The Canadian Medical Association (CMA) is pleased to provide the House of Commons Standing Committee on Finance this pre-budget submission. It provides recommendations to address major pan-Canadian challenges to the health of Canadians: improve how we provide care to our growing elderly population; improve access to primary care across the country; increase digital health literacy to take advantage of the benefits of new health information technologies; and better prepare for and mitigate the health impacts of a changing climate on Canadians.
Health systems across the country are currently struggling to meet the needs of our aging population. People aged 85 years and over—many of whom are frail—make up the fastest growing age group in Canadai.
Provincial and territorial health care systems (as well as care systems for populations falling under federal jurisdiction) are facing many challenges to meet the needs of an aging population. Canadians support a strong role for the federal government in leading a national seniors strategy and working with the provinces to ensure that all Canadians have the same level of access and quality of services, no matter where they live.
The 2017 federal/provincial/territorial funding agreement involving $6 billion over 10 years to improve access to home care services is a welcomed building block. But without greater investment in seniors care, health systems will not keep up. To be truly relevant and effectively respond to Canadians’ present and future needs, our health care system must provide integrated, continuing care able to meet the chronic and complex care needs of our growing and aging population. This includes recognizing the increased role for patients and their caregivers in the care process.
The federal government must ensure transfers are able to keep up with the real cost of health care. Current funding levels clearly fail to do so. Health transfers are estimated to rise by 3.6% while health care costs are expected to rise by 5.1% annually over the next decade.ii
The federal government ensure provincial and territorial health care systems meet the care needs of their aging populations by means of a demographic top-up to the Canada Health Transfer.iii
Providing care often comes with a financial cost such as lost income due to the caregiver’s withdrawal from the workforce to provide care. There are also increasing out-of-pocket costs for both caregivers and care receivers for health care-related expenses—privately covered expenditures on home and long-term care for seniors are projected to grow by an average of 5.8 per cent annually—nearly 1.5 times the pace of household disposable income growth. While the federal government offers tax credits that can be claimed by care receivers/caregivers, they are significantly under-utilized. While representing a significant proportion of caregivers, those with low or no income receive little to no federal government support through these programs. Middle-income earners also receive less than those earning high incomes.
The federal government create a Seniors Care Benefit that would be an easier, fairer and more effective way to support caregivers and care receivers alike.iv
Access to Care
Since the mid-1990s, the federal and provincial/territorial governments (FPT) have provided sustained leadership in promoting and supporting the transformation of primary care in Canada. In 2000, the First Ministers concluded the first of three Health Accords in which they agreed to promote the establishment of primary health care teamsv supported by a $800 million Primary Health Care Transition Fund (PHCTF) funded by the federal government, but jointly governed. The PHCTF resulted in large-scale sustained change in primary care delivery models in Ontario, Quebec and Alberta with interest in other jurisdictions as well.
However, the job is far from finished. Across Canada, access to primary care is challenging for many Canadians with a persistent shortage of family physicians. In 2017, 4.7 million Canadians aged 12+ reported they did not have a regular health care provider.vi Even those who have a regular provider experience wait time issues.
There has been widespread interest in primary care models since the development of the College of Family Physicians of Canada’s (CFPC) vision document Family Practice: The Patient’s Medical Home (PMH), initially launched in 2011vii and recently re-launched.viii The model is founded on 10 pillars depicted in Figure 1.
Figure 1. The Patient’s Medical Home, 2019
The updated model places increased emphasis on team-based care and introduces the concept of the patient’s medical neighborhood that sets out connections between the primacy care practice and all delivery points in the surrounding community. While comprehensive baseline data are lacking, it seems
safe to conjecture that most Canadians are not enrolled in a primary care model that would measure up to the model’s 10 pillars.
The federal government, in concert with provinces and territories, establish a targeted fund in the amount of $1.2 billion to support a new time-limited Primary Health Care Transition Fund that would build on the success of the fund launched in 2000 with the goal of widely introducing a sustainable medical home model across jurisdictions. This would include the following key elements:
Age-sex-weighted per capita allocation across the provinces and territories;
Joint governance of the FPT governments with meaningful stakeholder engagement;
Respect for the Canada Health Act principles;
Common objectives (e.g., modeled on the CFPC Patient’s Medical Home framework);
Canada and most industrialized countries will experience a digital health revolution over the next decade with great potential to improve patient and population health. Digital health can be described as the integration of the electronic collection and compilation of health data, decision support tools and analytics with the use of audio, video and other technologies to deliver preventive, diagnostic and treatment services that promote patient and population health.
While most Canadian physicians’ offices and health care facilities are now using some form of electronic record keeping and most households have internet access, there remains a large deficit in using virtual care, both within jurisdictions and across provincial/territorial boundaries. Recently the CMA, the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada established a Virtual Care Task Force to identify opportunities for digital health to improve health care delivery, including what regulatory changes are required for physicians to deliver care to patients within and across provincial/territorial boundaries.
To take full advantage of digital health capabilities it will be essential for the population to have a functional level of digital health literacy: the ability to seek, find, understand and appraise health information from electronic sources and apply the knowledge gained to addressing or solving a health problem.ix This also includes the capability of communicating about one’s health to health care professionals (e.g., e-consults), self-monitoring health (e.g., patient portals) and receiving treatment online (e.g., Web-based cognitive behavioral therapy).x
There are no current data available on health literacy in Canada, let alone digital health literacy. One basic barrier to achieving digital health literacy is access to, and usage of the Internet, which has been termed the “digital divide” (e.g., older Canadians and low income households are less likely to have Internet access).Error! Bookmark not defined.
