Canada and internationally, where law and order have improved in the areas surrounding those sites. The Supreme Court stated that there has been “no discernible negative impact on the public safety and health objectives of Canada during its [Insite’s] eight years of operation.”13 As well, the crime rate is not only influenced by the existence or not of a site, but by many other factors, such as unemployment and enforcement resources. A site would necessarily be located where there are high rates of drug use, for the very purpose of offering people who use drugs much needed harm reduction and support services. The last element, expressions of community support or opposition, should not represent a burden to applicants. As stated in our brief on Bill C-2, “although public opinion might initially be against the introduction of such facilities, public acceptance of supervised consumption sites is considerably high in most of the locations where they have been established, in both Vancouver sites and in European countries.”14 Communities, neighbourhoods and local authorities are usually involved in the good functioning of the facilities through cooperation and communication.15 Bill C-2 is an example of how this element could be interpreted. There was an extensive list of letters of opinion required, including from representatives of local police and local and provincial governments (ministers of health and public safety), chief public health officer, professional licensing authorities for physicians and for nurses, as well as reports from community consultations.16 Such a requirement represented a cumbersome and unnecessary burden. The CMA looks forward to continued collaboration with the federal government and other organizations in the development of further action as part of the much needed comprehensive approach to address the opioid crisis. Recommendations 1. The CMA recommends that there be provisions for an expedited review, at the request of provincial or territorial ministries of health, for situations in which there is an immediate need for such sites. 2. The CMA recommends that the elements required for an exemption application to the CDSA to open a supervised consumption site, proposed in Bill C-37, be clearly defined and simplified in order not to require unnecessary and extensive resources and funding by local public health authorities and community agencies. Bill C-37, An Act to amend the Controlled Drugs and Substances Act and to make related amendments to other Acts. Retrieved from: http://www.parl.gc.ca/HousePublications/Publication.aspx?Language=E&Mode=1&DocId=8769825 2 British Columbia Coroners Service. Coroners Report. Illicit Drug Overdose Deaths in BC: January 1, 2007 – February 28, 2017. Retrieved from: http://www2.gov.bc.ca/assets/gov/public-safety-and-emergency-services/death-investigation/statistical/illicit-drug.pdf 3 Health Canada “Government of Canada announces new comprehensive drug strategy supported by proposed legislative changes”. News release. December 12, 2016. Retrieved from: http://news.gc.ca/web/article-en.do?nid=1168519 4 Health Canada “Government of Canada announces new comprehensive drug strategy supported by proposed legislative changes”. News release. December 12, 2016. Retrieved from: http://news.gc.ca/web/article-en.do?nid=1168519 7 5 Bill C-37, An Act to amend the Controlled Drugs and Substances Act and to make related amendments to other Acts. Legislative Summary. Retrieved from: http://www.parl.gc.ca/LegisInfo/BillDetails.aspx?billId=8689350&Language=E&Mode=1&View=8 6 Bill C-2, An Act to amend the Controlled Drugs and Substances Act. http://www.parl.gc.ca/HousePublications/Publication.aspx?DocId=8056955&Language=E&Mode=1&File=24#1 7 Bill C-2 An Act to amend the Controlled Drugs and Substances Act (Respect for Communities Act). CMA submission to the Senate Standing Committee on Legal and Constitutional Affairs. May 14, 2015. Retrieved from: https://www.cma.ca/Assets/assets-library/document/en/advocacy/submissions/cma-brief-c2-respect-for-communities-act-senate-committee-may-14-2015-english.pdf 8 Supreme Court of Canada (2011) Canada (A.G.) v. PHS Comm. Serv. Soc. Retrieved from: http://scc-csc.lexum.com/scc-csc/scc-csc/en/item/7960/index.do 9 Supreme Court of Canada (2011) Canada (A.G.) v. PHS Comm. Serv. Soc. supra. p.192-3 10 Vancouver Coastal Health. News release. Further overdose response action to include BC Mobile Medical Unit and new overdose prevention sites. December 8, 2016. Retrieved from: http://www.vch.ca/about-us/news/news-releases/further-overdose-response-action-to-include-bc-mobile-medical-unit-and-new-overdose-prevention-sites 11 CTV. ‘Pop–up’ injection sites aim to combat overdoses in Vancouver. November 20, 2016. Retrieved from: http://www.ctvnews.ca/health/pop-up-injection-sites-aim-to-combat-overdoses-in-vancouver-1.3169397 12 Woo, A. & Perreaux, L. Health Canada approves three supervised consumption sites for Montreal. Globe and Mail. February 6, 2017. Retrieved from: http://www.theglobeandmail.com/news/politics/federal-government-approves-three-supervised-injection-sites-in-montreal/article33914459/ 