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Bill C-45: The Cannabis Act

https://policybase.cma.ca/en/permalink/policy13861
Date
2018-04-18
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Parliamentary submission
Date
2018-04-18
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
The CMA is pleased to provide this submission to the Senate Standing Committee, Social Affairs, Science &Technology 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. The CMA's approach to cannabis is grounded in broad public health policy. It includes promotion of health and prevention of drug dependence and addiction; access to assessment, counselling and treatment services; and a harm reduction perspective. The CMA believes that harm reduction encompasses policies, goals, strategies and programs directed at decreasing adverse health, social and economic consequences of drug use for the individual, the community and the society while allowing the user to continue to use drugs, not precluding abstinence.3,4 Specifically, the CMA recommends a multi-faceted cannabis public health strategy that prioritizes impactful and realistic goals before, and certainly no later than, any legalization of cannabis.5 We propose that the first goal should be to develop educational interventions for children, teenagers and young adults. Other goals relate to data collection; monitoring and surveillance; ensuring a proportionate balance between enforcement harms and the direct and indirect harms caused by cannabis use; and research. There is an ongoing need for research into the medicinal and harmful effects of cannabis use. As noted by the Lower-Risk Cannabis Use Guidelines, 6 there is limited evidence on such subjects as synthetic cannabinoids; practices like "deep inhalation" to increase the psychoactive effects of cannabis; and the combination of risky behaviours, like early-onset and frequent use, associated with experiencing acute or chronic health problems.6 Since 2002, the CMA has taken a public health perspective regarding cannabis and other illegal drugs. More recently, the CMA endorsed the Lower-Risk Cannabis Use Guidelines, and we submitted 22 recommendations to the Task Force on Cannabis Legalization and Regulation ("the Task Force").7 Overview According to the recent Canadian Tobacco, Alcohol and Drugs Survey, cannabis is the most used illicit drug in Canada.8 In particular, 25%-30% of adolescents or youth report past-year cannabis use.9 This concerns the CMA. The increasing rate of high usage, despite the fact that non-medical use of cannabis is illegal, coupled with cannabis' increased potency (from 2% in 1980 to 20% in 2015 in the United States),10 the complexity and versatility of the cannabis plant,ii the variable quality of the end product, and variations in the frequency, age of initiation 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 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. 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 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 The CMA, therefore, submits that if a two-system approach is implemented when the legislation is enacted, the legislation should be amended to include the requirement for evaluation within five years of enactment. Criteria for evaluation may include the number of users in the medical system and the number of physicians authorizing medical cannabis use. The CMA would expect to be involved in the determination of such criteria and evaluation process. Conclusion Support has risen steadily in Canada and internationally for the removal of criminal sanctions for simple cannabis possession, as well as for the legalization and regulation of cannabis' production, distribution and sale. The CMA has long-standing concerns about the health risks associated with consuming cannabis, especially by children and youth in its smoked form. Weighing societal trends against the health effects of cannabis, the CMA supports a broad legal-regulatory framework as part of a comprehensive and properly sequenced public health approach of harm reduction. Recommendations 1. The CMA recommends that the legalization age be amended to 21 years of age, to better protect the most vulnerable population, youth, from the developmental neurological harms associated with cannabis use. 2. The CMA recommends that a comprehensive cannabis public health strategy with a strong, effective health education component be implemented before, and no later than, the enactment of any legislation legalizing cannabis. 3a. The CMA recommends that there be only one regime for medical and non-medical use of cannabis, with provisions for the medical needs of those who would not be able to acquire cannabis in a legal manner (e.g., those below the minimum age). 3b. Alternatively, the CMA recommends that the legislation be amended to include a clause to review the legislation, including a review of having two regimes, within five years. 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 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). 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). vi The Federal Tobacco Control Strategy was initiated in 2001 for 10 years and renewed in 2012 for another five years. 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). 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. 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.
Documents
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Brief to the House of Commons Standing Committee on Finance 1995 Pre-Budget Consultation

https://policybase.cma.ca/en/permalink/policy1994
Last Reviewed
2019-03-03
Date
1994-11-18
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2019-03-03
Date
1994-11-18
Topics
Health systems, system funding and performance
Text
I. PURPOSE While Canada is undergoing significant social, political and economic change, the Canadian Medical Association (CMA) remains committed to the delivery of high quality health care and to safeguarding the national integrity of the health system. However, given the need for the federal government to gain control over our deficit and national debt, it seems clear that putting Canada's fiscal house in order remains a high priority. In this regard, CMA appreciates the invitation to submit its views on the 1995 pre-budget consultations that are underway. One overriding objective of the brief is to provide the Committee with a better understanding of the current pressures on physicians across Canada that have arisen as a direct result of past government decisions in this area. It is our firmly-held position that the health care system in general, and the medical profession in particular, have paid more than their fair share in terms of contributing to debt management. This brief focusses on five somewhat distinct areas of concern to Canadian physicians: (1) federal health transfers to the provinces; (2) taxable health benefits; (3) the goods and services tax (GST); (4) Registered Retirement Savings Plan (RRSP) contributions, and (5) the Lifetime Capital Gains Exemption (LCGE) for Small Businesses. In each case, the brief contains specific recommendations as to what the government should do, and more importantly what the government should not do, to balance its short-term deficit reduction targets against longer-term Canadian values. To summarize, good health policy and prudent economic policy go hand-in-hand provided the principles of fairness and good management practices are observed. If change is to come within an overall policy framework that is strategic, coordinated and fair and which preserves (or augments) the integrity of Canada's health care system, it behooves us to avoid short-term, stop-gap initiatives. As the government's 1994 Throne Speech put it "...the agenda of the government is based on an integrated approach to economic, social, environmental and foreign policy". Accordingly, in establishing an appropriate fiscal framework for health, change must take place within the context of a longer-term integrated view. II. BACKGROUND...."Medicare Is A Shared Value" Canada's system of universal health insurance is still one of the best in the world. Experts from around the world travel many thousands of miles to study and, in some cases, emulate our system. For most Canadians, medicare is a highly cherished, integral component of our social fabric. While Medicare's popularity has not diminished over the past 30 years, it is sometimes taken for granted in these difficult economic times. Recent public opinion surveys indicate that 84% of Canadians (with the highest response in Quebec) see medicare as a defining characteristic of being Canadian. Furthermore, 84% of Canadians are of the opinion that the system provides high quality care. 1 At the same time, however, 65% of Canadians are concerned about continued accessibility to a full range of publicly-financed benefits. According to the same poll, 83% of Canadians see current financing of the system as being "unsustainable" over the longer-term 2 and they are right. As much loved as the Canadian medicare system is, there is a large and growing consensus that we need to make changes. This brief is not about maintaining the status quo. Rather, it is about managing the changes required in the long-term best interests of all Canadians and of the physicians who are ultimately responsible for serving those interests, subject to the fiscal realities confronting government. III. CONSIDERATIONS CMA acknowledges that there is a pressing need, now more than ever, for the federal government to balance a number of competing social and economic policy challenges. In a time when deficit reduction measures are required, all segments of society are being asked to do more with the same or less. Health care is no exception, having done so for quite some time. At the same time, we must re-evaluate the variety of services provided or paid for by government. Deficit Management, but at what Costs? As of 1993/94, Canada's net public debt stood at $508.2 billion, or $17,484 for every Canadian. Combined with the debts of the provinces and territories, our national debt is in excess of $700 billion. Not to understate the case, currently one-third of each revenue dollar the government collects is allocated to debt service payments on the federal debt. 3 CMA believes enough is enough: we must not pass this burden on to future generations of Canadians. The federal government has managed to run operating surpluses for five of the past seven years. 4 While this is necessary it is no longer sufficient to meet our fiscal challenges. Maintaining the status quo would mean that debt service payments would further crowd out government expenditures at an accelerated rate. While the government's first priority should be to get us "out of hock", there is an equally- compelling need to respect the longstanding and fundamental principle of fairness/equity that help define Canadian society. One step toward meeting these twin objectives is to consider all possible methods of repatriating that portion of the national debt held by the international lending community. Some experts have argued that Canada, as a country, can no longer afford to have "massive leakages" in interest payments to individuals/countries abroad. 