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CMA letter to the House of Commons Standing Committee on Justice and Human Rights. Bill C-32 (An Act to amend the Criminal Code (Impaired driving) and to make consequential amendments to other Acts)

https://policybase.cma.ca/en/permalink/policy8789
Last Reviewed
2019-03-03
Date
2007-06-11
Topics
Health care and patient safety
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2019-03-03
Date
2007-06-11
Topics
Health care and patient safety
Text
The Canadian Medical Association (CMA) welcomes the opportunity to provide comments to the Standing Committee on Justice and Human Rights of the House of Commons concerning the study of Bill C-32 (An Act to amend the Criminal Code (impaired driving) and to make consequential amendments to other Acts). The CMA supports measures aimed at reducing the incidence of drug-impaired driving. We believe impaired driving, whether by alcohol or another drug, to be an important public health issue for Canadians that requires action by all governments and other concerned groups. The CMA has, on several occasions, provided detailed recommendations on legislative changes concerning impaired driving. In 1999, the CMA presented a brief to the House of Commons Standing Committee on Justice and Human Rights during its review of the impaired driving provisions of the Criminal Code (attached). While our 1999 brief focuses primarily on driving under the influence of alcohol, many of the recommendations are also relevant to the issue of driving under the influence of drugs. Recently, the CMA has published the 7th edition of its guide, Determining Medical Fitness to Operate Motor Vehicles (attached). It includes chapters on the importance of screening for alcohol or drug dependency and states that the abuse of such substances is incompatible with the safe operation of a vehicle. This publication is widely viewed by clinical and medical-legal practitioners as the authoritative Canadian source on the topic of driver competence. While changing the Criminal Code is an important step, the CMA believes further actions are also warranted. In our 2002 presentation to the Special Senate Committee on Illegal Drugs (attached), the CMA put forth our long standing position regarding the need for a comprehensive long-term effort that incorporates both deterrent legislation and public awareness and education campaigns. We believe such an approach, together with comprehensive treatment and cessation programs, constitutes the most effective policy in attempting to reduce the number of lives lost and injuries suffered in crashes involving impaired drivers. Drug-impaired drivers may be occasional users of drugs or they may also suffer from substance dependence, a well-recognized form of disease. Physicians should be assisted to screen for drug dependency, when indicated, using validated instruments. Government must create and fund appropriate assessment and treatment interventions. Physicians can assist in establishing programs in the community aimed at the recognition of the early signs of dependency. These programs should recognize the chronic, relapsing nature of drug addiction as a disease, as opposed to simply viewing it as criminal behaviour. While supporting the intent of the proposed legislation, the CMA urges caution on several significant issues. With regard to Clause 4 that amends the act as follows: 254.1 (1) The Governor in Council may make regulations (a) respecting the qualifications and training of evaluating officers; (b) prescribing the physical coordination tests to be conducted under paragraph 254(2)(a); and (c) prescribing the tests to be conducted and procedures to be followed during an evaluation under subsection 254(3.1). CMA contends that it is important that medical professionals and addiction medicine specialists in particular, should be consulted regarding the training offered to officers to conduct roadside assessment and sample collection. Provisions in the Act conferring upon police the power to compel roadside examination raises the important issue of security of the person and health information privacy. As well, information obtained at the roadside is personal medical information and regulations must ensure that it be treated with the same degree of confidentiality as any other element of an individual's medical record. Thus, the CMA would respectfully submit that Clause 9 of Bill-32 on the issue of unauthorized use or disclosure of the results needs to be strengthened because the wording is too broad, unduly infringes privacy and shows insufficient respect for the health information privacy interests at stake. For instance, clause 9(2) would permit the use, or allow the disclosure of the results "for the purpose of the administration or enforcement of the law of a province". This latter phrase needs to be narrowed in its scope so that it would not, on its face, encompass such a broad category of laws. Moreover, clause 9(4) would allow the disclosure of the results "to any other person, if the results are made anonymous and the disclosure is made for statistical or other research purposes" CMA would expect the federal government to exercise great caution in this instance, particularly since the results could be of individuals who are not actually convicted of an offence. One should query whether the Clause 9(4) should even exist in a Criminal Code as it would not appear to be a matter required to be addressed. If it is, then CMA would ask the government to conduct a rigorous privacy impact assessment on these components of the Bill, studying in particular, such matters as sample size, degree of anonymity, and other issues, especially given the highly sensitive nature of the material. CMA would ask whether clause 9(5) should specify that the offence for improper use or disclosure should be more serious than a summary conviction. Finally, it is important to base any roadside testing methods and threshold decisions on robust biological and clinical research. CMA also notes with interest Clause 5, specifically the creation of a new offence of being "over 80" (referring to 80mg of alcohol in 100ml of blood, or a .08 blood alcohol concentration level or BAC) and causing an accident that results in bodily harm which will carry a maximum sentence of 10 years and life imprisonment for causing an accident resulting in death. (Clause 5) We would also urge the Committee to take the opportunity that the review of this proposed legislation provides to recommend to Parliament a lower BAC level. Since 1988 the CMA has supported 50 mg% as the general legal limit. Studies suggest that a BAC limit of 50 mg% could translate into a 6% to 18% reduction in total motor vehicle fatalities or 185 to 555 fewer fatalities per year in Canada.1 A lower limit would recognize the significant detrimental effects on driving-related skills that occur below the current legal BAC.2 In our 1999 response to this Committee's issue paper on impaired driving3 and again in 2002 when we joined forces with Mothers Against Drunk Driving (MADD), CMA has consistently called for the federal government to reduce Canada's legal BAC to .05. Canada continues to lag behind countries such as Austria, Australia, Belgium, Denmark, France and Germany, which have set a lower legal limit. 