In 2001 the federal government established the Financial Consumer Agency of Canada (FCAC). Its mandate includes informing consumers about their rights and responsibilities in dealing with financial institutions and providing information and tools to help consumers understand and shop for financial products and services.xi In 2014 the FCAC appointed a Financial Literacy Leader who has focused on financial literacy, including activities such as conducting financial capability surveys and the development of a National Strategy for Financial Literacy.xii
Considering the anticipated growth of digital/virtual care it would be desirable to understand and promote digital health literacy across Canada. What the federal government has done for financial literacy could serve as a template for digital health literacy.
The federal government establish a Digital Health Literacy Secretariat to:
Develop indicators and conducting surveys to measure and track the digital health literacy of Canadians;
Develop tools that can be used both by Canadians and their health care providers to enhance their digital health literacy; and
Assess and make recommendations on the “digital divide” that may exist among some population sub-groups due to a lack of access to information technology and lower digital health literacy.
Climate Change and Health
Climate change is the public health imperative of our time. There is a high level of concern among Canadians about their changing climate. A 2017 poll commissioned by Health Canada demonstrates a high level of concern among Canadians about their changing climate: 79% were convinced that climate change is happening, and of these, 53% accepted that it is a current health risk, with 40% believing it will be a health risk in the future.
The World Health Organization (WHO) has identified air pollution and climate change as one of the biggest threats to global health. Health care professionals see first-hand the devastating health impacts of our changing climate including increased deaths from fine particulate matter air pollution and increased heat-related conditions. Impacts are most common in vulnerable populations such as adults over 65 years, the homeless, urban dwellers and people with a pre-existing disease.
Canada’s health care system is already treating the health effects of climate change. A lack of progress in reducing emissions and building adaptive capacity threatens both human lives and the viability of Canada’s health system, with the potential to disrupt core public health infrastructure and overwhelm health services, not to mention the economic and social costs. The federal government must provide leadership to deal with the impact already being felt in Canada and around the world.
The federal government make strong commitments to minimize the impact of climate change on the health of Canadians by:
Ensuring pan-Canadian and inter-jurisdictional coordination to standardize surveillance and reporting of climate-related health impacts such as heat-related deaths, develop knowledge translation strategies to inform the public, and generate clinical and public health response plans that minimize the health impacts;
Increasing funding for research on the mental health impacts of climate change and psychosocial adaptation opportunities; and
Ensuring funding is provided to the health sector to prepare for climate change impacts through efforts to increase resiliency (i.e., risk assessments, readiness to manage disease outbreaks, sustainable practice).
i Statistics Canada. The Chief Public Health Officer's Report on the State of Public Health in Canada, 2014: Public Health in the Future. Ottawa: Statistics Canada; 2015. Available: http://www.phac-aspc.gc.ca/cphorsphc-respcacsp/2014/chang-eng.php; (accessed 2016 Sep 19).
ii The Conference Board of Canada. Meeting the care needs of Canada’s aging population. Ottawa: The Conference Board; 2018.
iii Canadian Medical Association. Meeting the demographic challenge: Investments in seniors care. Pre-budget submission to the House of Commons Standing Committee on Finance. August 3, 2018. https://policybase.cma.ca/documents/Briefpdf/BR2018-16.pdf
iv The Conference Board of Canada. Measures to Better Support Seniors and Their Caregivers. March 2019. https://www.cma.ca/sites/default/files/pdf/health-advocacy/Measures-to-better-support-seniors-and-their-caregivers-e.pdf
v Canadian Intergovernmental Conference Secretariat. News release – First Ministers’ meeting communiqué on health. September 11, 2000. http://www.scics.ca/en/product-produit/news-release-first-ministers-meeting-communique-on-health/. Accessed 04/22/19.
vi Statistics Canada. Primary health care providers, 2017. https://www150.statcan.gc.ca/n1/en/pub/82-625-x/2019001/article/00001-eng.pdf?st=NGPiUkM5. Accessed 04/21/19.
vii College of Family Physicians of Canada. A vision for Canada. Family Practice: the patient’s medical home. http://www.cfpc.ca/uploadedFiles/Resources/Resource_Items/PMH_A_Vision_for_Canada.pdf. Accessed 04/22/19.
viii College of Family Physicians of Canada. The patient’s medical home 2019. https://patientsmedicalhome.ca/files/uploads/PMH_VISION2019_ENG_WEB_2.pdf. Accessed 04/21/19.
ix Norman C, Skinner H. eHealth literacy: essential skills for consumer health in a networked world. J Med Internet Res 2006;8(2):e9. Doi:10.2196/jmir.8.2.e9.
x Van der Vaart R, Drossaert C. Development of the digital health literacy instrument: measuring a broad spectrum of health 1.0 and health 2.0 skills. J Med Internet Res. 2017;19(1):e27. Doi:10.2196/jmir.6709.
xi Financial Consumer Agency of Canada. About FCAC.
xii Financial Consumer Agency of Canada. National Strategy for Financial Literacy. Phase 1: strengthening seniors’ financial literacy. https://www.canada.ca/content/dam/canada/financial-consumer-agency/migration/eng/financialliteracy/financialliteracycanada/documents/seniorsstrategyen.pdf. Accessed 06/24/19. https://www.canada.ca/en/financial-consumer-agency/corporate/about.html. Accessed 07/01/19.
Re: Standing Committee on Health’s study on violence faced by healthcare workers
Dear Mr. Casey:
I am writing on behalf of the Canadian Medical Association (CMA) to submit recommendations for
consideration by the Standing Committee on Health (the Committee) as part of the study on violence
faced by healthcare workers.
The CMA is deeply concerned with the state of workplace safety in all health care settings, including
hospitals, long-term care, and home care settings. As in all experiences of violence, it is
unacceptable for healthcare workers to be victims of violence in the provision of care to patients.