5 In so doing, we would also repatriate our ability as a sovereign nation to set and maintain social policy objectives. This involves guarding against the persistent "tyranny of the deficit" and the influence that international bond rating agencies can exert on the economy. Facts and Fallacies about Health Spending In reviewing expenditures in the public sector, some would suggest that health and health care spending are "out of control". This is a myth. While it is true that Canada spends 10.0% (1993) of Gross Domestic Product (GDP) on health care (second highest among OECD countries), the reality is that the public sector share of total health care expenditures has fallen from 76.4% in 1975 to approximately 71.9% in 1993 6 (falling to the lowest third of OECD countries). This process of reducing real public sector expenditures, in the absence of a well-coordinated and planned framework, has not always been in the best interests of health and health care. Specifically, federal offloading in terms of unilateral reductions in health cash transfers to the provinces have been followed by: * the elimination of entire programs, such as dental insurance programs for children and universal drug insurance programs; * hospital closures (e.g., 52 hospitals in Saskatchewan); * massive regionalization of health programs and the attendant disempowerment of community hospital boards; * the reduction of total bed capacity by as much as 20% in some provinces; * the reduction in medical school enrolment by 10% and a planned 10% reduction in post-MD residency slots; * global medical care expenditure caps in virtually every province in Canada; * individual physician income thresholds in at least five provinces; * a moratorium on interprovincial mobility of physicians; * legislative overrides of duly-negotiated contracts for health care providers; * widespread restrictions on the operation of high technology equipment; and * the de facto "expropriation" of physician business practices without compensation (e.g., Saskatchewan pathologists). These repercussions also serve to underline the fact that change is the only constant in the health care system. Many physicians across the country have expressed concerns that such changes or "threats" to our health care system are already beginning to have serious consequences for individual patients in terms of access to needed medical facilities. If the national integrity of medicare is to survive, federal fiscal policy changes must be assessed within a larger and longer-term framework; one that respects the need for innovation and professionalism in the health care system. Physicians as Responsible Professionals Some mistakenly argue that physician expenditures are responsible for the increasing costs to the health care system. The reality is that physician expenditures as a proportion of total health care expenditures in Canada have declined from 15.7% in 1975 to 15.1 in 1991. 7 Furthermore, physician expenditures constitute a declining share of GDP. Given the recent round of unilateral reductions in medical care spending in many jurisdictions, this percentage share will continue to drop significantly as more recent data become available. As health care resources have become increasingly constrained, physicians have taken on added responsibilities at the macro, meso and micro levels to better manage our health resources. * At the "macro" level, within the provinces and territories, the medical profession has been engaged in formalized consultation structures known as "Joint Management Committees" or "Administrative Councils" with government and other stakeholders to ensure value for money within a diminishing "real" globe of publicly-available resources for health care. * At the "meso" or institutional level, physicians are working hand-in-hand with health care administrators and other community stakeholders to "rationalize" services so as to provide the best value for money in all areas. In addition, to give a greater voice for choice and improve overall accountabilities in the system, physicians are providing formal input to governments that are looking to regionalize health system operations. * At the "micro" or clinical level, physicians have been taking the lead in developing and disseminating clinical practice guidelines (CPGs) to ensure that the care provided is both appropriate and cost-effective. More can and is being done, in collaboration with government, to ensure responsible use of the taxpayer's dollar while meeting the needs of individual patients. At all levels, physicians will continue to involve themselves as capable and responsible professionals. As the health policy agenda continues its rapid pace, physicians and the organizations that represent them should be viewed as "agents" for, rather than "objects" of, change. Good Health Policy Means Good Economic Policy Agencies such as the World Economic Forum, 8 tell us that our system of financing health care is one of Canada's greatest assets in competing in the new world economic order. We should heed this advice, as the Prime Minister recently observed. Compared to the United States, this economic advantage takes the form of 30 percent lower health spending (measured as a percent of GDP or in per capita expenditures) while providing for universal medical benefits and high quality care. In terms of our European trading partners, the fact that health insurance programs are financed primarily through consolidated revenues (rather than employment-based taxes), also confers a unit cost advantage to Canadian exporters. In this sense, good health policy and good economic policy should be mutually reinforcing. Aside from the complementary nature of the relationship between health and the economy, this fundamental concept also suggests that we need to take a longer-term, more integrated and more strategic approach to managing our collective debt and debt-servicing challenges. The federal government can no longer simply shift its financial obligations onto the backs of lower levels of government or individual Canadians without consultation or advance notice. We need to re-evaluate the full range of government- provided or -funded services. Again, however, if federal fiscal reductions are to take place, the principles of fairness and equity must begin to guide the development of sustainable economic and health policies. While there are no doubt trade-offs that can and must be made, if the price of getting our fiscal house in order is losing a national treasure - i.e., our health care system, it is a price too high to be paid. To summarize, we have set out a series of principles that should serve to guide the Committee in its decision-making, they are: * take the longer-term view; * adopt a system-wide, integrated approach for fiscal management; * strive for a strategic approach that mutually reinforces health and economic policies; and * strengthen the fundamental foundation of fairness and equity. These four principles form the building blocks of the remainder of CMA's submission. IV. ISSUES Canada is at a social, political and economic crossroad. The challenge to this Committee and to this Government is to balance short-term fiscal pressures against the longer-term need to re-position Canada to take advantage of economic opportunity while preserving that which is of fundamental importance to Canadian society as a whole. As the Committee looks to striking the right balance, there are five specific areas of concern that the CMA wishes to bring to your attention on behalf of the Canadian medical profession. The Temptation to Reduce Federal Health Transfers CMA commends this Government for exempting EPF health transfers from the extended freeze that was applied to other provincial transfer programs in its spring 1994 budget. We would have been surprised had this Government done anything else, given that medicare is the "Liberal legacy" of the 1960s and given the Liberal Party's consistent opposition to the previous government's "policy by stealth" (i.e., Bill C-69; Bill C-96). The fact is that medicare's contribution to getting our "fiscal house in order" is already large and continues to grow. In specific terms, the Committee will know that over the 1986/87 to 1995/96 fiscal period, it is estimated that $42.108 billion will have been removed via reductions in Established Program Financing for health and post-secondary education. For health alone, over $30 billion will have been removed from the system by fiscal year 1995/96. 9 Even with a resumption of GNP minus three percent growth formula in per capita EPF entitlements for health, beginning next spring, reduced cash contributions to medicare programs will continue to contribute to the attainment of the government's fiscal targets. Given the unprecedented health reforms taking place across the country, Canadians and the health care system can ill afford another federal fiscal shock. The system is already balkanizing, with poorer regions not being able to fiscally sustain some basic health care benefits. Any further acceleration in the rate of reduction in federal cash transfers will all but assure the demise of the national integrity of medicare programs. Moreover, any further reductions in federal health-related cash transfers will: (1) significantly hamper or stall the work of the newly-created National Health Forum; (2) further reduce the capacity for enforcement of national health principles under federal law; (3) exacerbate health-related problems of dealing with child poverty and problems of reducing health inequalities by socio-economic class; and (4) increase other areas of federal direct program expenditures in the context of renewed efforts to provincial program "uploading" (e.g., Canada Pension Plan Disability Program). A propos of health and economy going hand-in hand, it is useful to remind ourselves of the importance of maintaining the comparability of health benefits across Canada in terms of promoting regional development, shared opportunity and efficient resource allocation. Poor regions of this country are already finding it difficult to compete for scarce new business investment capital. The implications of competing from a more uneven playing field in terms of being able to offer only "bare bones" publicly-financed health benefits will further widen the gap between the "have" and "have not" provinces. It is for these reasons that the CMA joins with other national health organizations 10 in recommending the following: 1. THAT THE FEDERAL GOVERNMENT AVOID FURTHER CUTS TO THE EPF HEALTH TRANSFER AND LOCK IN THE CASH PORTION; 2. THAT THE FEDERAL GOVERNMENT NEGOTIATE A STABLE FIVE-YEAR FUNDING ARRANGEMENT WITH THE PROVINCES/TERRITORIES; 3. THAT THE FEDERAL GOVERNMENT MUST ENSURE THAT ACCOUNTABILITY OF THE HEALTH TRANSFER BE SEPARATE AND EXPLICIT. Taxable Health Benefits Canadians have already been dealt one blow with the increasing de-insurance of health care services (e.g., reduction of out-of-country benefits to an unfair and dangerous level, elimination or reduction in drug benefit programs). In the context of funding those services that remain public benefits, only the cruellest government would strike yet another blow to individual Canadians and to Canadian business by taxing the very benefits that taxes were raised to pay. If implemented, this proposal would be tantamount to nothing less than double taxation. Fairness and equity would suggest that the government should be doing more, not less at the legislative and regulatory levels to promote the availability of private health insurance benefits in areas increasingly vacated by government cutbacks. This is why CMA makes the following recommendation: 4. THAT THE CURRENT FEDERAL GOVERNMENT POLICY WITH RESPECT TO NON-TAXABLE HEALTH BENEFITS BE MAINTAINED; Goods and Services Tax (GST) When the GST was introduced in 1991, preoccupation with implementation issues resulted in a number of fundamental injustices at the micro level. One such injustice was dealt to the medical profession. Physicians, like other Canadians, expect to pay their fair share of taxes. We do not however, accept what essentially amounts to double taxation. Physicians in practice in Canada are in the unique, unenviable and unfair position of being forced to absorb all the GST on business inputs. Unlike all other professions, physicians are precluded from being able to pass on the tax to consumers (with provincial health insurance plans as payment in full) or from claiming input tax credits (ITCs) since insured medical services are deemed to be "tax exempt". Unlike other professions, physicians cannot claim input credits for the imputed taxes associated with providing needed medical care. In fact, all of the following health professionals are capable of recouping from patients the GST paid on inputs because their revenues are not