4 CMA expressed the opinion that injuries and deaths resulting from impaired driving must be recognized as a major public health concern. Therefore we once again recommend lowering the legal BAC limit to 50 mg%. or .05%. Finally, CMA believes that comprehensive long-term efforts that incorporate deterrent legislation, such as Bill C-32, must be accompanied by public awareness and education strategy. This constitutes the most effective approach to reducing the number of lives lost and injuries suffered in crashes involving impaired drivers. The CMA supports this multidimensional approach to the issue of the operation of a motor vehicle regardless of whether impairment is cause by alcohol or drugs. Again, the CMA appreciates the opportunity to provide input into the legislative proposal on drug-impaired driving. We stress that these legislative changes alone would not adequately address the issue of reducing injuries and fatalities due to drug-impaired driving, but support their intent as a partial, but important measure. Yours sincerely, Colin J. McMillan, MD, CM, FRCPC, FACP President Attachments (3) 1 Mann, Robert E., Scott Macdonald, Gina Stoduto, Abdul Shaikh and Susan Bondy (1998) Assessing the Potential Impact of Lowering the Blood Alcohol Limit to 50 MG % in Canada. Ottawa: Transport Canada, TP 13321 E. 2 Moskowitz, H. and Robinson, C.D. (1988). Effects of Low Doses of Alcohol on Driving Skills: A Review of the Evidence. Washington, DC: National Highway Traffic Safety Administration, DOT-HS-800-599 as cited in Mann, et al., note 8 at page 12-13 3 Proposed Amendments to the Criminal Code of Canada (Impaired Driving): Response to Issue Paper of the Standing Committee on Justice and Human Rights. March 5, 1999 4 Mann et al
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CMA Letter to the Legislative Committee on Bill C-30: Clean Air Act

https://policybase.cma.ca/en/permalink/policy8714
Last Reviewed
2019-03-03
Date
2007-02-28
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2019-03-03
Date
2007-02-28
Topics
Population health/ health equity/ public health
Text
The Canadian Medical Association (CMA) is pleased to participate in the review of the Clean Air Act, Bill C- 30. The CMA, first founded in 1867, currently represents more than 64,000 physicians across the country. Our mission includes advocating for the highest standard of health and health care for all Canadians and we are committed to activities that will result in healthy public policy. The Environment: A Key Determinant of Health The physical environment is a key determinant of a population's health and the medical profession is concerned about environmental conditions that contribute to declining health in individuals and the population as a whole. Physicians have been part of an early warning system of scientists and other health professionals calling attention to the effects on human health of poor air quality because we see the impact in our practice and in our communities. There is strong evidence that air pollution is the most harmful environmental problem in Canada in terms of human health effects. We know from the smog health studies undertaken by the Ontario Medical Association (OMA), Health Canada and others, about the public health crisis created by polluted air in many parts of Canada. And it is a crisis. A study by the federal government estimated that 5,900 premature deaths occur annually in eight large Canadian cities. This is a conservative estimate as the study focused on the short-term impact of smog pollutants using time-series studies. This study was never extrapolated to the whole Canadian population, but we know that only approximately one third of the Canadian population, mainly residents of large, urban areas, were included in the analysis.1 The OMA Illness Costs of Air Pollution study estimated that there were 5,800 premature deaths due to air pollution in Ontario alone in 2005, and examined both short-term and long-term health impacts. The OMA projected that the annual figure will grow to 10,000 premature deaths by 2026 unless effective steps are taken to reduce smog.2 In addition to premature deaths, the OMA estimated that there were 16,000 hospital admissions and 60,000 emergency room visits in Ontario in 2005 because of respiratory and cardiovascular illnesses associated with air pollution exposure. During that same year, the OMA also estimated that there were 29 million minor illness days, defined as days where individuals either suffered from asthma symptoms or had to restrict their activities. Most of the people affected by these so-called minor illness days are children. In British Columbia, the Provincial Officer for Health published a conservative estimate in 2004 that air pollution in B.C. is causing between 140 and 400 premature deaths, 700 to 2,100 hospital stays, and between 900 and 2,750 emergency room visits each year.3 The direct and indirect costs of air pollution on the health of Canadians are estimated to be in the billions of dollars. According to the Ontario Medical Association, in 2005, air pollution costs in Ontario were estimated at: - $374 million in lost productivity and work time; - $507 million in direct health care costs; - $537 million in pain and suffering due to non-fatal illness; and - $6.4 billion in loss due to premature death.4 In Canada the environment is currently considered to be the most important issue facing society. In a recent poll by the Strategic Counsel for the Globe & Mail/CTV5 a majority of respondents ranked the impact of toxic chemicals, air and water pollution and global warming as life threatening. The environment, while a major concern today for the general public, has been of concern to physicians for some time. CMA, Health and the Environment In 1991 the CMA, released a policy paper Health, the Environment and Sustainable Development6 that clearly linked health and the environment. Building on the 1987 Brundtland Report (World Commission on Environment and Development, Our Common Future) that tied sustainable development to the environment and the economy, the CMA inserted health into this pair of interactions and stated that "continued environmental degradation will increase hazard to human health." The paper concluded with a number of recommendations for governments, the health sector, and physicians in support of environmentally sustainable development. The CMA has continued to give attention to environmental issues urging the government, prior to Canada's ratification of the Kyoto Protocol, to commit to choosing a climate change strategy that satisfies Canada's international commitments while maximizing the clean air co-benefits and smog-reduction potential of any greenhouse gas reduction initiatives. In 2002, the CMA also recommended that the federal Environment and Health Ministers commit their departments to improved health-based reporting by regularly updating the health effects information for pollutants of concern. Clean Air Act: A Physicians Perspective Doctors understand the concept that success from an intervention can be nuanced. In the case of disease, physicians know and accept that there are benefits of treatment even if a patient