While there is limited data nationally to understand the incidence of violence against healthcare
workers, anecdotal evidence suggests that these experiences are increasing in frequency and severity.
A 2010 survey of members of the College of Family Physicians of Canada shockingly found that, in
the previous month, nearly one-third of respondents had been exposed to some form of aggressive
behaviour from a patient (90%) or patient’s family (70%). The study concluded that “Canadian family
physicians in active practice are subjected to regular abuse from their patients or family members of
These concerns were brought to the CMA’s General Council in 2015, where our members passed a
resolution calling for:
“the federal government to amend the Criminal Code by making it a specific criminal offence to
assault health care providers performing their duties.”
The CMA is prioritizing initiatives that support physician health and wellness. Increasingly, there is a
recognition of the role of the workplace, primarily health care settings, and safe working conditions as
having an important influence of physician health and wellness.
1 Miedema BB, Hamilton R, Tatemichi S et al. Monthly incidence rates of abusive encounters for Canadian family physicians by patients and their families. Int J Family
Med. 2010; 2010: 387202. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3275928/pdf/IJFM2010-387202.pdf (accessed 2019 May 9).
Mr. Bill Casey
Addressing violence against providers in healthcare settings will require action from both federal and
provincial/territorial governments. In light of the above, the CMA respectfully submits the following
recommendations for consideration by the Committee in its study on violence against healthcare
1) The CMA recommends that the Committee on Health support the call to amend the Criminal
Code of Canada to introduce a new criminal offence for assault against a healthcare
provider performing their duty.
2) The CMA recommends that the Committee on Health support establishing monitoring of
violence against healthcare workers, that is consistent across jurisdictions, and have an active
role in responding appropriately to trends.
3) The CMA recommends that the Committee on Health support federal leadership in a pan-
Canadian approach to support workplace safety in healthcare settings, including
collaborating with the provinces and territories to improve violence prevention.
Finally, the CMA welcomes and supports the petition recently tabled in the House of Commons by
Dr. Doug Eyolfson, calling for the Minister of Health “to develop a pan-Canadian prevention strategy
to address growing incidents of violence against health care workers.”
In closing, the CMA is encouraged that the Committee is undertaking this study. I look forward to the
Committee’s report on this topic and the opportunity to collaborate on federal and
provincial/territorial action in this matter.
F. Gigi Osler, BScMed, MD, FRCSC
c.c.: Marilyn Gladu, M.P., Vice Chair, Standing Committee on Health
Don Davies, M.P., Vice Chair Standing Committee on Health
The method a country chooses to fund and deliver health care demonstrates the values of its citizens and the type of nation that they wish to live in. Canadians, through their elected representatives, have placed a high value on a single-payer, tax-financed health care system with a delivery system that is essentially private and not-for-profit. The principles providing the underpinnings of the system are embodied in the Canada Health Act (CHA) and include the following: universality, comprehensiveness, access, portability and public administration.
Since the passing of the CHA, Canadians have grown increasingly passionate about these principles and have demonstrated time and again that these principles are in close alignment with their values.
Canadians have chosen tax-based financing for their health care system as it relates to hospital and physician services. The provincial and federal governments, through federal government transfers such as equalization payments and the Canada Health and Social Transfer and through provincial taxation, fund the various organizations and health care providers that deliver health care. Therefore the financing of the health care system has been socialized and publicly administered as opposed to privatized through compulsory private insurance. This indicates that Canadians view health care as not just an ordinary good, such as an automobile or a house that they pay for based on their own financial resources, but as a good whose cost should be shared by the community on the basis of the ability to pay of individuals. For those two components that are most likely to create true financial hardship for families and individuals, hospital services and physician services, the overwhelming majority of the funding is from public sources as opposed to private sources.
When it comes to the health services that are subject to the provisions of the CHA, namely hospital services and physicians' services, Canada has chosen a predominantly private delivery approach. Physicians are largely self-employed and operate within a private sector solo or group practice while community and teaching hospitals are largely private not-for-profit organizations. Most Canadian hospitals are governed by voluntary boards of trustees and are owned by voluntary organizations, municipal or provincial authorities or religious orders.
2.0 CANADIAN VALUES
The evolution of Canada's health care system has been profoundly influenced by Canadian values and as a result so will its future. The Prime Minister's National Forum on Health produced a series of documents on Canada's health care system including analyses that delved into Canadian values regarding health care and Canada's health care system in particular.
The following quotes are from Graves, Frank L. Beauchamp, Patrick, Herle, David, "Research on Canadian Values in Relation to Health and the Health Care System" Canada Health Action: Building on the Legacy, Papers Commissioned by the National Forum on Health, "Volume 5 - Making Decisions, Evidence and Information". These quotes exemplify the importance of health and the health care system in the hearts and minds of Canadians.