restricted by government: dentists; optometrists; chiropractors; physiotherapists; chiropodists; osteopaths; audiologists; speech therapists; occupational therapists and psychologists. Physicians are still angrily awaiting remedial steps to correct this injustice. To be clear, CMA is not asking for preferential treatment for Canadian physicians. What we want is the same fair and equitable treatment from the federal government accorded to other self-employed professional groups. Like physicians, other professions are purchasing inputs and paying GST; but unlike physicians, they are able to recoup the GST. Given this oversight in the legislation and regulations, physicians have already been asked to pay (over and above the GST paid by other professional groups) a cumulative total of $250 million since its introduction of the tax in 1991. The magnitude of this tax paid is not in dispute (as a result of a study prepared by KPMG). While the direct effects of the GST are significant and measurable, the indirect effects are even more significant though less measurable. It is estimated that the 55,000 physicians in Canada employ up to 100,000 Canadians. Given the disproportionate effects of the GST on the medical profession as employers, the employment dampening could be at least as high as 1,000 full-time jobs lost. In addition, the tax-induced distorting effects in terms of efficient resource allocation in the health care system cannot be measured, but are thought to be significant. A goal of health reform in many parts of the country is to move care services out of institutions and into the community. Current federal GST policy, by taxing supplies in a clinical practice setting but not in a hospital setting, acts to discourage this shift in emphasis. No other issue in recent years has raised the ire of individual practitioners as much as the imposition of this most unfair and inequitable tax on business inputs. Understanding that the Minister of Finance is in the process of consulting with the provinces as to the nature of a replacement tax for the GST, we are confident that this oversight will be remedied. In the interests of fundamental fairness/equity and allocative efficiency, CMA respectfully recommends the following: 5. THAT THE COMMITTEE WORK TO ENSURE THAT CANADIAN PHYSICIANS, AS SMALL BUSINESSES, PAY NO MORE THAN OTHER PROFESSIONS UNDER ANY REPLACEMENT TAX FOR THE GST; 6. THAT ALL TAXES ON BUSINESS EXPENSES BE FAIRLY AND FULLY REMOVED UNDER ANY REPLACEMENT TAX FOR THE GST; 7. THAT IF ANY REMEDIAL STEPS ARE TAKEN TO ENSURE NO TAXES ARE LEVIED ON BUSINESS INPUTS, THESE BE APPLIED UNIFORMLY ACROSS ALL EXEMPT SERVICES. Registered Retirement Savings Plan (RRSP) Canadian physicians, while receiving a large proportion of their professional earnings from the public sector (94%), do not benefit as self-employed individuals from defined benefit plans or from publicly-financed pension benefits that accrue to employed professionals. They, like other self-employed individuals, must plan and fund their own retirement. Fairness/equity once again demands that there be symmetry between money-purchase (MP) and defined-benefit (DB) retirement plans. This is all the more important for physicians because of their compressed period of lifetime earnings in relation to other groups. This Committee will have heard various calls for either reducing the annual contribution limit or taxing assets within RRSPs. Such arguments are both specious and patently unfair. Both propositions potentially involve double taxation. Experts both within and outside government argue, quite correctly, that the current policy be maintained, and that equity between employees and the self-employed before the taxman be assured. It is for these reasons, that CMA has led an unprecedented alliance for the preservation of retirement savings, and recommends the following: 8. THAT THE FEDERAL GOVERNMENT CONSIDER THE TOTAL COST OF THE RETIREMENT SAVINGS SYSTEM BEFORE MAKING ANY CHANGES TO THE INCOME TAX ACT; 9. THAT THE EQUITY ESTABLISHED DURING PENSION REFORM NOT BE DISTURBED BY DISCRIMINATORY CHANGES AND THAT ANY FUNDAMENTAL CHANGES TO THE SYSTEM INVOLVE A PROCESS OF INFORMED AND THOUGHTFUL INQUIRY AND DEBATE; 10. THAT THE FEDERAL GOVERNMENT FOSTER ECONOMIC DEVELOPMENT BY TREATING RRSP CONTRIBUTIONS AS ASSETS RATHER THAN LIABILITIES AND BY EXPLORING THE REGULATORY CHANGES NECESSARY TO ENSURE INCREASED ACCESS TO SUCH FUNDS BY SMALL AND MEDIUM-SIZED BUSINESSES. Lifetime Capital Gains Exemption (LCGE) for Small Businesses Most Canadian physicians are independent, self-employed practitioners. As such, they have the ability if they are incorporated to claim the LCGE when they sell their practices. Over time, several provinces have accorded physicians the right to incorporate (e.g., Prince Edward Island, New Brunswick, Alberta, British Columbia, and the Yukon Territory), in other jurisdictions, physician incorporation is under active review (e.g., Nova Scotia, Quebec, Ontario and the Northwest Territories). While physicians have benefited from incorporation on a limited basis, this issue takes on added importance when one considers the "national" move towards incorporation allowing a greater number of eligible physicians to claim the LCGE. Recent health reforms have also underscored the importance of maintaining the current policy. Previously, physicians were free to move their practices from one location to another to meet the changing health needs of Canadians. Over the past two years, provincial governments have moved to restrict inter-provincial mobility of physicians and indeed mobility within any given province or territory. These "barriers" not only restrict the number of new entrants into the system in addition to those who wish to move to other areas of the country, but also can be thought of as increasing the capitalized value of established practices. Indeed, with the advent of regional physician resource plans across Canada, the cost of establishing a new practice can be expected to continue to grow at an unprecedented rate. So while some physicians have yet to claim the LCGE, it is reasonable to think that they will some time in the future. As the health needs of Canadians change, and as people move, medical care services will have to respond accordingly. The elimination of the LCGE, by significantly increasing the purchase price of a new medical practice, unnecessarily and unfairly raises additional economic barriers to shifting practices in response to changing community health needs. CMA therefore recommends: 11. THAT THE FEDERAL GOVERNMENT MAINTAIN THE CURRENT POLICY FOR THE LIFETIME CAPITAL GAINS EXEMPTION FOR SMALL BUSINESSES. V. TRADE-OFFS To summarize: in broad terms the health care sector has already paid its fair (and to a larger extent unfair) share. Everyone who has appeared before this Committee will argue that cuts should not occur in their backyard. They can't all be right! The government of Canada must decide where its priorities lie over the longer-term. Deficit reduction targets can no longer be met by simply chipping away at the full range of federally-sponsored programs. The national integrity of national health insurance programs, given their importance to Canada's economic, social and political future must be on the short list of safeguarded social programs. If further reductions in federal health transfers are deemed appropriate, the Committee should be prepared to publicly acknowledge that the principles of universality or comprehensiveness (i.e., the choice between covering everyone versus everything) will have to be fundamentally re-examined. Given the degree of support for the universality principle, if the federal government is serious about further reducing its direct or indirect contributions to health, then it must reconsider the range of core benefits that will be made available to Canadians. In fact, we may now have reached the point where we need to get back to basics; reminding ourselves of the original medicare promise, which was to protect Canadians from the spectre of personal bankruptcy associated with large and unexpected health care bills. Not to pay the day-to-day ("grocery") bill of health care. The recently-announced National Health Forum, chaired by the Prime Minister, will provide an important opportunity to assess the breadth and depth of publicly-financed health care. The contribution of medicine to the health of Canadians and to the economy is just too important to be traded off. Physicians are still feeling the "aftershocks" of recent federal fiscal decisions. They have also had to absorb sharp unilateral reductions at the provincial level. The provinces of Nova Scotia, Prince Edward Island and Alberta - to name only three - have disproportionately singled out the medical profession on a net earnings basis in decreasing health funding. Taken together, these fiscal forces could trigger an unprecedented exodus of physicians from Canada. As governments move to restrict the ability of physicians to provide needed medical care, CMA is increasingly concerned about the growing number of physicians who are being actively recruited by the United States, and those who feel they have no alternative but to leave the country. At a macro level, we as a society, must recognize that we are in a North American labour market, and as such, each physician heading south represents both a short-term pain and long-term pain. VI. SUMMARY OF RECOMMENDATIONS The CMA offers the following recommendations to the Committee in its deliberations: 1. THAT THE FEDERAL GOVERNMENT AVOID FURTHER CUTS TO THE EPF HEALTH TRANSFER AND LOCK IN THE CASH PORTION; 2. THAT THE FEDERAL GOVERNMENT NEGOTIATE A STABLE FIVE-YEAR FUNDING ARRANGEMENT WITH THE PROVINCES/TERRITORIES; 3. THAT THE FEDERAL GOVERNMENT MUST ENSURE THAT ACCOUNTABILITY OF THE HEALTH TRANSFER BE SEPARATE AND EXPLICIT. 4. THAT THE CURRENT FEDERAL GOVERNMENT POLICY WITH RESPECT TO NON-TAXABLE HEALTH BENEFITS BE MAINTAINED; 5. THAT THE COMMITTEE WORK TO ENSURE THAT CANADIAN PHYSICIANS, AS SMALL BUSINESSES, PAY NO MORE THAN OTHER PROFESSIONS UNDER ANY REPLACEMENT TAX FOR THE GST; 6. THAT ALL TAXES ON BUSINESS EXPENSES BE FAIRLY AND FULLY REMOVED UNDER ANY REPLACEMENT TAX FOR THE GST; 7. THAT IF ANY REMEDIAL STEPS ARE TAKEN TO ENSURE NO TAXES ARE LEVIED ON BUSINESS INPUTS, THESE BE APPLIED UNIFORMLY ACROSS ALL EXEMPT SERVICES. 8. THAT THE FEDERAL GOVERNMENT CONSIDER THE TOTAL COST OF THE RETIREMENT SAVINGS SYSTEM BEFORE MAKING ANY CHANGES TO THE INCOME TAX ACT; 9. THAT THE EQUITY ESTABLISHED DURING PENSION REFORM NOT BE DISTURBED BY DISCRIMINATORY CHANGES AND THAT ANY FUNDAMENTAL CHANGES TO THE SYSTEM INVOLVE A PROCESS OF INFORMED AND THOUGHTFUL INQUIRY AND DEBATE; 10. THAT THE FEDERAL GOVERNMENT FOSTER ECONOMIC DEVELOPMENT BY TREATING RRSP CONTRIBUTIONS AS ASSETS RATHER THAN LIABILITIES AND BY EXPLORING THE REGULATORY CHANGES NECESSARY TO ENSURE INCREASED ACCESS TO SUCH FUNDS BY SMALL AND MEDIUM-SIZED BUSINESSES. 11. THAT THE FEDERAL GOVERNMENT MAINTAIN THE CURRENT POLICY FOR THE LIFETIME CAPITAL GAINS EXEMPTION FOR SMALL BUSINESSES. _______________ 1 The Angus Reid Group, The Reid Report. Vol. 8, No. 7, July/August, 1993 and Vol. 8, No. 8, September, 1993. 2 Ibid. 3 Agenda: Jobs and Growth: Creating A Healthy Fiscal Climate (The Economic and Fiscal Climate), Department of Finance, October 1994. 4 Economic and Fiscal Reference Tables, Department of Finance, September 1994; Annual Financial Report of the Government of Canada, Fiscal Year, 1993/94. 5 Valaskakis K.: The Debt Monster, Montreal Gazette, November 5, 1994. 6 National Health Expenditures in Canada, 1975-1993. Health Canada. 7 Ibid. 8 World Economic Forum 1991: The World Competitiveness report 1990, Institut pour l'étude des méthodes de direction de l'entreprise, Lausanne, Switzerland. 9 Thomson A 1991: Federal Support for Health Care: A Background Paper. Health Action Lobby, Ottawa, June 1991. 10 See the 1995/96 Pre-Budget Submission to the Standing Committee on Finance by the Health Action Lobby (HEAL), November 15, 1994.