cannot be cured. Sometimes we just reduce their symptoms, or slow their rate of decline. But when treating the natural environment, so critical to human health, we suggest that you cannot accept a palliative solution. We must aim for cure. We must commit to measures of success in terms of real improvement in health. It is through this lens that the CMA urges that you view the Clean Air Act to ensure that it is health-relevant. The CMA would like to commend this government for acknowledging the impact of the physical environment on human health and we are encouraged that the Act recognizes the intimate connection between greenhouse gas reductions and improved air quality. Air pollution does not respect provincial borders therefore it is very important to establish national objectives and Canada wide standards that are strong and consistent across the country. To be health relevant national air quality objectives must result in air quality improvements. To this end, regardless of whether they are called objectives or standards, national air quality targets must protect the health of all Canadians and must be binding. Voluntary air quality guidelines guarantee no health benefit. The federal government must ensure that there is a regulatory framework in place to ensure that the standards are mandatory across the country. The annual reporting to Parliament on the attainment of the national air quality objectives and the effectiveness of measures to attain the objectives, as outlined in the Act, is very important. Transparency in reporting is essential to the integrity of any program, but is integral to the determination of health benefit. The International Panel on Climate Change's Fourth Assessment report released on February 2, 2007, concluded that global warming is unequivocal and that human activity is the main driver, asserting with near certainty - more than 90 percent confidence - that carbon dioxide and other heat-trapping greenhouse gases from human activities have been the main causes of warming since 1950. Its Third Assessment report: Climate Change 2001: Working Group II: Impacts, Adaptation and Vulnerability noted that global climate change will have a wide range of impacts on human health. "Overall, negative health impacts are expected to outweigh positive health impacts. Some health impacts would result from changes in the frequencies and intensities of extremes of heat and cold and of floods and droughts. Other health impacts would result from the impacts of climate change on ecological and social systems and would include changes in infectious disease occurrence, local food production and nutritional adequacy, and concentrations of local air pollutants and aeroallergens, as well as various health consequences of population displacement and economic disruption."7 Given the indisputable impact of greenhouse gas increases on climate change and its connection to human health, it is critical to ensure that Canada is moving quickly to reduce greenhouse gas emissions. The Clean Air Act and the subsequent notice of intent sets out short, medium and long term targets and timelines for the reduction of greenhouse gas emissions in Canada. The target setting approach proposed in the Act, based on emission intensity in the short and medium term is not health relevant. To be health relevant, targets should be presented in the context of overall emissions, i.e., emissions reductions minus emissions increases. An emission reduction from a particular source is only health-relevant if we can guarantee that there is not a corresponding emissions increase at another source nearby, because it is the absolute exposure that an individual experiences that affects the risk of an adverse health effect. Just as slowing the progression of a disease can never be considered a cure, attempting only to limit the growth of those emissions cannot result in true success by any measure. It is not until 2050 that the government has committed to achieving an absolute reduction in greenhouse gas emissions of between 45 - 65% of 2003 levels. Based on the emission intensity targets in the Clean Air Act, emissions and air pollution levels will, in fact, continue to rise as will the health consequences. In order to protect the health of Canadians the government needs to set policies, with targets and timelines that maximize absolute reductions in greenhouse gases, which are consistent with the scale and urgency of the challenge. To ensure that prescribed policies result in the intended environment and health outcomes, short and medium-term targets for absolute emission reductions would benchmark progress and allow for mid-course corrections, if they were needed. With respect to indoor air quality, physicians have long been proponents of initiatives to reduce exposure to contaminants such as second-hand tobacco smoke. The CMA is concerned about the impact on human health of exposure to high levels of radon and the associated increased risk of lung cancer. The intention to develop measures to address indoor air quality through a national radon strategy is a positive step. It is important that our patients are made aware of such threats in their homes, and also that they are presented with a way to reduce their exposure. Environmentally related illness is essentially the combined result of exposure and vulnerability. We are vulnerable because we are human beings; each human being has different physical strengths and weaknesses. Some vulnerabilities to environmental influences are genetic, and some the results of pre-existing disease. There is not much that government can do about this part of the equation. Our exposure, on the other hand is related to the air we breathe, water we drink and food we eat. This is where the federal government is critical, and where the measures of success will be the most important. Proxy measures for the health outcomes that matter must be relevant from a health perspective. Health-based success can only be measured by quantifiable reductions in the exposure levels of contaminants in our air as well as in our water and soil. Clean air is absolutely fundamental to a healthy population - without it all else is irrelevant. Actions to curb air pollution must be taken in all sectors and levels of society in a concerted, non-partisan effort with the health of the population and the planet as our yardstick of success. Thank you for the opportunity to provide our comments on Bill C-30, the Clean Air Act. We look forward to working with you to improve the Clean Air Act and ensure that the measure of its success will benefit the health of Canadians. Sincerely Colin J. McMillan, MD, CM, FRCPC, FACP President 1 S. Judek, B. Jessiman, D. Stieb, and R. Vet. 2005. Estimated Number of Excess Deaths in Canada Due to Air Pollution". Health Canada and Environment Canada. http://www.hc-sc.gc.ca/ahc-asc/media/ nr-cp/2005/2005_32bk2_e.html#top 2 Ontario Medical Association. 2005. The Illness Costs of Air Pollution: 2005-2026 Health and Economic Damage Estimates. Toronto: OMA. 3 B.C. Provincial Health Officer. 2004. Every Breath You Take: Air Quality in British Columbia, A Public Health Perspective. 2003 Annual Report. Victoria: Ministry of Health Services. 4 Ontario Medical Association , 2005 5 GLOBE/CTV POLL Climate concerns now top security and health One in four label environmental issues as most important, The Globe and Mail, Fri 26 Jan 2007, Page: A1, Section: National News , Byline: Brian Laghi 6 Health, the Environment and Sustainable Development, Canadian Medical Association , 1991 7 WMO Intergovernmental Panel on Climate Change, Climate Change 2001, IPPC Third Assessment Report: Working Group II: Impacts, Adaptation and Vulnerability, accessed Feb 7, 2007 http://www.grida.no/climate/ipcc_tar/wg2/348.htm