"There is a broad consensus that the Canadian health care system is a collective accomplishment, a source of pride, and a symbol of core Canadian values. The values of equality, access, and compassion are salient to perceptions of the system and often held in contradistinction to perceptions of the American system. Moreover, the system is seen as relatively effective and sound. It may be the only area of current public endeavour which is seen as a clear success story." p. 352
"The public perceptions of problems in the health care system reflect many of the themes evident in broader concerns about government. One of these themes is a growing wariness of "expert" prescriptions for the health care system." p. 353
"This finding reconfirms a consistent conclusion of other research in this area - the gap between expert rationality and public values. It would be prudent to acknowledge the public's entrenched resistance to a purely economic mode on health care." p. 354
"A number of key conclusions are evident. First, people were generally loath to trade-off elements of the current system against the promise of better or fairer future performance." p. 355
"The public will be resistant to a rational discourse on these cost issues because they are more likely to see these issues in terms of higher-order values. The evidence suggests that further dialogue will tilt the debate more to values than economics. The public will insist on inclusion and influence in this crucial debate and they will reject elite and expert authority." p. 356
"In response to a question on how health care was different from other commodities and services sold in the marketplace, participants agreed that its main difference lies in the fact that it was directly related to "life and death"." p. 370
"Most simply did not want efficiency to be the driving force in health policy." p. 378
"The focus group discussions augmented the belief that health care is more about values than economics." p. 389
"Although other competing priorities emerged over the period of the discussion, it is equality of access that serves as the primary source of this pride. The "Canadian" values are wrapped up in equality of access - everybody gets relatively equal care when they are sick and nobody has to lose their house to pay their hospital or doctor bill. It is this feature of the system which is seen to most distinguish it from the American model (which is the point of comparison)." p. 393
"Many people readily acknowledge that their belief in egalitarianism is restricted to health care and that they are not troubled by wide discrepancies based on ability to pay or status in other areas of society. They have no trouble isolating health care in this way because they see health care as something of a completely different character than housing or automobiles or vacations." p. 393
"There is an overwhelming consensus among Canadians about the importance of equality of access as the defining characteristic of our system. That consensus is premised upon the assumption that quality is a given, as they have perceived it to be in the past." p. 395
"It is also true that, since Canadians recognize that a truly private system like the U.S. version might provide even greater levels or quality of freedom of choice to at least some citizens, they are choosing to sacrifice some of that from the system in order to provide equality of access to a universal system." p. 396
Clearly, Canadians value their health care system and the principles that it is based on.
3.0 IMPLICATIONS FOR TRADE LIBERALIZATION
The core values that Canadians have expressed in relation to the health care system raise certain issues as to the impact of trade liberalization on those core values. Following is an analysis based on an examination of the various modes of trade.
3.1 Modes of Trade in Services
The Uruguay Round of trade negotiations leading to the World Trade Organization's creation in 1995 classified services into 160 sectors. Health services are classified as a sector. In addition, trade in insurance services may affect health services where a market for health insurance exists.
The General Agreement on Trade in Services (GATS) distinguishes among four modes of trade in services. Each is briefly described below, together with examples, (involving the mythic countries 'A' and 'B') from the health sector.
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- provision of diagnosis or treatment planning services in country A by suppliers in country B, via telecommunications ('telemedicine')
- movement of patients from country A to country B for treatment
- establishment of hospitals in country A whose owners are from country B, i.e. foreign direct investment
Presence of natural persons1
- service provision in country A by health professionals who have emigrated from country B
To date, Canada has made no commitments in the health services sector. Commitments in general have been shallow in the health sector in comparison to the most liberalized sectors, telecommunications and financial services, reflecting in part the substantial uncertainty about how such commitments will affect health care systems. Many of the countries that have undertaken health sector commitments have opted for enshrining the status quo, or even the status quo with commitments that include language proficiency requirements for health care professionals.
Some WTO Members, however, have made more extensive commitments, driven in part by the hope that this will facilitate development of export opportunities and importation of foreign capital and know-how. Where developing countries have made such commitments, the general lack of resources appears to be a far more potent barrier to trade than the presence or absence of such commitments.
3.2 GATS and the Health System: Role of Insurance and Health System Structure
To understand trade implications for the health sector, it may be helpful to distinguish between three functions that undergird all health systems: regulation/stewardship, financing, and service provision. Since the inception of Medicare, Canadians have received their health care through a system of private providers regulated under statutes. This links them closely to a financing system comprised largely of public funds in the form of general taxation revenues disbursed to health care providers by provincial and territorial governments and drawn from provincial and federal revenues through the progressive income tax system.
The regulatory/stewardship established by the Canada Health Act and provincial regulation is pivotal to the system's structure. For example, building private hospitals need not be explicitly banned because funding levers make this a difficult business proposition as services provided there would not be automatically covered by provincially managed insurance schemes. A further useful distinction arises between input goods and services (drugs, devices, health care personnel, cleaning, laundry etc.) and the output of health care services. It is difficult to argue that the cleaning of hospitals is fundamentally part of the output of health services, rather it is similar to cleaning of other facilities and is increasingly performed by commercial entities in contractual relationships with health care facilities. These commercial entities include firms with foreign ownership or shareholders. Similarly many of the drugs and devices used in Canadian health care facilities are traded goods, moving in international trade from foreign-based suppliers and being accompanied by Canadian goods exported to other health care systems.
Another input into the health care system is medical education. Physicians have to be trained so that Canadians have access to appropriate physician resources. There is some concern about the effects of GATS on the medical education enterprise and the quality of medical education currently delivered in Canada. As well, there is international recognition of Canada's expertise in medical education and evaluation and that this is a part of the health care system that Canada should be exporting.
4.0 RESPONDING TO GATS: POTENTIAL IMPLICATIONS
In responding to GATS, it is helpful to consider each of the four modes of trade in health services, current levels of trade, and how GATS liberalization, (i.e. commitments by the government of Canada) could impact Canada's health care system.
Mode 1 - Cross-border supply
Cross border supply of health services, where the provider (health care professional) and consumer (patient) are in different jurisdictions has recently moved from the realm of science fiction to reality with advances in telemedicine. However, certain services, particularly those involving direct patient contact (nursing, rehabilitation professionals) are unlikely to be provided, regardless of advances in telemedicine. Cross-border supply appears most relevant to services involving diagnosis and treatment planning.
For example, a physician in Canada may digitize radiology films and send them for interpretation to a radiologist in the Caribbean or South Asia. Similarly, several experiments within Canada have attempted to use telediagnosis to spare families long trips from remote communities to consult with highly specialized paediatricians. If this were to occur across national borders with exchange of payment for services, it would constitute a form of international services trade.