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The Canadian Medical Association's brief to the Standing Committee on Finance concerning the 2007 budget

https://policybase.cma.ca/en/permalink/policy8566
Last Reviewed
2019-03-03
Date
2006-09-27
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2019-03-03
Date
2006-09-27
Topics
Health systems, system funding and performance
Text
Making Canadians healthy and wealthy In the face of an increasingly competitive global economy, Canada must create incentives for its citizens and businesses to invest so that greater investment will increase productivity and our standard of living. The first place to invest is in the health of the workforce. The CMA recognizes the benefits of aligning tax policy with health policy in order to create the right incentives for citizens to realize their potential. Global competitiveness is about getting Canada beyond commodities The latest Canadian economic outlook is mixed. Our economy is forecast to grow by 3 per cent in 2007 which is the fastest growing economy among the G7 countries, according to the International Monetary Fund's semi-annual World Economic Outlook. While this may seem impressive, this growth is fuelled by commodity prices. "The Canadian economy continues to perform robustly, benefiting from...the boom in global commodity prices,'' the IMF said. In fact this is one of the key concerns included in the latest outlook from TD Economics, namely that, "Weakening U.S. demand will lead to a pullback in commodity prices, including a drop in the price of oil to $50 US a barrel in 2007"1. What can the federal government do to mitigate these bumps in the global economy? Investing in "specialized factors" is the key to global competitiveness Canada's place in a competitive world cannot be sustained by commodities or what the godfather of competitive advantage theory, world-renowned Harvard Professor Michael Porter, calls "non-key" factors. Instead, Porter suggests that sustainable competitive advantage is based on "specialized factors" such as skilled labour, capital and infrastructure. These specialized factors are created, not inherited. Moreover, Porter makes the important distinction that the crafting of "social" policies must make them reinforcing to the true sources of sustainable prosperity.2 The demand for highly skilled labour forces does not fluctuate as commodity prices do. This submission follows Porter's line of thinking in suggesting that Canada should build on these specialized factors, emphasizing the health of our skilled labour force, enhancing the skills of our health care providers and making key investment in our electronic health infrastructure. Why the CMA is addressing Canada's place in competitive world The 63,000 members of the Canadian Medical Association are best known for taking care of Canadians - 32.3 million of them - individually and collectively. Through prevention, treatment and research, physicians are also vital in supporting business by ensuring that our work force is as healthy as can be. But our members are also an important economic force in their own right as they own and operate over 30,000 small businesses employing 142,000 people across the country. 3 What's more, small businesses, like the ones physicians run, invest in research and development proportionally on a far larger scale than big corporations. 4 In addition to the clinical services they provide, physicians are vitally engaged in advancing medical knowledge through teaching and research, leading to greater innovation. Health as an investment -"the greatest benefit to mankind" According to distinguished Yale economist, William Nordhaus, "The medical revolution over the last century appears to qualify, at least from an economic point of view, for Samuel Johnson's accolade as "the greatest benefit to mankind." 5 People demand and spend more money on health because it is useful. The goal of a competitive economy is to produce more wealth. The wealthier our citizens become, the more health care they demand. In other words health care is in economic terms a "superior good". Short, medium and long-run incentives for increased productivity The pursuit of productivity to ensure Canada's competitiveness in the world is not and cannot be a short-term goal. Productivity is apolitical. Setting the foundation for productivity requires dedication to long-term goals in education, physical infrastructure and health. However, there are recommendations that can create immediate incentives for citizens and businesses to kick start more productive activity sooner than later. Executive Summary The CMA's pre-budget submission presents the facts on how investments in citizens, businesses and health infrastructure make our economy more competitive. Improvements in the quality of care, and especially timely access to care, enable the Canadian labour force to increase its performance and fully reach its potential. Our submission is also sensitive to the constraints facing the federal government and so we have considered the return on investment for these recommendations. The CMA recognizes the benefits of aligning tax policy with health policy in order to create the right incentives for citizens to realize their potential. Accordingly, our proposals include tax incentives for healthy living and a recommendation to encourage savings for long-term health care. The time horizon for our 10 recommendations ranges from short-term wins such as getting Canadian doctors working in the U.S. back to Canada sooner than later to turning the tide of rising obesity in Canada. We hope that the Standing Committee on Finance considers these short-term returns on investment as well as the longer returns on investment. A Greek proverb said it best, "A society grows great when old men plant trees whose shade they know they shall never sit in". This can be a great legacy of the Committee. On behalf of the members of the Canadian Medical Association, I wish you all the best in your deliberations. Recommendations for Committee consideration Medicine for a More Competitive Canadian Economy6 -10 recommendations with investment estimates A. CITIZENS - healthy living Recommendation 1: That the government consider the use of taxes on sales of high-calorie, nutrient-poor foods as part of an overall strategy of using tax incentives and disincentives to help promote healthy eating in Canada. Recommendation 2: That the government assess the feasibility of an individual, tax-sheltered, long-term health care savings plan. B. BUSINESS - healthy workforce Recommendation 3: That the government advances the remaining $1-billion from the 2004 First Ministers Accord that was originally intended to augment the Wait Times Reduction Fund (2010-2014) to support the establishment of a Patient Wait Times Guarantee and deliver on the speech from the throne commitment. Recommendation 4: That the federal government provide the Canadian Institute for Health Information with additional funding for the purpose of enhancing its information gathering efforts for measuring, monitoring and managing waiting lists and extending the development and collection of health human resource data to additional health professions. Recommendation 5: That the government launch a direct advertising campaign in the United States to encourage expatriate Canadian physicians and other health professionals to return to practice in Canada. Investment: A one-time investment of $10-million. Recommendation 6: That the government provide a rebate to physicians for the GST/HST on costs relating to health care services provided by a medical practitioner and reimbursed by a province or provincial health plan. Investment: $52.7-million per year or 0.2 % of total $31.5- billion GST revenues. C. INFRASTRUCTURE - healthy systems Recommendation 7: That the government follow through on the recommendation by the Federal Advisor on Wait Times to provide Canada Health Infoway with an additional $2.4-billion to secure an interoperable pan-Canadian electronic medical record with a targeted investment toward physician office automation. Investment: $2.4-billion over 5 years. Recommendation 8: That the government establish a Public Health Infrastructure Renewal Fund ($350-million annually) to build partnerships between federal, provincial and municipal governments, build capacity at the local level, and advance pandemic planning. Recommendation 9: That the government recommit to the $100-million per year for immunization programs under the National Immunization Strategy. Recommendation 10: That the government Increase the base budget of the Canadian Institutes of Health Research to enhance research efforts in the area of population health and public health, as well as significantly accelerate the pace of knowledge transfer. Investment: $600-million over 3 years. Introduction It is well known that Canada's place in a competitive world cannot be sustained by commodities or what the godfather of competitive advantage theory, Michael Porter calls "non-key" factors. Instead Porter suggests that sustainable competitive advantage is based on "specialized factors" such as skilled labour, capital and infrastructure. These specialized factors are created, not inherited. Moreover, Porter makes the important distinction that the crafting of "social" policies must make them reinforcing to the true sources of sustainable prosperity.7 The demand for highly skilled labour forces does not fluctuate as commodity prices do. This submission follows that line of thinking in suggesting that Canada should build on these specialized factors, emphasizing the health of our skilled labour force, enhancing the skills of our health care providers as well as making key investment in our health infrastructure - electronic and otherwise. Outline: healthy citizens, businesses, infrastructure and affordable government The Canadian Medical Association (CMA) brief submitted to the Standing Committee on Finance will make 10 recommendations on how the federal government can make our economy more competitive by investing in three priorities: health, health care and health infrastructure. The brief will address these topics, aligning them with support for our (A) citizens, (B) businesses and (C) infrastructure. The CMA also recognizes that the federal government does not have unlimited resources and suggests actions to be taken in order to ensure that these recommendations are both affordable and sustainable. Accordingly, we will also provide a "balance sheet" of investments, return on investments, as well as revenue raising possibilities that could help create incentives for healthy living and, in turn, a more competitive economy. A. Citizens - healthy living Canadians must become fitter and healthier. Almost 60% of all Canadian adults and 26% of our children and adolescents are overweight or obese. 