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Restoring access to quality health care : Brief Submitted to the House of Commons Standing Committee on Finance 1998 pre-budget consultations

https://policybase.cma.ca/en/permalink/policy1985
Last Reviewed
2019-03-03
Date
1997-11-07
Topics
Health human resources
Health systems, system funding and performance
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2019-03-03
Date
1997-11-07
Topics
Health human resources
Health systems, system funding and performance
Population health/ health equity/ public health
Text
I. INTRODUCTION The Canadian Medical Association (CMA) commends the federal government, in its second mandate, for continuing the pre-budget consultation process. This open process encourages public dialogue in the finance and economics of the country and the CMA appreciates the opportunity to submit its views to the House of Commons Standing Committee on Finance. Many issues were raised by the CMA and other health organizations, with members of the Standing Committee, at the "health roundtable" held on October 28, 1997. This brief provides greater detail of those concerns that were discussed by the members of the CMA delegation. II. BACKGROUND "Good health is fundamental to the quality of life of every Canadian. In this century, we have learned a great deal about the effective treatment of illness and disease, which requires early access to appropriate and high-quality health care services." 1 Over the past year, Canadians, their physicians and the provincial/territorial governments have all been voicing their concerns about the state of the health care system across the country. In every instance it is a united voice that shares concerns about access to quality health care services as well as the sustainability of the health care system. A consistent theme is "will the health care system be there for me or my family when needed"? Canadians perceive that access to services has further deteriorated over the past year. CMA surveys undertaken by the Angus Reid Group between the spring of 1996 and 1997 clearly demonstrate that Canadians perceive a deterioration in many critical areas of the health care system. If one looks at indicators such as waiting times over the past two years it is quite clear that Canadians have felt the cutbacks in the health care sector: * in 1997 65% reported that waiting times in emergency departments had worsened, up from 54% in 1996, * 63% reported that waiting times for surgery had worsened, up from 53% in 1996, * 50% reported that waiting times for tests had worsened, up from 43% in 1996, * 49% reported that access to specialists had worsened, up from 40% in 1996, * 64% reported that availability of nurses in hospital had worsened, up from 58% in 1996. Physicians not only provide direct care to their patients but are also concerned about their patients' access to quality health care. In Ontario, more than 16,000 were reported to be waiting for placement in long-term care institutions 2. In Newfoundland patients requiring heart surgery have had to be sent to other provinces to alleviate growing waiting lists 3 . The Conference of Provincial/Territorial Ministers of Health has expressed concerns about the ability of provinces and territories to maintain current services. The Ministers state that "Federal reductions in transfer payments have created a critical revenue shortfall for the provinces and territories which has accelerated the need for system adjustments and has seriously challenged the ability of provinces and territories to maintain current services. Federal funding reductions are forcing the acceleration of change beyond the system's ability to absorb and sustain adjustments". 4 The concerns of the Provincial/Territorial Ministers of Health about the ability of the system to absorb and sustain adjustments are well founded as demonstrated by the anxieties expressed by the public and by physicians. The CMA has clearly stated and continues to state that "health cuts hurt everyone". III. FEDERAL HEALTH CARE FUNDING AND THE CANADA HEALTH AND SOCIAL TRANSFER (CHST) (i). Getting the facts straight Prior to April 1, 1996 the federal government's commitment to insured health services, post-secondary education and social assistance programs could be readily determined since the federal government made separate payments 5 to the provinces/territories in each of these areas. However, with the introduction of the Canada Health and Social Transfer (CHST), on April 1, 1996, the federal government combined all of its payments into one transfer payment to the provinces and territories. The net result is that there are no separately identifiable contributions to health, post-secondary education or social assistance programs. The federal government's accountability and commitment to health care have been blurred. However, prior to the CHST, the federal government's diminishing commitment to health care could at least be documented. Under the Established Programs Financing (EPF) arrangements the federal government has unilaterally revised the EPF funding formula eight times over the past decade. During the period 1986/87 to 1995/96, it was estimated that $30 billion in cash transfers has been withheld from health care (and an additional $12.1 billion for post-secondary education - for a total of $42.1 billion) 6. Federal "offloading" has forced all provinces/territories to make do with significantly less resources for their health care systems. [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Table 1: Canada Health and Social Transfer (in $ billions) Year Total Entitlement (1) Tax Point Transfer (2) Cash Entitlement (3) Quebec Abatement (4) Cash Payments (5) Cumulative Reductions from 95/96 (6) 1997 Budget Health Items (7) 1995-96 29.7 11.2 18.5 1.9 16.6 0.0 1996-97 26.9 11.9 15.0 2.0 13.0 (3.6) 1997-98 25.1 12.6 12.5 2.1 10.4 (9.8) 0.1 1998-99 25.8 13.3 12.5 2.2 10.3 (16.1) 0.1 1999-00 26.5 14 12.5 2.3 10.2 (22.5) 0.1 2000-01 27.1 14.6 12.5 2.4 10.1 (29.0) 2001-02 27.8 15.3 12.5 2.5 10.0 (35.6) 2002-03 28.6 16.1 12.5 2.6 9.9 (42.3) [TABLE END] The September 1997 Throne Speech stated that the government "... will introduce legislation to increase to $12.5 billion a year the guaranteed annual cash payment to provinces and territories under the Canada Health and Social Transfer" 7. Table 1 illustrates what the $12.5 billion cash entitlement will mean in terms of actual cash payments in 2002-03. The important point to remember is that this so called "increase" in the cash entitlement (3) is merely a stop in cuts . For 1998-99 the previous cash entitlement would have dropped to $11.8 billion with a further drop in 1999-00 to $11.1 billion, whereas cash