Current limits on telemedicine's growth are essentially no longer technological but rather the regulatory/stewardship issues of professional certification and payment systems for services rendered. A commitment under mode 1 would do nothing to address either of these questions, particularly the first as governments retain full authority to establish licensing and certification regimes for professionals. Within Canada, payment has been hampered by provincial insurance plan insistence that the doctor-patient encounter must occur in such a way that both are in the same physical space.
At present, efforts have been directed to establishing cross-border recognition of professional accounting certification, fueled in large part by the concentration of accounting services work within a handful of multinational firms on behalf of their increasingly globalized clients. By contrast, similar efforts directed to social sector professions are unlikely given the atomistic nature of the professionals and the institutions and organizations where they work. The absence of a concerted desire for such cross-border recognition, coupled with the powerful role of governments in regulating not only certification but also numbers of health care professionals, suggests cross-border recognition will remain unlikely for the foreseeable future.
That having been said, a commitment by Canada and other countries to mode 1 liberalization could increase pressure on licensing authorities to develop programs of cross-border recognition. If this were to happen the export of telemedicine services outside of Canada would represent physician resources that would not be available to Canadians. Given the physician workforce issues that Canada is presently facing such a commitment could exacerbate an already difficult position. In addition, there are other implications that would have to be determined through stakeholder consultation, for example: provider legal liability and malpractice insurance, patient privacy and confidentiality of medical records to name a few.
Mode 2 - Consumption abroad
Individual Canadians have long sought care in other jurisdictions, most notably the United States. This is typically paid for from private health insurance or out of pocket funds. Changes to provincial insurance reimbursement for out-of-country care have dramatically limited publicly funded consumption abroad by Canadians. Two exceptions to this are treatment for specific rare conditions and, in several provinces, contracting for radiation therapy services with American institutions. Liberalization under mode 2 would do little for Canada in affecting the outward flow of Canadian patients to the US given the ease with which Canadians can cross the Canada-US border to purchase medical care. Similarly, opportunities for Canadian professionals and facilities to attract additional foreign patients are unlikely to grow substantially should a mode 2 commitment be made.
The obvious growth potential for Canadian physicians and facilities lies in the USA but has been substantially limited by two synergistic factors. First is the non-portability of insurance coverage, both publicly financed Medicare/Medicaid benefits and most market-purchased insurance. Exclusion from health maintenance organizations' (HMOs) networks of providers are a further impediment for Canadian providers seeking to attract American consumers. Should the United States be willing to commit to the generalized portability of Medicare benefits, Canada would be a logical destination for American consumers seeking care, but that would be contingent on a commitment from the United States or other action regarding portability, rather than a specific mode 2 commitment by Canada. Commitments in this direction may, however, only be made if similar commitments are made by potential trading partners for health services, notably Canada and Mexico.
A commitment by Canada and other countries, especially the United States, to mode 2 liberalization could change the business plans or strategies to attract foreign patients by some physicians especially certain niche subspecialists. Such a change could result in access difficulties for Canadian patients as providers substitute higher-paying foreign patients for Canadian ones for which payment is fixed by provincial insurance plans.
Mode 3 - Commercial presence
Commercial presence, usually through foreign direct investment (FDI), is often necessary for providing services such as banking or supply chain management. FDI in Canada's health service sector is relatively insignificant and that would appear unlikely to change with a mode 3 commitment. As with several of the other modes of trade, the regulatory and stewardship environment creates structural impediments to FDI, specifically concerning which services will be paid for in which facilities, that a mode 3 commitment is unlikely to remove.
A related area for the health system is that of consulting services, where multinational, foreign-origin firms already play a substantial role in providing various forms of management consulting services. While some hospital boards are reported to have been approached regarding the outsourcing of their management to foreign management services firms, the extent of implementation to date has been minimal. Should hospital management be outsourced in this way or hospital facilities networked through supra-facility organizations, American based firms are logical candidates for such work and can be expected to bring with them substantial experience in shaping and constraining physician decision-making, particularly around access to expensive procedures.
Mode 3 commitments are arguably neither necessary nor sufficient for such a change in hospital governance and management when compared to the power of provincial government regulation and financing mechanisms. If Canada made a mode 3 commitment, provincial governments would still have substantial latitude to regulate financing and provision of services, so long as these regulations applied to all potential suppliers, regardless of country of origin, thus ensuring national treatment.
However, the full ramifications of such a commitment remain largely unknown and there appears little to be gained by Canada in making such commitments.
Mode 4 - Presence of natural persons
Presence of natural persons, specifically physicians and other health professionals, is one of the most pressing issues in health systems around the world. For countries like South Africa, emigration of physicians hamstrings efforts to deliver health services. For parts of Canada, immigration of those physicians has been essential to providing Canadians with health care, particularly in rural and remote areas.
Nevertheless, mode 4 commitments are unlikely to be particularly useful for health human resource planning. For destination countries like Canada, a mode 4 commitment to liberalize immigration of natural persons, specifically health sector professionals, does not bind that country to forego national systems of certification and licensure. Moreover, existing systems of visas and work authorizations offer far more effective control over inflows than would a mode 4 commitment. Similarly, Canadian physicians who wish to emigrate, typically to the US, do so in the absence of a Mode 4 commitment by either country. Of concern to Canadians is the increased recognition of physician shortages as demonstrated by the fact that several provinces have increased medical school enrolment. Therefore any measures that would make it easier for physicians and other health care professionals to leave Canada and to practice elsewhere, especially the United States, could exacerbate an already tight supply of human health resources in several provinces.