8 Dr. Ruth Collins-Nakai, the immediate past-president of the CMA and a cardiac-care specialist, recently said ""I have a very real fear we are killing our children with kindness by setting them up for a lifetime of inactivity and poor health,". Canada should follow the lead of European countries, which have recently recommended a minimum of 90 minutes a day of moderate activity for children. Kicking a soccer ball or riding a skateboard for 15 to 30 minutes two or three times a week is not good enough, she said. Obesity costs Canada $9.6 billion per year. 9 These costs continue to climb. The federal government must use every policy lever possible at its disposal in order to empower Canadians to make healthy choices, help to reduce the incidence of obesity and encourage exercise as well as a proper diet. Obesity and absenteeism affect the bottom line Obesity not only hurts our citizens it is also a drag on Canadian competitiveness. There is a direct correlation between increasing weights and increasing absenteeism. The costs associated with employee absenteeism are staggering. Employee illness and disability cost employers over $16-billion each year.10 For instance, the average rate of absence due to illness or disability for full-time Canadian workers was 9.2 days in 2004, a 26% increase over the last 8 years, according to Statistics Canada's latest labour force survey. While there is a growing awareness of the costs due to obesity are well known. The programs and incentives in place now are clearly not working as the incidence of obesity continues to grow. The benefits of turning the tide of obesity are also clear. In his remarks to the CMA in August 2006, Minister Tony Clement made the following statement: "And you know and I know that health promotion, disease and injury prevention not only contribute to better health outcomes, they help reduce wait times as well." The experts agree, "The economic drive towards eating more and exercising less represents a failure of the free market that governments must act to reverse it."11 Recommendation 1: That the government consider the use of taxes on sales of high-calorie, nutrient-poor foods as part of an overall strategy of using tax incentives and disincentives to help promote healthy eating in Canada. Tax-sheltered savings for long-term care - aligning tax policy and health policy Canada is entering an unprecedented period of accelerated population aging that will see the share of seniors aged 65 and over increase from 13% in 2005 to 23% in 2031. At the same time, the cost of privately funded health services such as drugs and long-term care are projected to increase at double-digit rates as new technologies are developed and as governments continue to reduce coverage for non-Medicare services in order to curb fiscal pressures12. Since seniors tend to use the health system more intensively than non-seniors, the rising cost of privately funded health services will have a disproportionately high impact on seniors. Canadians are not well equipped to deal with this new reality. Private long-term care insurance exists in Canada, but is relatively on the Canadian scene and has not achieved a high degree of market penetration. New savings vehicles may be needed to help seniors offset the growing costs of privately funded health services. One approach would be extend the very successful model of RRSPs to enable individuals save for their long-term care needs via a tax-sheltered savings plan. Recommendation 2: That the government assess the feasibility of an individual tax-sheltered long-term health care savings plan. B. Business - healthy workforce In spite of the fact that health as an economic investment has proven returns, governments have been letting up in their support of their citizens' health. The impact is felt not only in terms of poorer health but it also affects businesses through increased absenteeism, as well as governments through lower tax revenues. According to the Center for Spatial Economics, "...the cumulative economic cost of waiting for treatment across Ontario, Saskatchewan, Alberta and BC in 2006 is estimated to be just over $1.8-billion. This reduction in economic activity lowers federal government revenues by $300-million." 13 The total costs to the federal government are even higher if all 10 provinces were included. The estimate is based on four of the five priority areas identified in the 2004 First Ministers Health Accord: total joint replacement surgery, cataract surgery, coronary artery bypass graft, and MRI scans. If you wonder what all this has to do with Canadian business, ask yourself how many person/hours employers lose due to illness? How much productive time is lost due to the stress of an employee forced to help an elderly parent who cannot find a doctor? This challenging situation is going to get worse, as the population ages, and as our health professionals age and retire. Supporting the Patient Wait Time Guarantee The establishment of pan-Canadian wait time benchmarks and a Patient Wait Times Guarantee are key to reducing wait times and improving access to health services. The 2004 First Ministers' health care agreement set aside $5.5-billion for the Wait Time Reduction Fund, of which $1-billion is scheduled to flow to provinces between 2010 and 2014. To assist provinces with the implementation of the wait time guarantee while remaining within the financial parameters of the health care agreement, the federal government could advance the remaining $1-billion and flow these funds to provinces immediately. Recommendation 3: That the government advances the remaining $1-billion from the 2004 First Ministers Accord that was originally intended to augment the Wait Times Reduction Fund (2010-2014) to support the establishment of a Patient Wait Times Guarantee and deliver on the speech from the throne commitment. Making investments count and counting our investments It would be irresponsible for government to make investments if the results were not being measured. As management guru Tom Peters suggests, "What you do not measure, you cannot control." And, "What gets measured gets done." As billion dollar federal funding of health care reaches new heights, the value of measuring these investment increases. That is where the Canadian Institute for Health Information (CIHI) comes in. CIHI has been involved in developing wait time indicators and tracking Canada's progress on wait times. It is essential that we have an arm's length body responsible for collecting data on wait times as part of Canada's effort to improve timely access to care for Canadians. CIHI has also played an active role in health human resource data collection and research. Their financial support for the 2004 National Physician Survey resulted in a one-of-a-kind research file with input from over 20,000 Canadian physicians. Recommendation 4: That the federal government provide the Canadian Institute for Health Information with additional funding for the purpose of enhancing its information gathering efforts for measuring, monitoring and managing waiting lists and extending the development and collection of health human resource data to additional health professions. Direct advertising in the U.S. to bolster health human resources deficit The primary barrier affecting timely access to quality health care is the shortage of health care professionals. Canada currently ranks 26th in the OECD in terms of physicians per capita, at 2.1 MDs per 1,000 people. More than three million Canadians do not have a family physician. This situation will get worse as the population ages and as our health professionals age and retire. Fortunately, another short-term source of health professionals exists that Canada should pursue. Thousands of health care professionals are currently working in the United States including approximately 9,000 Canadian trained physicians. We know that many of the physicians who do come back to Canada are of relatively young age meaning that they have significant practice life left. While a minority of these physicians do come back on their own, many more can be repatriated in the short-term through a relatively small but focussed effort by the federal government led by a secretariat within Health Canada. Recommendation 5: That the government launch a direct advertising campaign in the United States to encourage expatriate Canadian physicians and other health professionals to return to practice in Canada. Investment: A one-time investment of $10-million. Re-investing the GST for 30,000 small businesses The continued application of the GST on physician practices is an unfair tax on health. Because physicians cannot recapture the GST paid on goods and services for their practices in the same way most other businesses can, the GST distorts resource allocation for the provision of medical care. As a result, physicians end up investing less than they otherwise could on goods and services that could improve patient care and enhance health care productivity such as information management and information technology systems. The introduction of the GST was never intended to fall onto the human and physical capital used to produce goods and services. The GST is a value-added tax on consumption that was put into place to remove the distorting impact that the federal manufacturers sales tax was having on business decisions. However, the GST was applied to physician practices in a way that does exactly the opposite. The federal government must rectify the situation once and for all. Based on estimates by KPMG, physicians have paid $1.1-billion in GST related to their medical practice since 1991. This is $1.1-billion that could have been invested in better technology to increase care and productivity. Recommendation 6: That the government provide a rebate to physicians for the GST/HST on costs relating to health care services provided by a medical practitioner and reimbursed by a province or provincial health plan. Investment: $52.7-million per year or 0.2 % of total $31.5-billion GST revenues. C. Infrastructure -healthy system Recovery of health information technology investments is almost immediate A Booz, Allen, Hamilton study on the Canadian health care system estimates that the benefits of an EHR could provide annual system-wide savings of $6.1 billion, due to a reduction in duplicate testing, transcription savings, fewer chart pulls and filing time, reduction in office supplies and reduced expenditures due to fewer adverse drug reactions. The study went on to state that the benefits to health care outcomes would equal or surpass these annual savings. Evidence shows that the sooner we have a pan-Canadian EHR in place, the sooner the quality of, and access to health care will improve.14 Mobilizing physicians to operationalize a pan-Canadian Electronic Health Record The physician community can play a pivotal role in helping the federal governments make a connected health care system a realizable goal in the years to come. Through a multi-stakeholder process encompassing the entire health care team, the CMA will work toward achieving cooperation and buy-in. This will require a true partnership between provincial medical associations, provincial and territorial governments and Canada Health Infoway (CHI). The CMA is urging the federal government to allocate an additional investment of $2.4-billion to Canada Health Infoway over the next five years15 to build the necessary information technology infostructure to address wait times16 as well as support improved care delivery. Both the Federal Wait Times Report and Booz Allen Study concur that this requires automating all community points of care - i.e., getting individual physician offices equipped with electronic medical records (EMRs). This is a necessary, key element to the success of the EHR agenda in Canada and recent assessments place the investment required at $1.9-billion of the $ 2.4-billion. CHI has proven to be an effective vehicle for IT investment in Canadian health care. For example, as a result of CHI initiatives, unit costs for Digital Imaging have been reduced significantly and are already saving the health care system up to 60-million dollars. In fact as a result of joint procurements and negotiated preferred pricing arrangements through existing procurement efforts with jurisdictional partners the estimated current cost avoidance is between $135-million to $145-million. Moreover, in the area of a Public Health Surveillance IT solution, a pan Canadian approach to CHI investments with jurisdictional partners has lead to benefits for users, the vendor and Canadians. The negotiation of a pan-Canadian licence enables any jurisdiction to execute a specific licence agreement with the vendor and spawn as many copies as they need to meet their requirements. The vendor still owns the IP and is free to market the solution internationally - clearly a win/win for both industry and the jurisdictions. Recommendation 7: That the government follow through on the recommendation by the Federal Advisor on Wait Times to provide Canada Health Infoway with an additional $2.4-billion to secure an interoperable pan-Canadian electronic medical record with a targeted investment toward physician office automation. Investment: $2.4-billion over 5 years. Establishing a Public Health Infrastructure Renewal Fund The CMA remains concerned about the state of Canada's public health system. Public health, including the professionals providing public health services, constitutes our front line against a wide range of threats to the health of Canadians. While there is much talk about the arrival of possible pandemics, Canada's public health system must be ready to take on a broad range of public health issues. The CMA has been supportive of the Naylor report which provides a blue print for action and reinvestment in the public health system for the 21st century. While this will take several years to achieve, there are some immediate steps that can be taken which will lessen the burden of disease on Canadians and our health care system. These steps include establishing a Public Health Partnership Program with provincial and territorial governments to build capacity