entitlements are now stabilized at $12.5 billion. However, cash payments will continue to drop into the foreseeable future. Cash payments (5) exclude the Quebec abatement which is comprised of tax points not cash payments. For Canadians the CHST has meant, and continues to mean, less federal government commitment to our health care system and has compromised the federal government's ability to preserve and enhance national standards. (ii). Implications for the future of health care in Canada The reduction in federal government funding has not only compromised the federal government's ability to preserve and enhance national standards but this continued policy of "under-funding" has compromised access to quality health care for Canadians. As previously mentioned, declining public sector resources allocated to health care has manifested itself in the form of longer waiting times in emergency departments, for surgery, for diagnostic tests and in decreased access to specialists and decreased availability of nurses in hospitals. In the federal government's 1997/98 budget released this past February much fanfare was made about sustaining and improving Canada's health care system. The government announced three health care initiatives 8 totalling $300 million in expenditures over 3 years, or $100 million per year. If, on the other hand, one looks at the accumulated reduction in CHST cash payments to the provinces/territories during the same 3 years when the federal government will spend this $300 million it can be seen that the accumulated reductions total $18.9 9 billion. Therefore, during the same 3-year period the "investment" in health care by the federal government represents 1.5% of the reductions to cash payments to the provinces and territories during the same period. For the longer term, the federal government can demonstrate its commitment to health care by linking growth in CHST cash payments to factors other than the economy. The factors that are becoming increasingly important are those such as technological change, population growth and aging. Such linkage of cash payments would be less subject to fluctuations in the economy and would be an acknowledgement of the impact of technological and population structure changes on the need for health care services. From Table 2, which shows 1994 per capita provincial government health expenditures by age group, it can be concluded that as the population of Canada ages the cost structure of health care increases reflecting the fact that as we age we make greater use of the health care system to maintain our health. The age group 65 and over continues to grow, in 1994 11.9% of the population was over the age of 65, in 2016 this is projected to increase to 16% and by 2041 to 23%. 10 [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Table 2: Per Capita Provincial Government Expenditures by Age Group, Canada 1994 11 Age Group $ per Capita Increase 0-14 514 15-44 914 77.8% 45-64 1446 58.2% 65+ 6,818 371.5% Total 1,642 [TABLE END] In other areas of health care the CMA commends the federal government for their recent commitments to applied health services research. On an international basis however, Canada does not fare very well. In fact, on a per capita basis Canada came in last out of the five G-7 countries for which recent data were available. Figure 1 shows the per capita health R&D expenditures for G7 countries for which 1994 data are available. Canada's per capita spending was $22 (U.S.), compared with $35 for Japan, $59 for the U.S., $63 for France and $78 for the U.K. 12 While applied health services research is important, it must be recognized that research is a continuum beginning with basic biomedical research, moving to clinical research and ending with applied health services research. The CMA is concerned with the governments plans to cut the annual budget of the Medical Research Council (MRC) from $238 million in 1997-98 to $219 million in 2000-01. In Prime Minister Jean Chrétien's reply to the Speech from the Throne on September 24, 1997 he states that there is " . . . no better role for government than to help young Canadians prepare for the knowledge-based society of the next century." He then makes a commitment to establish, ". . . at arms-length from government, a Canada Millennium Scholarship Endowment Fund." which is to reward academic excellence. The Government of Canada should also be reminded that a knowledge-based society and scholarship also requires a commitment to research funds. Therefore the CMA calls on the Federal Government to establish national targets for spending and an implementation plan for health care research. Such an approach would buttress the other initiatives as announced by the Prime Minister. To restore access to quality health care for all Canadians, the CMA respectfully recommends: 1. At a minimum, that the federal government restore CHST cash entitlements to 1996/97 levels. 2. That, beginning April 1, 1998, the federal government fully index CHST cash payments through the use of a combination of factors that would take into account: technology, economic growth, population growth and demographics. 3. That the federal government establish a national target (either in per capita terms or as a proportion of total health spending) and an implementation plan for health research and development spending including the full spectrum of basic biomedical to applied health services research, with the objective of improving Canada's position relative to other G-7 countries where we now rank last among the five G-7 countries for which recent data are available. IV. HEALTHY PUBLIC POLICY The federal role in funding health care is clearly important to physicians and to their patients given its influence on access to quality health care services. However, there are other important issues that the CMA would like to bring to the attention of the Standing Committee on Finance. (i). Tobacco Taxation Smoking is the leading preventable cause of premature mortality in Canada. The most recent estimates suggest that more than 45,000 deaths annually in Canadaaredirectlyattributable to tobacco use., The estimated economic cost to society from tobacco use in Canada has been estimated from $11 billion to $15 billion. Tobacco use directly costs the Canadian health care system $3 billion to $3.5 billion annually. These estimates do not consider intangible costs such as pain and suffering. CMA is concerned that the 1994 reduction in the federal cigarette tax has had a significant effect in slowing the decline in cigarette smoking in the Canadian population, particularly in the youngest age groups - where the number of young smokers (15-19) is in the 22% to 30% range and 14% for those age 10-14. A 1997 Canada Health Monitor Survey found that smoking among girls 15-19 is at 42%. A Quebec study found that smoking rates for high school students went from 19% to 38%, between 1991 and 1996. The CMA understands that tobacco tax strategies are extremely complex. Strategies need to consider the effects of tax increases on reduced consumption of tobacco products with increases in interprovincial/territorial and international smuggling. In order to tackle this issue, the government could consider a selective