After a decade of efforts to reduce the number of physicians in Canada, assessments of Canadian physician supply are increasingly identifying shortages or, at the very least, chronic undersupply, in rural areas. Substantial numbers of foreign-trained physicians already reside in Canada but are unable to practice due to some combination of limited language skills, insufficient training, or 'queuing' for the various transition requirements imposed on international medical graduates (IMGs) by provincial licensing authorities.
Commitments by Canada in this area however could result in pressure on licensing authorities to modify their requirements with potential implications on quality of care. Again, there is little to be gained for Canada to pursue commitments in this area until the ramifications are fully explored.
Two areas that are to be explored are: 1) cross-sectoral horse trading, and 2) equity perceptions.
'Cross-sectional horse trading' refers to countries offering commitments in one sector in return for commitments in other, unrelated sectors. As an example, Canada may wish to increase its access to foreign markets for financial or telecommunications services and face the choice of putting the health services sector 'into play' as part of negotiating on matters unrelated to health services. This would be potentially disastrous if Canada were to undertake specific health services commitments in the rush to secure benefits in other sectors without attention to the federal-provincial cooperation and coordination to ensure that such commitments did not undermine the foundations of Canada's health system.
Such cooperation and coordination appears to be becoming increasingly difficult and the pressure of a GATS commitment perceived to be negotiated by persons outside the health sector and health ministry would seem a surefire way to increase that difficulty.
The second issue, equity perceptions, arises from the confluence of increasing concern among Canadians about access to their health care system and the likely additional concern that would arise if Canadian physicians were perceived to be favouring foreign patients over Canadian patients. The clearest example of access concerns to date is likely that of ophthalmology services where the opportunities for these specialists to provide non-insured laser treatment to American citizens may have reduced the services available to provincially insured Canadians. Non-insured care, whether for Canadians or foreign patients is a growing part of physician revenues, but pushing for its expansion through a mode 2 commitment under GATS appears unlikely to generate benefits sufficient to offset the potential negatives when compared with other methods of expanding revenue from non-insured services.
The Government of Canada's bargaining position regarding health services in relation to the ongoing liberalization of trade in health services through the GATS will evolve from an assessment of the opportunities and costs associated with various levels of commitment. A major factor in the equation are the values of Canadians and their affinity for the publicly funded health care system.
"The Canadian Medical Association (CMA) recognizes that trade liberalization can have positive economic impacts on the Canadian economy, however the type of healthcare system that Canadians and health care providers want is of primary concern whereas the goals of trade liberalization in health services is of a secondary nature. Recognizing that the GATS process is an on-going and long-term approach to trade liberalization, the CMA recommends that the Federal government undertake extensive consultative sessions with the Canadian public and healthcare providers. Such a consultation process would help answer questions as to the implications of trade liberalization and would provide feedback as to what level of trade liberalization in health care services is consistent with Canadian values."
1 Mode 4: "Presence of 1Natural Persons" - this covers the conditions under which a service supplier can travel in person to a country in order to supply a service. Source: http://gats-info.eu.int/gats-info/gatscomm.pl?MENU=hhh
Based on a well-established collaboration addressing concussion, the Canadian Academy of Sport and Exercise Medicine (CASEM) the College of Family Physicians of Canada (CFPC), and the Canadian Medical Association (CMA) are pleased to submit this brief to the Subcommittee on Sport-Related Concussions (SCSC) of the House of Commons Standing Committee on Health.
About the Canadian Academy of Sport and Exercise Medicine (CASEM)
CASEM is a physician member-based organization comprised of 850 medical doctors from many specialties who have specialized training and skills in sport and exercise related injuries/illnesses for active patients of all ages and abilities, including concussion care. CASEM physicians hold national and international leadership roles in concussion care. Namely, at the national level, CASEM chairs the Canadian Concussion Collaborative (CCC) and at the international level, several CASEM members played leadership roles in the development of the International Consensus Statements on Concussion in Sport which is the key document that establishes concussion management recommendation every 4 years.
About the College of Family Physicians of Canada (CFPC)
The CFPC is the professional organization that represents more than 38,000 family physician members across the country. The College establishes the standards for, and accredits, postgraduate family medicine training for Canada’s 17 medical schools. It reviews and certifies continuing professional development programs, and materials, that enable family physicians to meet certification and licensing requirements. The CFPC provides high-quality services, supports family medicine teaching and research, and advocates on behalf of family physicians and the specialty of family medicine.
About the Canadian Medical Association (CMA)
The Canadian Medical Association unites 85,000 physicians on national health and medical matters. Formed in Quebec City in 1867, the CMA’s rich history of advocacy led to some of Canada’s most important health policy changes. As we look to the future, the CMA will focus on advocating for a healthy population and a vibrant profession. Along with CASEM, the CMA is a co-founding member of the CCC.
KEY KEY THEMESTHEMES AND RECOMMENDATIONSAND RECOMMENDATIONS:
In this brief, CASEM, CFPC, and the CMA submit a series of recommendations under two key themes. Taken as a whole, we believe these will help inform the Subcommittee’s study on how to improve concussion awareness, prevention and treatment for all Canadians. Background information regarding the groups and initiatives mentioned in the key themes and recommendations, is provided in the subsequent part of this document.
KEY THEME #1:
The impacts of concussion and the benefits of awareness efforts are slowly becoming better known at the higher levels of sport participation that received support for the implementation of proper concussion management strategies (namely through the Canadian Concussion Protocol Harmonization Project). Further efforts and government funding should address the issue at all levels of sport participation. This must include school-based sport programs, and concussion occurring in other contexts (e.g. leisure, occupation, etc.).
RECOMMENDATIONS related to key theme #1:
#1.1 The federal government should commission and fund the development and evaluation of additional efforts to improve awareness and proper management of concussion at all levels of sport participation and contexts where concussions occur in Canada.