at the local level and to advance pandemic planning. In addition, we call on the government to continue its funding of immunization programs under its National Immunization Strategy. Public health must be funded consistently in order to reap the full benefit of the initial investment. Investments in public health will produce healthier Canadians and a more productivity workforce for the Canadian economy. But this takes time. By the same token, neglect of the public health system will cost lives and hit the Canadian economy hard. Recommendation 8: That the government establish a Public Health Infrastructure Renewal Fund ($350-million annually) to build partnerships between federal, provincial and municipal governments, build capacity at the local level, and advance pandemic planning. Supporting the National Immunization Strategy Dr. Ian Gemmell, Co-Chair of the Canadian Coalition for Immunization Awareness and Promotion, has said, "Vaccines provide the most effective, longest-lasting method of preventing infectious diseases in all ages." strongly urge that immunization programs be supported. Healthy citizens are productive citizens and strong immunization programs across the country pay for themselves over time. Recommendation 9: That the Federal Government recommit to the $100-million per year for immunization programs under the National Immunization Strategy. Making medical research investments count - supporting knowledge transfer The Canada Institutes of Health Research (CIHR) was created to be Canada's premier health research funding agency. One of the most successful aspects of the CIHR is its promotion of inter-disciplinary research across the four pillars of biomedical, clinical, health systems and services as well as population health. This has made Canada a world leader in new ways of conducting health research. However, with its current level of funding, Canada is significantly lagging other industrialized countries in its commitment to health research. Knowledge transfer is one of the areas where additional resources would be most usefully invested. Knowledge Translation (KT) is a prominent and innovative feature of the CIHR mandate. Successful knowledge translation significantly increases and accelerates the benefits flowing to Canadians from their investments in health research. Through the CIHR, Canada has the opportunity to establish itself as an innovative and authoritative contributor to health-related knowledge translation. Population and public health research is another area where increased funding commitments would yield long-term dividends. Recommendation 10: That the government Increase the base budget of the Canadian Institutes of Health Research to enhance research efforts in the area of population health and public health, as well as significantly accelerate the pace of knowledge transfer. Investment: $600-million over 3 years. Conclusion The CMA recognizes the benefits of aligning tax policy with health policy in order to create the right incentives for citizens to realize their potential. Accordingly our proposals include tax incentives for healthy living as well as a recommendation to encourage savings for long-term health care. The time horizon for our 10 recommendations ranges from short-term wins such as getting Canadian doctors working in the U.S. back to Canada sooner than later to turning the tide of rising obesity in Canada. We hope that the Standing Committee on Finance considers these short-term returns on investment as well as the longer returns on investment. A Greek proverb said it best, "A society grows great when old men plant trees whose shade they know they shall never sit in". This can be a great legacy of the Committee. On behalf of the members of the Canadian Medical Association, I wish you all the best in your deliberations. Appendix 1 - Recommendations for Committee consideration 10 point plan with estimated investments and revenues Appendix 2 - The Information Technology Agenda in the Canadian Health Care Sector * The Health Council of Canada, the Presidents and CEOs from the Academic Healthcare Organizations and the federal advisor on wait times all agree on the need to accelerate the building out of the information technology infostructure for the healthcare sector * All these groups amongst others argue that there are large gains to be made on improving healthcare delivery and achieving efficiencies in operating the health care system * Automating health care delivery in Canada will lead to a more efficient healthcare system and will build industry capacity to compete in the international market place * A $10-billion investment is estimated to result in a return on investment (ROI) exceeding investment dollars by an 8:1 margin, and a net savings of $39.8-billion over a 20-year period. It is estimated that a net positive cash flow would occur in Year Seven of implementation, and an investment breakeven by Year 11, resulting in an annual net benefit of $6.1-billion.17 * Part of this investment is to automate the over 35,000 physicians who have a clinic in a community setting * It is estimated that $1.9-billion is needed to accomplish this task which when complete will facilitate better management of wait times, improved patient safety, helping to address in part the human resource shortage for providers as well as make a contribution to improved First Nation health. * Our recommendation is that the Federal government provide a further direct investment of $1-billion into Canada Health Infoway (CHI) that is targeted to the automation of physician offices. This funding would pay for 50% of the costs to automate a physician's clinic. * The funds would be allocated to provinces and medical associations through CHI once an agreement has been developed. A jointly developed program would ensure complementarity with a provincial health IT strategy and a program that has been designed by physicians such that it does the most to improve health care delivery * Physicians would be asked to pay the other 50% and through tax policy they would be able to claim a deduction for capital information technology acquisitions * This arrangement mirrors current programs funded by CHI on a 75%-25% cost sharing model with provinces but with physicians picking up approximately 25% of the costs Appendix 3 Can taxation curb obesity? A recent article in the New Scientiest.com1 asks, Can taxation curb obesity? "The economic drive towards eating more and exercising less represents a failure of the free market that governments must act to reverse."18 "We have market failure in obesity, because we have social costs greater than the private costs," according to Lynee Pezullo director of the economic advisory group Access Economics. "The government also bears the health costs, and people don't take into account costs they bear themselves. If people had to pay for their own dialysis they might bear these things in mind a bit more." When two-thirds of the population of countries like Australia or the US are obese or overweight, you can't handle the problem with simple solutions like education," Barry Popkin of the University of North Carolina, Chapel Hill. A Yale University professor is generating support for a "twinkie tax"1 on high-calorie foods like french fries. This tax works In California in 1988, Proposition 99 increased the state tax by 25 cents per cigarette pack and allocated a minimum of 20% of revenue to fund anti-tobacco education. From 1988 to 1993, the state saw tobacco use decline by 27%, three times better than the U.S. average.1 CMA is not alone in supporting a junk food tax In December, 2003, the World Health Organization proposed that nations consider taxing junk foods to encourage people to make healthier food choices. According to the WHO report, "Several countries use fiscal measures to promote availability of and access to certain foods; others use taxes to increase or decrease consumption of food; and some use public funds and subsidies to promote access among poor communities to recreational and sporting facilities." The American Medical Association is planning to demand the government to levy heavy tax on the America's soft drinks industry. Currently, 18 U.S. states have some form of "snack" food tax in place and five states have proposed policy and legislative recommendations. The economic costs of obesity are estimated at $238-billion annually, and rising. Along the same lines, the former Surgeon General, C. Everett Koop, believes that after smoking, "obesity is now the number one cause of death in [the U.S.]...we're not doing the same kind of things with obesity that we have done with smoking and alcohol as far as government programs are concerned ... It's got to be like smoking, a constant drum beat." 1 "U.S. Slowdown Underway Canada in for a Bumpy Ride" See www. td.com/economics/ (accessed Sept. 19, 2006) 2www.worldbank.org/mdf/mdf1/advantge.htm (accessed Sept. 19, 2006) 3 Source: Statistics Canada, Business Register 2005. 4 Source: Statistics Canada, Industrial Research and Development -2004 intentions, No. 88-202-XIB, January 2005. 5 Nordhaus notes that over the 1990-1995 period the value of improved health or health income grew at between 2.2 and 3.0 per cent per year in the United States, compared to only 2.1 per cent for consumption. See The Health of Nations: The Contribution of Improved Health to Living Standards William D. Nordhaus, Yale University www.laskerfoundation.org/reports/pdf/economic.pdf (accessed Sept. 18, 2006) 6 See Appendix 1 for 3-year investment details as well as short, medium and long-term returns on investment 7 www.worldbank.org/mdf/mdf1/advantge.htm Accessed September 20, 2006. 8 Source: ww2.heartandstroke.ca/Page.asp?PageID=1366&ArticleID=4321&Src=blank&From=SubCategory Accessed August 14, 2006. 9 P.Katzmarzyk, I. Janssen "The Economic costs associated with physical inactivity and obesity in Canada: An Update" Can J Applied Physiology 2004 Apr; 29(2):90-115. www.phe.queensu.ca/epi/ABSTRACTS/abst81.htm Accessed August 14, 2006. 10 Staying@Work 2002/2003 Building on Disability Management, Watson Wyatt Worldwide www.watsonwyatt.com/canada-english/pubs/stayingatwork/ Accessed July 31, 2006. 11 Swinburn, et al. International Journal of Pediatric Obesity (vol 1, p 133) (accessed Sept. 19, 2006) 12 Canada's Public Health Care System Through to 2020, the Conference Board of Canada, November 2003. 13 The Economic Cost of Wait Times in Canada, by the Center for Spatial Economics, June 2006. www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/CMA_This_Week/BCMA-CMA-waittimes.pdf 14 Booz, Allan, Hamilton Study, Pan-Canadian Electronic Health Record, Canada's Health Infoway's 10-Year Investment Strategy, March 2005-09-06 15 See Appendix 1 and Appendix 2 for more investment details and background. 16 Final Report of the Federal Advisor on Wait Times, June 2006, Dr. Brian Postl 17 Booz Allen Hamilton Study, Pan-Canadian Electronic Health Record, Canada Health Infoway's 10-Year Investment Strategy, March 2005 18 Can taxation curb obesity? See www.newscientist.com/article/dn9787-can-taxation-curb-obesity.html (accessed September 20, 2006.) Medicine for a more competitive Canadian economy
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CMA’s Recommendations for Bill S-5 An Act to amend the Tobacco Act and the Non-smokers’ Health Act and to make consequential amendments to other Acts

https://policybase.cma.ca/en/permalink/policy13918
Date
2018-02-15
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Health care and patient safety
  1 document  
Policy Type
Parliamentary submission
Date
2018-02-15
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Health care and patient safety
Text