tax strategy. This strategy requires continuous stepwise increases to tobacco taxes in those selective areas with lower tobacco tax (i.e., Ontario, Quebec and Atlantic Canada). The goal of selective increases in tobacco tax is to increase the price to the tobacco consumer over time (65-70% of tobacco products are sold in Ontario and Quebec). The selective stepwise tax increases will approach but may not achieve parity amongst all provinces however, the tobacco tax will attain a level such that inter-provincial/territorial smuggling would be unprofitable. The selective stepwise increases would need to be monitored so that the new tax level and US/Canadian exchange rates does not make international smuggling profitable. The objectives of this strategy are: * reduce tobacco consumption; * minimize interprovincial/territorial smuggling of tobacco products; and * minimize international smuggling of tobacco products. The selective stepwise increase in tobacco taxes can be combined with other tax strategies. The federal government should apply the export tax and remove the exemption available on shipments in accordance with each manufacturers historic levels. The objective of implementing the export tax would be to make cross-border smuggling unprofitable. The ultimate goals for implementing this strategy are: * reduce international smuggling of tobacco products; * reduce and/or minimize Canadian consumption of internationally smuggled tobacco products. The federal government should establish a dialogue with the US federal government. Canada and the US should hold discussions regarding harmonizing US tobacco taxes to Canadian levels at the factory gate. Alternatively, US tobacco taxes could be raised to a level that when offset with the US/Canada exchange rate differential renders international smuggling unprofitable. The objective of implementing the harmonizing US/Canadian tobacco tax levels (at or near the Canadian levels) would be to increase the price of internationally smuggled tobacco products to the Canadian and American consumers. The ultimate goals for implementing this strategy are: * reduce risk of international smuggling of tobacco products from both the Canadian and American perspective; * reduce and/or minimize Canadian/American consumption of internationally smuggled tobacco products. 4. The Canadian Medical Association is recommending that the federal government follow a comprehensive integrated tobacco tax policy: (a) That the federal government implement selective stepwise tobacco tax increases to achieve the following objectives: * reduce tobacco consumption, * minimize interprovincial/territorial smuggling of tobacco products, * minimize international smuggling of tobacco products; (b) That the federal government apply the export tax on tobacco products and remove the exemption available on tobacco shipments in accordance with each manufacturers historic levels; (c) That the federal government enter into discussions with the US federal government to explore options regarding tobacco tax policy, bringing US tobacco tax levels in line with or near Canadian levels, in order to minimize international smuggling. The Excise Act Review, A Proposal for a Revised Framework for the Taxation of Alcohol and Tobacco Products (1996), proposes that tobacco excise duties and taxes (Excise Act and Excise Tax Act) for domestically produced tobacco products be combined into a new excise duty and come under the jurisdiction of the Excise Act. The new excise duty is levied at the point of packaging where the products are produced. The Excise Act Review also proposes that the tobacco customs duty equivalent and the excise tax (Customs Tariff and Excise Tax Act) for imported tobacco products be combined into the new excise duty [equivalent tax to domestically produced tobacco products] and come under the jurisdiction of the Excise Act. The new excise duty will be levied at the time of importation. The CMA supports the proposal of the Excise Act Review. It is consistent with previous CMA recommendations calling for tobacco taxes at the point of production. (ii). Tobacco Control Taxation should be used in conjunction with other strategies for promoting healthy public policy, such as, programs for tobacco prevention and cessation. The Liberal party, recognising the importance of this type of strategy , promised: "...to double the funding for the Tobacco Demand Reduction Strategy from $50 million to $100 million over five years, investing the additional funds in smoking prevention and cessation programs for young people, to be delivered by community organizations that promote the health and well-being of Canadian children and youth". The CMA applauds the federal government's efforts in the area of tobacco prevention and cessation. However, a time limited investment is not enough. More money is required for investment in this area. Program funding is required for more efforts and programs in tobacco prevention and cessation. A possible source for this type of program investment could come from tobacco tax revenues or the tobacco surtax. 5. In the short term, the Canadian Medical Association calls upon the federal government to fulfil the its promise to invest $100 million, over five years, into the Tobacco Demand Reduction Strategy. In the longer term, the Canadian Medical Association calls upon the federal government to establish stable program funding for its comprehensive tobacco control strategy, including smoking prevention and cessation. (iii). Non-taxable health benefits The federal government is to be commended for its decision to maintain the non-taxable status of supplementary health benefits. This decision is an example of the federal governments' commitment to maintain good tax policy that supports good health policy (the current incentive fosters risk pooling). Approximately 70% or 20 million Canadians rely on full or partial private supplementary health care benefits (e.g., dental, drugs, vision care, private duty nursing, etc.). As governments reduce the level of public funding, the private component of health expenditures is expanding. Canadians are becoming increasingly reliant on the services of private insurance. In the context of funding those health care services that remain public benefits, the government cannot strike yet another blow to individual Canadians and to Canadian business by taxing the very benefits for which taxes were raised. In terms of fairness, it would seem unfair to "penalize" 70% of Canadians by taxing supplementary health benefits to put them on an equal basis with the remaining 30%. It would be preferable to develop incentives to allow the remaining 30% of Canadians to achieve similar benefits attributable to the tax status of supplementary health benefits. If supplementary health benefits were to become taxable, it is likely that young healthy people would opt for cash compensation instead of paying taxes on benefits they do not receive. These Canadians would become uninsured for supplementary health services. It follows that employer-paid premiums may increase as a result of this exodus in order to offset the additional costs of maintaining benefit levels due to diminishing ability to achieve risk pooling. In addition, 6. That