13 Supreme Court of Canada (2011) Canada (A.G.) v. PHS Comm. Serv. Soc. supra. p.192-3 14 Bill C-2 An Act to amend the Controlled Drugs and Substances Act (Respect for Communities Act). CMA submission to the Senate Standing Committee on Legal and Constitutional Affairs. May 14, 2015. Retrieved from: https://www.cma.ca/Assets/assets-library/document/en/advocacy/submissions/cma-brief-c2-respect-for-communities-act-senate-committee-may-14-2015-english.pdf 15 Schatz, E. & Nougier, M. (2012) Drug consumption rooms: evidence and practice. International Drug Policy Consortium Briefing Paper. (p.20) Retrieved from: http://www.drugsandalcohol.ie/17898/1/IDPC-Briefing-Paper_Drug-consumption-rooms.pdf 16 Bill C-2, An Act to amend the Controlled Drugs and Substances Act. http://www.parl.gc.ca/HousePublications/Publication.aspx?DocId=8056955&Language=E&Mode=1&File=24#1
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CMA’s recommendations for effective poverty reduction strategies

https://policybase.cma.ca/en/permalink/policy13582
Date
2017-02-28
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Date
2017-02-28
Topics
Population health/ health equity/ public health
Text
The Canadian Medical Association is pleased to present its views to the study on poverty reduction strategies by the House of Commons Standing Committee on Human Resources, Skills and Social Development and the Status of Persons with Disabilities. The focus of the Committee’s study on improving the delivery of federal resources and services for the Canadian Poverty Reduction Strategy is of profound interest to the CMA, given our concerns about the need to address the social determinants of health. It is that perspective from which this paper will approach the Committee’s areas of interest. Social Determinants of Health The consequences of poverty on health are well established and include lower life expectancy, higher disease burden, and poorer overall health. Research suggests that 15% of population health is determined by biology and genetics, 10% by physical environments, 25% by the actions of the health care system, with 50% being determined by our social and economic environment.1 Many studies show that people low on the socioeconomic scale are likely to carry a higher burden of just about any disease.2 1 Keon, WJ, Pépin L. (2008) Population Health Policy: Issues and Options. Ottawa: The Senate of Canada; 2008. Available at: https://sencanada.ca/content/sen/Committee/392/soci/rep/rep10apr08-e.pdf 2 Op cit. Dunn JR. The Health Determinants Partnership Making Connections Project 3 Munro D. Healthy People, Healthy Performance, Healthy Profits: The Case for Business Action on the SocioEconomic Determinants of Health. The Conference Board of Canada, Ottawa (ON); 2008. Reducing inequities and thereby improving population health should be an overall objective for all governments in Canada. The societal cost of poor health extends beyond the cost to the health care system: healthier people lose fewer days of work and contribute to overall economic productivity.3 Those living in the most disadvantaged neighbourhoods experience almost 20 years less disability-free life. It is fundamental that the health impact of social and economic decisions be part of the policy development and decision-making process. Recommendation 1. The CMA recommends that health impact assessments be included as part of the policy development and decision-making process in poverty reduction strategies, including in the development of legislation and regulations. Neighbourhoods and Housing Mounting evidence suggests that the built environment can play a significant role in our state of health. The literature indicates that the following connections between the built environment and public health are possible: o Decreased physical activity; o Increased prevalence of obesity; o Increased prevalence of asthma and other respiratory diseases; o Injuries and unintended fatalities; o Heat exposure.4 4 Frank , L., Kavage S, & Devlin A. (2012). Health and the Built Environment: A Review. World Medical Association 5 Canadian Society of Exercise Physiology. (2011). Canadian Physical Activity Guidelines. Canadian Society of Exercise Physiology 6 CMA. Active Transportation http://policybase.cma.ca/dbtw-wpd/Policypdf/PD09-04.pdf 2009 7 Statistics Canada. (2006, June 28). Childhood Obesity: A Troubling Situation. Retrieved July 15, 2012, from StatsCan: http://www41.statcan.ca/2006/2966/ceb2966_004-eng.htm 8 Ibid 9 Ibid . Canada's physical activity guidelines recommend that children ages 5 to 11 should be active for at least 60 minutes a day; those 18 and over should be active for at least 150 minutes per week.5 However, physical activity includes more than exercise and leisure time activity, it also includes active transportation such as walking to school, work or errands as part of daily living. CMA’s policy on Active Transportation recommends that all sectors (physicians and other health professionals, government, business and the public) work together, as a matter of priority, to support and encourage active