The Canadian Medical Association (CMA) is pleased to provide this submission to the House of Commons Standing Committee on Health for its study of Bill S-5, An Act to amend the Tobacco Act and the Non-Smokers Health Act and to make consequential amendments to other Acts. We support the government’s effort to implement a new legislative and regulatory framework to address vaping products and related matters. Vaping products, such as electronic cigarettes (or e-cigarettes) replicate the act and taste of smoking but do not contain tobacco. We also recognize that the federal government is attempting to find a balance between regulating vaping devices and making them available to adults. Canada’s physicians, who see the devastating effects of tobacco use every day in their practices, have been working for decades toward the goal of a smoke-free Canada. The CMA issued its first public warning concerning the hazards of tobacco in 1954 and has continued to advocate for the strongest possible measures to control its use. The CMA has always supported strong, comprehensive tobacco control legislation, enacted and enforced by all levels of government, and we continue to do so. Our most recent efforts centred on our participation in the 2016 Endgame Summit, held late last year in Kingston, Ontario. This brief will focus on three areas: supporting population health; the importance of protecting youth; and, the promotion of vaping products. Overview Tobacco is an addictive and hazardous product, and a leading cause of preventable disease and death in Canada. Smoking has been on the decline in Canada the most recent Canadian Community Health Survey reports that 17.7% of the population aged 12 and older were current daily or occasional smokers in 2015 (5.3 million smokers); that is down from 18.1% in 2014.1 Many strong laws and regulations have already been enacted but some areas remain to be addressed and strengthened especially as the 1 Statistics Canada. Smoking, 2015. Health Fact Sheets. Statistics Canada Cat. 82-625-X. Ottawa: Statistics Canada; 2016. Available: http://www.statcan.gc.ca/pub/82-625-x/2017001/article/14770-eng.htm (accessed 2018 Feb 1). 2 Czoli CD, Hammond D, White CM. Electronic cigarettes in Canada: Prevalence of use and perceptions among youth and young adults. Can J Public Health. 2014;105(2):e97-e102. 3 Filippos FT, Laverty AA, Gerovasili V, et al. Two-year trends and predictors of e-cigarette use in 27 European Union member states. Tob Control. 2017;26:98-104. 4 Malas M, van der Tempel J, Schwartz R, Minichiello A, Lightfoot C, Noormohamed A, et al. Electronic cigarettes for smoking cessation: A systematic review. Nicotine Tob Res. 2016;18(10):1926–36. 5 O’Leary R, MacDonald M, Stockwell T, Reist D. Clearing the air: A systematic review on the harms and benefits of e-cigarettes and vapour devices. Victoria, BC: Centre for Addictions Research of BC; 2017. Available: http://ectaofcanada.com/clearing-the-air-a-systematic-review-on-the-harms-and-benefits-of-e-cigarettes-and-vapour-devices/ (accessed 2018 Feb 1). 6 El Dib R, Suzumura EA, Akl EA, Gomaa H, Agarwal A, Chang Y, et al. Electronic nicotine delivery systems and/or electronic non-nicotine delivery systems for tobacco smoking cessation or reduction: a systematic review and meta-analysis. BMJ Open. 2017 23;7:e012680. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5337697/pdf/bmjopen-2016-012680.pdf (accessed 2018 Feb 1). 7 Shahab L, Goniewicz M, Blount B, et al. Nicotine, carcinogen, and toxin exposure in long-term e- cigarette and nicotine replacement therapy users: A cross sectional study. Annals of Internal Medicine. 2017;166(6):390-400. 8 Collier R. E-cigs have lower levels of harmful toxins. CMAJ. 2017 Feb 27;189:E331. 9 Sleiman M, Logue J, Montesinos VN, et al. Emissions from electronic cigarettes: Key parameters affecting the release of harmful chemicals. Environmental Science and Technology. 2016 Jul 27;50(17):9644-9651. 10 England LJ, Bunnell RE, Pechacek TF, Tong VT, McAfee TA. Nicotine and the developing human: A neglected element in the electronic cigarette debate. Am J Prev Med. 2015 Aug;49(2):286-93. 11 Foulds J. Use of Electronic Cigarettes by Adolescents. J Adolesc Health. 2015 Dec;57(6):569-70. 12 Khoury M, Manlhiot C, Fan CP, Gibson D, Stearne K, Chahal N, et al. Reported electronic cigarette use among adolescents in the Niagara region of Ontario. CMAJ. 2016 Aug 9;188(11):794-800. 13 U.S. National Cancer Institute and World Health Organization. The Economics of Tobacco and Tobacco Control. National Cancer Institute Tobacco Control Monograph 21. NIH Publication No. 16-CA- 8029A. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute; and Geneva, CH: World Health Organization; 2016. 14 Miech R, Patrick ME, O’Malley PM, Johnston LD. E-cigarette use as a predictor of cigarette smoking: results from a 1-year follow-up of a national sample of 12th grade students. Tob Control. 2017 Dec;26(e2):e106–11. 15 Primack BA, Soneji S, Stoolmiller M, Fine MJ, Sargent JD. Progression to traditional cigarette smoking after electronic cigarette use among US adolescents and young adults. JAMA Pediatr. 2015 Nov;169(11):1018–23. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4800740/pdf/nihms768746.pdf (accessed 2018 Feb 1). 16 Hoe J, Thrul J, Ling P. Qualitative analysis of young adult ENDS users’ expectations and experiences. BMJ Open. 2017;7:e014990. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5353280/pdf/bmjopen-2016-014990.pdf (accessed 2018 Feb 1). 17 Fairchild AL, Bayer R, Colgrove J. The renormalization of smoking? E-cigarettes and the tobacco “endgame.” N Engl J Med. 2014 Jan 23;370:4 Available: http://www.nejm.org/doi/pdf/10.1056/NEJMp1313940 (accessed 2018 Feb 1). 18 Choi K, Grana R, Bernat D. Electronic nicotine delivery systems and acceptability of adult cigarette smoking among Florida youth: Renormalization of smoking? J Adolesc Health. 2017 May;60(5):592–8. tobacco industry continues to evolve. Electronic cigarettes and vaping represents the next step in that evolution. While Canada is to be congratulated on its success to date, it needs to maintain an environment that encourages Canadians to remain tobacco-free if smoking prevalence is to be reduced further in Canada. The CMA believes it is incumbent on all levels of government in Canada to keep working on comprehensive, coordinated and effective tobacco control strategies, including vaping products, to achieve that goal. Supporting Population Health The arrival of vaping products in Canada placed them in a “grey zone” with respect to legislation and regulation. Clarification of their status is crucial from a public health perspective because of their growing popularity, particularly among youth.2 E-cigarettes have both defenders and opponents. Proponents say they are safer than tobacco cigarettes since they do not contain the tar and other toxic ingredients that are the cause of tobacco related disease. Indeed, some believe they serve a useful purpose as a harm reduction tool or cessation aid (though it is forbidden to market them as such since that claim has never been approved by Health Canada). Opponents are concerned that the nicotine delivered via e-cigarettes is addictive and that the cigarettes may contain other toxic ingredients such as nitrosamines. Also, they worry that acceptance of e-cigarettes will undermine efforts to de-normalize smoking, and that they may be a gateway to the use of tobacco by people who might otherwise have remained smoke-free. This issue will be addressed later in this brief. This difference of opinion certainly highlights the need for more research into the harms and benefits of vaping products and the factors that cause people to use them.3 Encouraging smokers to move from combustible tobacco products to a less harmful form of nicotine may be a positive step. However the current available evidence is not yet sufficient to establish them as a reliable cessation method. A systematic review published by M. Malas et al. (2016) concluded that while “a majority of studies demonstrate a positive relationship between e-cigarette use and smoking cessation, the evidence remains inconclusive due to the low quality of the research published to date.”4 Indeed, some are helped by these devices to quit smoking but “more carefully designed and scientifically sound studies are urgently needed to establish unequivocally the long-term cessation effects of e-cigarettes and to better understand how and when e-cigarettes may be helpful.”4 The authors found that the evidence examining e-cigarettes as an aid to quitting smoking was determined to be “very low to low.”4 A similar result was found for their use in reducing smoking; the quality of the evidence was revealed as being “very low to moderate.”4 This conclusion is supported by another review conducted by the University of Victoria (2017). It too indicates that there are not enough studies available to fully determine the efficacy of vaping devices as a tobacco cessation device.5 This review also noted that there is “encouraging evidence that vapour devices can be at least as effective as other nicotine replacements.”5 Another review by R. El Dib et al. (2017) reinforces these findings. Limited evidence was also found with respect to the impact of electronic devices to aide cessation. They also noted that the data available from randomized control trials are of “low certainty” and the “observational studies are of very low certainty.”6 The wide range of devices available makes it very difficult to test which are the most effective in helping cessation efforts. Many of the studies are on older devices so it is possible that as second-generation technology becomes available they will prove to be more successful. In view of this uncertainty, the CMA calls for more scientific research into the potential effectiveness and value of these devices as cessation aids. Physicians need to be confident that if they recommend such therapy to their patients it will have the desired outcome. To that end, we are pleased that Health Canada will continue to require manufacturers to apply for authorization under the Food and Drugs Act to sell products containing nicotine and make therapeutic claims. Risk and Safety In addition to the discussion concerning the usefulness of vaping devices as cessation devices, concerns from a public health standpoint involve the aerosol or vapour produced by heating the liquids used in these devices, and the nicotine some may contain. The tube of an e-cigarette contains heat-producing batteries and a chamber holding liquid. When heated, the liquid is turned into vapour which is drawn into the lungs. Ingredients vary by brand but many contain nicotine and/or flavourings that are intended to boost their appeal to young people. The CMA is concerned that not enough is known about the safety of the ingredients in the liquids being used in vaping devices. While it is the case that because e-cigarettes heat rather than burn the key constituent, they produce less harmful toxins and are much safer than conventional cigarettes. Research in the UK suggested that “long-term Nicotine Replacement Therapy (NRT)-only and e-cigarette-only use, but not dual-use of NRTs or e-cigarettes with combustible cigarettes, is associated with substantially reduced levels of measured carcinogens and toxins relative to smoking only combustible cigarettes.”7 However, this study has been criticized because “it only looked at a few toxins and didn’t test for any toxins that could be produced by e- cigarettes.”8 The variety of flavourings and delivery systems available make it imperative that the risks associated with these products be fully understood. As one study noted “analysis of e-liquids and vapours emitted by e-cigarettes led to the identification of several compounds of concern due to their potentially harmful effects on users and passively exposed non-users.”9 The study found that the emissions were associated with both cancer and non-cancer health impacts and required further study.9 There is another aspect of the public health question surrounding vaping devices. There is data to support the idea that “nicotine exposure during periods of developmental vulnerability (e.g., fetal through adolescent stages) has multiple adverse health consequences, including impaired fetal brain and lung development.”10 Therefore it is imperative that pregnant women and youth be protected. There is not enough known about the effects of long-term exposure to the nicotine inhaled through vaping devices at this time.11 Recommendations: 1) Given the scarcity of research on e-cigarettes the Canadian Medical Association calls for ongoing research into the potential harms of electronic cigarette use, including the use of flavourings and nicotine. 