the current federal government policy with respect to non-taxable health benefits be maintained. V. FAIR AND EQUITABLE TAX POLICY CMA has demonstrated that good economic policy reinforces good health policy in past submissions to the Standing Committee on Finance. The CMA again reiterated the important role that fair tax policy plays in supporting healthy public policy. (i). The Goods and Services Tax (GST)& the Harmonized Sales Tax (HST) The CMA strongly believes in a tax system that is fair and equitable. This point has been made on several occasions to the Standing Committee on Finance. In particular, the point was stressed as part of the Standing Committee's consultation process leading to the report "Replacing the GST: Options for Canada". In the case of the GST, however, the reality is that physicians as self-employed Canadians are singled out and discriminated against by virtue of not being able to claim input tax credits (ITCs) since medical services are designated as "tax exempt". The CMA does not dispute the importance that the federal government has attached to medical services such that Canadians are not subject to GST/HST for having availed themselves of such medical services from their physician. However, the GST/HST are consumption taxes and as such are paid for by the end consumer. If, however, government determines that such a consumption tax should not be applied to the consumers (in this case physicians' patients) of a particular good or service it behooves government not to implement half measures that bring into question the equity and fairness of the Canadian tax system. While other self-employed professionals and small business claim ITCs, an independent (KPMG) study has estimated that physicians have "over contributed" in terms of unclaimed ITCs to the extend of $57.2 million per year. Since the inception of the GST and by the end of this calendar year, physicians will have been unfairly taxed in excess of $400 million. All this for providing a necessary service that has been deemed so important by government. Physicians are not asking for special treatment. What they are asking for, however, is to be treated in a fair and equitable manner like other self-employed Canadians and small businesses. Unlike other businesses and professionals, physicians cannot recoup the GST/HST by claiming ITCs or passing the GST/HST onto customers/patients. The federal government has acknowledged the inequitable impact of the GST/HST on other providers in the health care sector. Municipalities, universities, schools and hospitals have been given special consideration because they, like physicians, are not able to pass the GST/HST on to their clients. Hospitals have been afforded an 83% rebate for purchases made in providing patient care while physicians must absorb the full GST/HST costs on purchases also made in providing patient care. At a time when health policy measures are attempting to expand community-based practices, the current tax policy (and now harmonized tax policy) which taxes supplies in a clinical practice setting but not in a hospital setting acts to discourage this shift in emphasis. To complicate matters further, the recent agreement between the federal government and some Atlantic provinces to harmonize their sales taxes will make matters worse for physicians. With no ability to claim ITCs, physicians will, once again, have to absorb the additional costs associated with the practice of medicine. It has been estimated that harmonization will cost physicians in Atlantic Canada an additional $4.7 million each year (over and above the current GST inequity). In the current fiscal environment, this unresolved issue does not help matters when it comes to physician recruitment and retention across the country. Furthermore, for established physicians who have had to live with the current policy, the GST/HST serves as a constant reminder that the basic and fundamental principles of equity and fairness in the tax system is not being extended to the physicians of Canada. To date, the CMA has made representations to the Minister of Finance and Finance Department Officials but yet to no avail. We look to this Committee and to the federal government to not only ensure that the tax system is perceived to be fair and equitable but that it is in fact fair and equitable to all members of society. The unfairness of the GST/HST, as applied to medical services, has raised the ire of physicians and has made them question their sense of fair play in Canada's tax system. In the interests of fairness and equity, the CMA respectfully recommends the following: 7. The CMA recommends that health care services funded by the provinces and territories be zero-rated. The above recommendation could be accomplished by amending the Excise Tax Act as follows: (1). Section 5 part II of Schedule V to the Excise Tax Act is replaced by the following: 5. "A supply (other than a zero-rated supply) made by a medical practitioner of a consultative, diagnostic, treatment or other health care service rendered to an individual (other than a surgical or dental service that is performed for cosmetic purposes and not for medical or reconstructive purposes)." (2). Section 9 Part II of Schedule V to the Excise Tax Act is repealed. (3). Part II of Schedule VI to the Excise Tax Act is amended by adding the following after section 40: 41. A supply of any property or service but only if, and to the extent that, the consideration for the supply is payable or reimbursed by the government under a plan established under an Act of the legislature of the province to provide for health care services for all insured persons of the province. Our recommendation fulfils at least two over-arching policy objectives: 1) strengthening the relationship between good economic policy and good health policy in Canada; and 2) applying the fundamental principles that underpin our taxation system (fairness, efficiency, effectiveness), in all cases. (ii). Registered Retirement Savings Plan (RRSP) Experts have stated that there are (at least) two fundamental goals of retirement savings: (1) to guarantee a basic level of retirement income for all Canadians; and, (2) to assist Canadians in avoiding serious disruption of their pre-retirement living standards upon retirement. Looking at the demographic picture in Canada, we can see that an increasing portion of society is not only aging, but is living longer. Assuming that current demographic trends will continue and peak in the first quarter of the next century, it is important to recognize the role that private RRSPs savings will play in ensuring that Canadians may continue to live dignified lives well past their retirement from the labour force. This becomes even more critical when one considers that Canadians are not setting aside sufficient resources for their retirement. Specifically, according to Statistics Canada, it is estimated that 53% of men and 82% of women starting their career at age 25 will require financial aid at retirement age - only 8% of men and 2% women will be financially secure. The 1996 federal government policy changes with respect to RRSP contribution limits run counter to the White Paper released in 1983 (The Tax Treatment of Retirement