transportation and physical activity.6 Urban planners must work together with health professionals to understand the impact on health. Research shows that specific populations, such as children, the elderly, and low-income populations, are more affected. Children: Obesity is an issue for Canadians nationwide, but particularly so for children. Between 1978 and 2004 there was a 70% increase in overweight and obese children aged 12-17.7 Obesity in children can lead to health issues such as hypertension, glucose intolerance, and orthopaedic complications.8 Furthermore it has a high likelihood of carrying over into adulthood and may result in further health problems such as diabetes and heart disease.9 Environments that promote physical activity are especially important, including mixed use communities with walkable destinations, parks and recreational facilities.10 10 Dannenberg, A., Frumkin, H., & Jackson, R. J. (2011). Making Healthy Places Designing and Building for Health, Well-Being and Sustainability. Island Press. 11 Vogel, T., Brechat, P., Lepetre, P., Kaltenbach, G., Berthel, M., & Lonsdorfer, J. (2009). Health Benefits of Physical Activity in Older Patients: A Review. The International Journal of Clinical Practice, 63(2), 303-320. 12 Centre for Chronic Disease Prevention and Control. . (2002). Diabetes in Canada, 2nd Edition. Ottawa: Health Canada 13 Statistics Canada. (1996-97, May 29). National Population Health Survey, Cycle 2. Canada: The Daily. 14 Creatore, M., Gozdyra, P., Booth, G., & Glazier, R. (2007). Chapter 1: Setting the Context. In M. Creatore, P. Gozdyra, G. Booth, R. Glazier, & M. Tynan, Neighbourhood Environments and Resources for Healthy Living - A Focus on Diabetes in Toronto: ICES Atlas. Toronto: Institute for Clinical Evaluative Sciences. 15 Op cit Dunn JR. The Health Determinants Partnership Making Connections Project 16 Raphael D. Addressing The Social Determinants of Health In Canada: Bridging The Gap Between Research Findings and Public Policy. Policy Options. March 2003 pp.35-40. Elderly: The elderly population is generally less physically robust and more prone to chronic illnesses, which make them especially vulnerable to air pollution and heat exposure. Physical activity is an important aspect of daily life for this age group as it has been shown to reduce the negative health impacts of aging.11 Being physically active, however, requires accessible and safe streets, and transportation systems that cater to the needs of individuals with mobility issues. Special consideration is required when constructing the built environment to ensure the needs of this growing population. Low Income Populations: Low income populations are at higher risk for chronic illnesses such as high blood pressure and diabetes, and have a lower overall survivability for major heart attacks.12,13 They are also more likely to smoke, be overweight or obese, and are less likely to be physically active.14 Many of these factors can be linked to limited access to stable housing, housing location (normally close to highways or industrial zones with high pollution exposure), neighbourhood safety, and lack of access to or affordability of healthy food options. Recommendation 2. The CMA recommends that the federal government work with all sectors to create a culture within communities that supports and encourages active transportation and physical activity. Income Hundreds of research papers have confirmed that people in the lowest socio-economic groups carry the greatest burden of illness.15 Studies also suggest that adverse socio-economic conditions in childhood can be a greater predictor of cardiovascular disease and diabetes in adults than later life circumstances and behavioural choices.16 Finally, the countries reporting the highest population health status are those with the greatest income equality, not the greatest wealth.17 17 Hofrichter R ed. Tackling Health Inequities Through Public Health Practice: A Handbook for Action. The National Association of County and City Health Officials & The Ingham County Health Department. Lansing (USA); 2006. 18 Bierman AS, Angus J, Ahmad F, et al. Ontario Women’s Health Equity Report : Access to Health Care Services : Chapter 7. Toronto (ON) Project for and Ontario Women’s Health Evidence-Based Report; 2010. 19 Bierman AS, Johns A, Hyndman B, et al. Ontario Women’s Health Equity Report: Social Determinants of Health & Populations at Risk: Chapter 12. Toronto (ON) Project for and Ontario Women’s Health EvidenceBased Report; 2010.; Williamson DL, Stewart MJ, Hayward K. Low-income Canadians’ experiences with health-related services: Implications for health care reform. Health Policy 2006; 76:106-121. 20 Canadian Institute for Health Information. Hospitalization Disparities by Socio-Economic Status for Males and Females. Ottawa(ON); 2010. Available: https://secure.cihi.ca/free_products/disparities_in_hospitalization_by_sex2010_e.pdf (accessed 2017 Jan 5) 21 Canadian Institute for Health Information. Hospitalization Disparities by Socio-Economic Status…;Roos LL, Walld R, Uhanova J, et al. Physician Visits, Hospitalizations, and Socioeconomic Status: Ambulatory Care Sensitive Conditions in a Canadian Setting. HSR 2005; 40(4): 1167-1185. 