#1.2 Since “key aspects of concussion prevention, detection and management occur prior to, as well as after, the initial medical intervention”1, “public health strategies should be developed and implemented to address the issue of concussions.”1
#1.3 Given their competencies and expertise in this area, “family physicians2 and sport and exercise medicine (SEM) physicians should play a central role in the design and implementation of strategies that work in conjunction with families, schools, sports organizations, employers and governments to educate, support and empower the implementation of proper concussion prevention, detection and management protocols.”1
#1.4 Any future effort to improve concussion awareness and management should, whenever possible, be evidenced-informed, and aim for synergy with ongoing Canadian initiatives.
#1.5 Innovative dissemination strategies that have the potential to reach all levels of sport participation and contexts where concussions occur should be considered and evaluated (e.g. massive open online course or MOOC 3).
1 The Role of Family Physicians and physicians with Added Competencies in Sport and Exercise Medicine in a Public Health Approach to Concussions. A joint position statement of CASEM, CFPC, and the CMA. 2017 https://www.cfpc.ca/ProjectAssets/Templates/Resource.aspx?id=4319&langType=4105
2 This is not meant to exclude the possible role of other health care disciplines, such as nurse practitioners, that can be involved in the diagnosis and medical management of concussions in some Canadian jurisdictions.
KEY THEME #2:
For the majority of Canadians affected by a concussion, family physicians play a central role in concussion identification and management through the recovery process. However, where persistent concussion symptoms arise, family physicians and their patients require timely access to SEM physicians, and multidisciplinary care for the development and implementation of individualized treatment plans. As it presently stands, access to such expert medical and multidisciplinary resources for concussion is very limited (especially in rural and remote regions). To complicate matters, Canadians affected by a concussion are all too often uncertain how best to navigate a health care system that isn’t well organized to address their unique needs.
RECOMMENDATIONS related to key theme #2:
#2.1 Medical schools and organizations should maintain continuous efforts aiming for the rapid integration of the most current clinical practice recommendations about concussion.
#2.2 Initial care for Canadians affected by a concussion should be coordinated by the patient’s family physician.
#2.3 To work in collaboration with their family physicians, patients affected by persistent symptoms following a concussion should have timely access to medical experts on concussion and allied professionals with expertise in concussion management.
#2.4 The potential of telemedicine strategies or other virtual network to improve access to concussion experts for support in the management of concussion should be considered and evaluated. BACKGROUNDBACKGROUND::
The challenging dynamics of concussion: Sport-related concussion seriously impacts the health and well-being of Canadians across the country; to say nothing of the costs to the health care system and concussed individuals. Canadian statistics show that among children and youth (10-18 years) who visit an emergency department for a sports-related head injury, 39% were diagnosed with concussions, while a further 24% were possible concussions.4
Between 2003 and 2013 in Ontario, a 4.4-fold increase of pediatric concussion-related consultations has been observed, with a sharp increase between 2010 and 2013 and nearly 35000 visits in 2013.5 Although, the precise reasons for this increased incidence of concussion are unknown, the study suggests that “…concussion education and awareness, improved diagnosis of
5 Zemek et al. J Pediatr 2017; 181: 222-8 (https://doi.org/10.1016/j.jpeds.2016.10.067)
concussion, and revised concussion guidelines advocating stricter follow-up…” played an important role.
The body of knowledge regarding concussion is rapidly and constantly changing; a dynamic that is unlikely to change for the foreseeable future. One important limitation of our knowledge about concussion is the lack of information on the true burden of concussion in Canada. A significant proportion of all concussions are not captured by traditional health-related databases, or clinical research, because individuals often do not consult a physician. One positive and recent development that will help better understand the true burden of sport related concussion in youth occurred in November 2018 when a group of more than 30 Canadian researchers including CASEM and CFPC leaders on concussion received $12 million from the National Football League “Play Smart, Play Safe” initiative.6 This 3-year longitudinal cohort study will evaluate diagnostic tools, prognostic indicators, prevention strategies, and treatment strategies. This study will characterize the true incidence rate and recovery characteristics of concussion in high school-based sport settings.
Psychological and social factors must also be considered. Attitudes and awareness towards injury are complicating factors that highlight the need for improved concussion prevention and awareness. These include injury minimization, the lack of a visible injury, and a general lack of both pre and post-injury awareness. Those closely associated with a concussed individual (coaches, co-workers, employers, or an injured individual themselves) may have an incentive, or experience pressure, to hide/downplay injury or avoid medical assessment due to stigma.7 The natural human predilection towards downplaying the nature of injury is another important factor to consider, especially where, post-injury, the effects aren’t clearly visible. A concussed individual may lack the mental acuity to be able to understand that their symptoms require medical attention.
Another area to consider is the availability of qualified health care resources. Family physicians, whether in primary care settings or emergency departments, and SEM physicians, are generally the first medical professionals seen by a person who has sustained a concussion during a sport, leisure or occupational activity. They are the first point of contact for proper management, advice, and education regarding that person’s gradual return to cognitive (e.g. school and work) and physical activities (e.g. sport, exercise or work).8 Gaps in medical training, and the fast-paced evolution of concussion best practices, means that clinicians sometimes struggle to maintain up-to-date knowledge regarding the detection and treatment of concussions. These factors are further complicated by ambiguous scopes of practice across the multidisciplinary professions involved
7 Delaney J, Caron J, Correa J, et al. Why Professional Football Players Choose not to Reveal their Concussion Symptoms During a Practice or Game. Clin J Sport Med, 2018, 28(1): 1-12.
8 College of Family Physicians of Canada & Canadian Academy of Sport and Exercise. Joint Position Statement - The Role of Family Physicians and Physicians with Added Competencies in Sport and Exercise Medicine in a Public Health Approach to Concussions. 2017.
with concussion management. Finally, there is general lack of available medical experts on concussion to whom family physicians can refer patients that present persistent symptoms.