Savings), where the House of Commons Special Committee on Pension Reform recommended that the limits on contributions to tax-assisted retirement savings plans be amended so that the same comprehensive limit would apply regardless of the retirement savings vehicle or combination of vehicles used. In short, the Liberal government endorsed the principle of "pension parity". According to three more recent papers released by the federal government, the principle of pension parity would have been achieved between money-purchase (MP) plans and defined benefit (DB) plans had RRSP contribution limits risen to $15,500 in 1988. The federal government postponed the scheduling of the $15,500 limit for seven years, that is achieving the goal pension parity was delayed until 1995. In its 1996 Budget Statement, the federal government altered its course of action and froze the dollar limit of RRSPs at $13,500 through to 2003/04, with increases to $14,500 and $15,500 in 2004/05 and 2005/06, respectively. As well, the maximum pension limit for defined benefit registered pension plans will be frozen at its current level of $1,722 per year of service through 2004/05. This is a de facto increase in tax payable. The CMA is frustrated that ten years of careful and deliberate government planning around pension reform has not come to fruition, in fact if the current policy remains in place will have taken more than 17 years to implement (from 1988 to 2005). As a consequence, the current policy of freezing RRSP contribution limits and RPP limits without making adjustments to RRSP limits to achieve pension parity serves to maintain inequities between the two plans until 2005/2006. This is patently unfair for self-employed Canadians who rely on RRSPs as their sole vehicle for retirement planning. CMA respectfully recommends to the Standing Committee: 8. That the dollar limit of RRSPs at $13,500 increase to $14,500 and $15,500 in 1998/1999 and 1999/2000, respectively. Subsequently, dollar limits increase at the growth in the yearly maximum pensionable earnings (YMPE). VI. SUMMARY OF RECOMMENDATIONS With the future access to quality health care for all Canadians at stake, the CMA strongly believes that the federal government must demonstrate that it is prepared to take a leadership role and re-invest in the health care of Canadians. The CMA therefore makes the following recommendations to the Standing Committee in its deliberations: Canada Health and Social Transfer (CHST) 1. At a minimum, that the federal government restore CHST cash entitlements to 1996/97 levels. 2. That, beginning April 1, 1998, the federal government fully index CHST cash payments through the use of a combination of factors that would take into account: technology, economic growth, population growth and demographics. 3. That the federal government establish a national target (either in per capita terms or as a proportion of total health spending) and an implementation plan for health research and development spending including the full spectrum of basic biomedical to applied health services research, with the objective of improving Canada's position relative to other G-7 countries where we now rank last among the five G-7 countries for which recent data are available. Tobacco Taxation 4. The Canadian Medical Association is recommending that the federal government follow a comprehensive integrated tobacco tax policy: (a) That the federal government implement selective stepwise tobacco tax increases to achieve the following objectives: < reduce tobacco consumption, < minimize interprovincial/territorial smuggling of tobacco products, < minimize international smuggling of tobacco products; (b) That the federal government apply the export tax on tobacco products and remove the exemption available on tobacco shipments in accordance with each manufacturers historic levels; (c) That the federal government enter into discussions with the US federal government to explore options regarding tobacco tax policy, bringing US tobacco tax levels in line with or near Canadian levels, in order to minimize international smuggling. Tobacco Control 5. In the short term, the Canadian Medical Association calls upon the federal government to fulfil the its promise to invest $100 million, over five years, into the Tobacco Demand Reduction Strategy. In the longer term, the Canadian Medical Association calls upon the federal government to establish stable program funding for its comprehensive tobacco control strategy, including tobacco prevention and cessation. Non-Taxable Health Benefits 6. That the current federal government policy with respect to non-taxable health benefits be maintained. The Goods and Services Tax (GST)& the Harmonized Sales Tax (HST) 7. The CMA recommends that health care services funded by the provinces and territories be zero-rated. Registered Retirement Savings Plan (RRSP) 8. That the dollar limit of RRSPs at $13,500 increase to $14,500 and $15,500 in 1998/1999 and 1999/2000, respectively. Subsequently, dollar limits increase at the growth in the yearly maximum pensionable earnings (YMPE). 13 1 Liberal Party, Securing Our Future Together. The Liberal Party of Canada, , Ottawa, 1997. p. 71. 2 Lipovenko, D,1997: Seniors face shortage of care. Globe & Mail [Toronto]; Feb 26 Sect A:5 3 Joan Marie Aylward, Minister of Health, Newfoundland and Labrador, public statement, May 14, 1997 4 Conference of Provincial/Territorial Ministers of Health, A Renewed Vision for Canada's Health System. January 1997. p. 7. 5 Thomson, A., Diminishing Expectations - Implications of the CHST, [report] Canadian Medical Association, Ottawa. May, 1996. 6 Thomson A: Federal Support for Health Care: A Background Paper. Health Action Lobby, June 1991. 7 Speech from the Throne to Open the First Session Thirty-Sixth Parliament of Canada. Ottawa; 1997 Sept 23. 8 Health Transition Fund: $150 million over 3 years - to help provinces to test ways to improve their health system, for example, new approaches to home care, drug coverage, and other innovations. Canada Health Information System: $50 million over 3 years - to create a network for health care providers and planners for sharing information. Community Action Program for Children: $100 million over 3 years - for support of community groups for parent education for children at risk and for Canada Prenatal Nutrition Program to ensure the birth of healthy babies. 9 See Table 1: Cumulative reductions to 1999/00 of $22.5 billion subtracting $3.6 billion for 1996/97 gives a cumulative reduction during 1997/98 to 1999/00 of $18.9 billion. 10 Statistics Canada, Population Projections for Canada, Provinces and Territories 1993-2016. Ottawa: Statistics Canada; 1994. p. 73. Cat no 91-520 [occasional]. 11 Health Canada, National Health Expenditures in Canada, 1975-1994 [Full Report]. Ottawa: Health Canada; January 1996. p. 41. 12 Organization for Economic Cooperation and Development. OECD Health Data 97. Paris: OECD; 1997. 13 Cunningham R, Smoke and Mirrors: The Canadian War on Tobacco, International Development Research Centre, Ottawa, Canada, 1996. p. 8. "Restoring Access to Quality Health Care" 1998 Pre-Budget Consultations Page " 1998 Pre-Budget Consultations Page
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