22 Canadian Medical Association. Policy resolution GC15-70 - Basic income guarantee. Approved August 26, 2015 Income plays a role in access to appropriate health care as well. Individuals living in lower income neighbourhoods, are less likely to have primary care physicians18, and are more likely to report unmet health care needs.19 They are more likely to be hospitalized for conditions which could potentially be avoided with appropriate primary care.20,21 In 2015, the CMA passed a resolution endorsing the concept of a basic income guarantee”22, which is a cash transfer from government to citizens not tied to labour market participation. It ensures sufficient income to meet basic needs and live with dignity, regardless of employment status. A basic income guarantee has the potential to alleviate or even eliminate poverty. It has the potential to reduce the substantial, long-term social consequences of poverty, including higher crime rates and fewer students achieving success in the educational system. In addition, resources and supports are needed to assist low-income Canadians regarding diet, shelter, skills development and other needs.. Recommendation 3. The CMA urges the Government of Canada to prioritize consideration of a basic income guarantee as a policy option for reducing poverty. Prenatal and Early Childhood Research suggests that 90% of a child’s brain capacity is developed by age five.23 High quality early childhood programs including programs to nurture and stimulate children and educate parents are highly correlated with the amelioration of the effects of disadvantage on cognitive, emotional and physical development among children.24,25 23 Arkin E, Braveman P, Egerter S & Williams D. Time to Act: Investing in the Health of Our Children and Communities: Recommendations From the Robert Wood Johnson Foundation Commission to Build a Healthier America. Robert Wood Johnson Foundation. Princeton (NJ); 2014. 24 Braveman P, Egerter D & Williams DR. The Social Determinants of Health: Coming of Age. Annu Rev Publ Health. 32:3.1-3.18. 2011. 25 European Union. Commission Recommendation of 20.2.2013: Investing in children: breaking the cycle of disadvantage. Brussels (Belgium); 2013. 26 Canadian Medical Association, Canadian Paediatric Society, College of Family Physicians of Canada. Child and Youth Health: Our Challenge: Canada’s Child and Youth Health Charter. Ottawa October 9, 2007. In 2007, the Canadian Medical Association, the Canadian Paediatric Society and the College of Family Physicians of Canada released Canada’s Child and Youth Health Charter.26 To reach their potential, children and youth need to grow up in a place where they can thrive — spiritually, emotionally, mentally, physically and intellectually — and get high-quality health care when they need it. That place must have three fundamental elements: a safe and secure environment; good health and development; and a full range of health resources available to all. Children and youth of distinct populations in Canada, including First Nations, Inuit and Métis, must be offered equal opportunities as other Canadian children and youth through culturally appropriate resources. Our children and youth must have a safe and secure environment where they can access clean water, air and soil; be protected from injury, exploitation and discrimination; and live in healthy family, homes and communities. Further, to ensure good health and development there must be access to prenatal and maternal care for the best possible health at birth and access to quality nutrition for proper growth, development and long-term health. As well, early learning opportunities and high-quality care, at home and in the community must be accessible. Opportunities and encouragement for physical activity are crucial as well as access to high-quality primary and secondary education. Finally, affordable and available post-secondary education and a commitment to social well-being and mental health are paramount. Recommendation 4. The CMA recommends that the federal government and the provinces and territories work to ensure that poverty does not continue to be a barrier to the healthy development of Canadian children, particularly in their first five years. Conclusion Socio-economic factors play a larger role in creating (or damaging) health than either biological factors or the health care system. Health equity is increasingly recognized as a necessary means by which we will make gains in the health status of all Canadians. Despite a commitment to equal access to health care for all Canadians there are differences in access and quality of care for many groups. For those that are most vulnerable, this lack of access can serve to further exacerbate their already increased burden of illness and disease. Action is still required by the federal government to tackle the underlying social and economic factors which lead to the disparities in the health of Canadians.
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