Our recommendations also take into consideration the following factors:
The simple principles of initial concussion management6-8 are within the scope of practice of family physicians.
In the vast majority (80-90%) of cases, once simple principles of initial management have been implemented, concussion is a condition that will evolve favorably within 7-10 days.8
Even with proper initial management, some concussion patients will present with persistent symptoms that require a multidisciplinary team approach.
“Persistent symptoms” has been defined as more than 4 weeks in youth and more than 2 weeks in adults.9
Access to physicians with added competencies in concussion care (e.g. SEM Physicians, Physiatrists, Neurologists), and allied health professionals with experience in treating specific presentations of concussions is limited, especially in Canada’s rural and remote areas.
CASEM & CFPC’s concussion efforts to date: Since 2012, CASEM has played a key role in the evolution of concussion care in Canada by leading the work of the CCC10. The CCC is composed of 18 health organizations concerned with concussions that aim “to improve education about concussions, and the implementation of best practices for the prevention and management of concussions”. The CFPC has been involved with the CCC from the start. In 2015, the CCC published 2 key recommendations in a document entitled “Recommendations for policy development regarding sport-related concussion prevention and management in Canada”11 that state:
Organizations responsible for operating, regulating or planning sport and sporting events with a risk of concussion should be required to develop/adapt and implement a concussion management protocol, based on current best practices, that is customized for their context and available resources.
In situations where timely and sufficient availability of medical resources qualified for concussion management is lacking, multidisciplinary collaborative approaches should be used to improve concussion management outcomes while facilitating access to medical resources where appropriate.
Since 2015, the CCC has contributed a multidisciplinary health care perspective to key concussion-related initiatives in Canada. The first of these initiatives was initiated in January 2015 by Sport Canada and led to the creation of a Federal-Provincial-Territorial working group (FTP-WG) on
9 McCrory et al. Consensus statement on concussion in sport. (2017) https://bjsm.bmj.com/content/51/11/838
concussion that brings together sport, education, government and health stakeholders. Later in 2015, the mandate letters from Prime Minister Trudeau asked the Minister of Health and the Minister of Sport and Persons with Disabilities to collaborate on a national strategy on concussion. The Federal government budgeted $1.4 million to allow the Public Health Agency of Canada to work with provinces and territories to develop harmonized concussion management guidelines across Canada.12 Most of that work has been accomplished by funding to Parachute for the development of the Canadian guideline on concussion in sport.13 Members of the CCC and concussion leaders from the CFPC and CASEM were closely involved.
Since 2016, one of the CASEM and CFPC leaders on concussion developed a Massive Open Online Course (MOOC) to develop general awareness on concussion and facilitate the implementation of proper concussion management protocols in specific settings. After 4 iterations of that French language MOOC, over 8000 participants have accessed it. Presently an English version is being developed in collaboration between Laval University and the University of Calgary.
In August 2017, CASEM and CFPC, published a joint position statement entitled “The role of family physicians and physicians with added competencies in sport and exercise medicine in a public health approach to concussions”14 that is directly related to the recommendations presented in this brief.
Finally, since mid-2018, CASEM and CFPC have partnered with the Canadian Medical Association (CMA) to completely revamp the CMA’s policy on Head Injury in Sport. To foster high-level advocacy, cultural sensitivity, and awareness messaging on concussion, it has been redeveloped for a host of target audiences from all relevant perspectives. It is set for release in early 2019.
Concussion is a pressing public health issue in Canada. The members of the SCSC should keep in mind that concussions are not limited to higher level organized sport. It’s a sudden, and unwanted challenge that hundreds of unsuspecting and unprepared Canadians face each day. These concussions occur in a range of situations, inside and outside of sports settings, and often go untreated; with a potential for tragic consequences.
To truly address the issue and make progress towards the objectives expressed by Prime Minister Trudeau in the mandate letters, the Government of Canada must provide significant investments. To make progress across the spectrum of sports, leisure and other context where concussions
12 https://www.budget.gc.ca/2016/docs/plan/ch5-en.html 13 The Canadian guideline on concussion in sport was part of the Parachute-led Concussion Protocol Harmonization Project.
occur, the Government funding should minimally represent a 10-fold increase from the initial $1.4M budgeted in 2016.
With their respective membership, tools and resources, CASEM and the CFPC can play an important role in addressing the burden that concussions place on Canadians. With this brief, we are expressing the willingness of our organizations to collaborate with the government in the design and implementation of strategies to systemically address concussion from all causes as a public health issue. To be successful this must occur across all levels of sport participation and include: leisure, school-based sports, occupational activities and address the rural and remote areas of the country.
On behalf of CASEM, and the CFPC, we would welcome the opportunity, and privilege, to present and discuss these recommendations with your Committee.
Dr. Paul Watson
Dr. Pierre Fremont
Chair of the CFPC’s SEM Committee and Past President of CASEM
Past President of CASEM
Dr. Gigi Osler
Contacts: Dawn Haworth, Executive Director, CASEM
613 748 5851 – ext 1
Artem Safarov, Director of Health Policy and Government Relations, CFPC
905-629-0900 x 249
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.
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.
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.
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.
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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.
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.
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).
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.
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
Personal and Medical Care
worth $25 billion in
Social-emo ional Suppor
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.
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.
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.
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).
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.
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.
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.
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
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.
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.
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.
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.
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).
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.
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.
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.
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 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.
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.
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.
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.
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.
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
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.
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
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.
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
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.
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.
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
*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.
# 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
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
Work $5.5 in lost absence: productivity
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.
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.
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.
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.
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.
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).
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).
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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).
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
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.
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.
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.
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.
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
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.
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.