2) The CMA calls for more scientific research into the potential effectiveness and value of these devices as cessation aids. 3) The Canadian Medical Association supports efforts to expand smoke-free policies to include a ban on the use of electronic cigarettes in areas where smoking is prohibited. Protecting Youth The CMA is encouraged by the government’s desire to protect youth from developing nicotine addiction and inducements to use tobacco products. Young people are particularly vulnerable to peer pressure, and to tobacco industry marketing tactics. The CMA supports continued health promotion and social marketing programs aimed at addressing the reasons why young people use tobacco and have been drawn to vaping devices, discouraging them from starting to use them and persuading them to quit, and raising their awareness of tobacco industry marketing tactics so that they can recognize and counteract them. These programs should be available continuously in schools and should begin in the earliest grades. The “cool/fun/new” factor that seems to have developed around vaping devices among youth make such programs all the more imperative.12 The CMA recommends a ban on the sale of all electronic cigarettes to Canadians younger than the minimum age for tobacco consumption in their province or territory. We are pleased to see that Bill S-5 aims to restrict access to youth, including prohibiting the sale of both tobacco and vaping products in vending machines as well as prohibiting sales of quantities that do not comply with the regulations. In fact, the CMA recommends tightening the licensing system to limit the number of outlets where tobacco products, including vaping devices, can be purchased. The more restricted is availability, the easier it is to regulate. The CMA considers prohibiting the promotion of flavours in vaping products that may appeal to youth, such as soft drinks and cannabis, to be a positive step. A recent report published by the World Health Organization and the US National Cancer Institute indicated that websites dedicated to retailing e-cigarettes “contain themes that may appeal to young people, including images or claims of modernity, enhanced social status or social activity, romance, and the use of e-cigarettes by celebrities.”13 We are therefore pleased that sales of vaping products via the internet will be restricted through prohibiting the sending and delivering of such products to someone under the age of 18. This will be critical to limiting the tobacco industry’s reach with respect to youth. There have also been arguments around whether vaping products will serve as gateways to the use of combusted tobacco products. The University of Victoria (2017) paper suggests this isn’t the case; it notes that “there is no evidence of any gateway effect whereby youth who experiment with vapour devices are, as a result, more likely to take up tobacco use.”5) They base this on the decline in youth smoking while rates of the use of vaping devices rise.Error! Bookmark not defined. Others contend that vaping is indeed a gateway, saying it acts as a “one-way bridge to cigarette smoking among youth. Vaping as a risk factor for future smoking is a strong, scientifically-based rationale for restricting access to e-cigarettes.”14 Further, in a “national sample of US adolescents and young adults, use of e-cigarettes at baseline was associated with progression to traditional cigarette smoking. These findings support regulations to limit sales and decrease the appeal of e- cigarettes to adolescents and young adults.”15 However, there may be a role for vaping products in relation to young users. A New Zealand study conducted among young adults that examined how electronic nicotine delivery systems (ENDS) were used to recreate or replace smoking habits. It found that study participants “used ENDS to construct rituals that recreated or replaced smoking attributes, and that varied in the emphasis given to device appearance.”16 Further, it was suggested that ascertaining how “ENDS users create new rituals and the components they privilege within these could help promote full transition from smoking to ENDS and identify those at greatest risk of dual use or relapse to cigarette smoking.”16 The CMA believes that further research is needed on the question of the use of vaping products as a gateway for youth into combustible tobacco products. Recommendations: 4) The Canadian Medical Association recommends a ban on the sale of all electronic cigarettes to Canadians younger than the minimum age for tobacco consumption in their province or territory. 5) The Canadian Medical Association calls for ongoing research into the potential harms and benefits of electronic cigarette use among youth. 6) The Canadian Medical Association recommends tightening the licensing system to limit the number of outlets where tobacco products, including vaping devices, can be purchased. Promotion of Vaping Products The CMA has been a leader in advocating for plain and standardized packaging for tobacco products for many years. We established our position in 1986 when we passed a resolution at our General Council in Vancouver recommending to the federal government “that all tobacco products be sold in plain packages of standard size with the words “this product is injurious to your health” printed in the same size lettering as the brand name, and that no extraneous information be printed on the package.” The CMA would like to see the proposed plain packing provisions for tobacco be extended to vaping products as well. The inclusion of the health warning messages on vaping products is a good first step but efforts should be made to ensure that they are of similar size and type as those on tobacco as soon as possible. The restrictions being applied to the promotion of vaping products is a positive step, especially those that could be aimed at youth, but they do not go far enough. The CMA believes the restrictions on promotion should be the same as those for tobacco products. As the WHO/U.S. National Cancer Institute has already demonstrated, e- cigarette retailers are very good at using social media to promote their products, relying on appeals to lifestyle changes to encourage the use of their products. The CMA is also concerned that e-cigarette advertising could appear in locations and on mediums popular with children and youth if they are not prohibited explicitly in the regulations. This would include television and radio advertisements during times and programs popular with children and youth, billboards near schools, hockey arenas, and on promotional products such as t-shirts and ball caps. As efforts continue to reduce the use of combustible tobacco products there is growing concern that the rising popularity of vaping products will lead to a “renormalization” of smoking. In fact, worry has been expressed that the manner they have been promoted “threaten(s) to reverse the successful, decades-long public health campaign to de- normalize smoking.”17 A recent US study indicated that students that use vaping products themselves, exposure to advertising of these devices, and living with other users of vaping products is “associated with acceptability of cigarette smoking, particularly among never smokers.”18 Further research is needed to explore these findings. Recommendations: 7) The Canadian Medical Association recommends similar plain packaging provisions proposed for tobacco be extended to vaping products. 8) Health warning messages on vaping products should be of similar size and type as those on tobacco as soon as possible 9) The Canadian Medical Association believes the restrictions on promotion of vaping products and devices should be the same as those for tobacco products. Conclusion Tobacco is an addictive and hazardous product, and a leading cause of preventable disease and death in Canada. Our members see the devastating effects of tobacco use every day in their practices and to that end the CMA has been working for decades toward the goal of a smoke-free Canada. The tobacco industry continues to evolve and vaping represents the next step in that evolution. The CMA believes it is incumbent on all levels of government in Canada to keep working on comprehensive, coordinated and effective tobacco control strategies, including vaping products, to achieve that goal. Bill S-5 is another step in that journey. Researchers have identified potential benefits as well as harms associated with these products that require much more scrutiny. The association of the tobacco industry with these products means that strong regulations, enforcement, and oversight are needed. Recommendations: 1) Given the scarcity of research on e-cigarettes the Canadian Medical Association calls for ongoing research into the potential harms of electronic cigarette use, including the use of flavourings and nicotine. 2) The CMA calls for more scientific research into the potential effectiveness and value of these devices as cessation aids.. 3) The Canadian Medical Association supports efforts to expand smoke-free policies to include a ban on the use of electronic cigarettes in areas where smoking is prohibited. 4) The Canadian Medical Association recommends a ban on the sale of all electronic cigarettes to Canadians younger than the minimum age for tobacco consumption in their province or territory. 5) The Canadian Medical Association calls for ongoing research into the potential harms and benefits of electronic cigarette use among youth. 6) The Canadian Medical Association recommends tightening the licensing system to limit the number of outlets where tobacco products, including vaping devices, can be purchased. 7) The Canadian Medical Association recommends similar plain packaging provisions proposed for tobacco be extended to vaping products. 8) Health warning messages on vaping products should be of similar size and type as those on tobacco as soon as possible 9) The Canadian Medical Association believes the restrictions on promotion of vaping products and devices should be the same as those for tobacco products.
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Letter - CMA’s 2006 Pre-Budget Submission to the Minister of Finance

https://policybase.cma.ca/en/permalink/policy2031
Last Reviewed
2013-03-02
Date
2006-04-19
Topics
Health human resources
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2013-03-02
Date
2006-04-19
Topics
Health human resources
Health systems, system funding and performance
Text
On behalf of the Canadian Medical Association (CMA), I am pleased to present you with our pre-budget submission for your government's consideration. The CMA appreciates the opportunity to provide input into this government's first budget and to identify strategic investment opportunities for the long term health of Canadians. While Canada's health system faces many challenges, we believe that immediate action by the federal government in four key areas will offer both short term and long term benefits. They are: (1) the establishment of a Canada Health Access Strategy to support a patient wait-times guarantee; (2) a proposed Visa position buyback program and a repatriation program to immediately address shortfalls in health human resources; (3) a strengthening of Canada's public health infrastructure; and (4) a remedy for GST-induced distortions in the health care system.We believe these proposals fit well with the government's stated priorities. While information on each of these recommendations is attached for your information and consideration, I would like to provide you with an overview of each. 1. CANADA HEALTH ACCESS STRATEGY The CMA has been advocating for the implementation of maximum wait time thresholds or care guarantees for a number of years and is pleased that the government has included this as one of its top five priorities. As a first step, the CMA worked with six other specialty societies as part of the Wait Times Alliance (WTA) to develop a set of pan-Canadian wait-time benchmarks or performance goals released last August. We believe this work served as a catalyst for the provincial and territorial governments to move some way toward meeting their commitment in announcing pan-Canadian wait-time benchmarks last December. We must continue to work with governments and the academic community to improve access to medical care beyond the five priority health issues identified in the First Ministers' 2004 10-year health care plan. The second step in implementing patient wait-time guarantees is the issue of honouring the commitment and providing for patient recourse. As a member of the WTA, the CMA strongly supports accelerating the timetable to reduce wait times nationwide. However, the federal government needs to do its part to assist provinces in advancing the timetable by stepping up the flow of funds earmarked for the last four years of the accord. Our proposed Canada Health Access Strategy is comprised of three components directed at making this happen: supporting provinces to expand capacity and to handle surges in demand; supporting the creation of regional and/or national referral networks; and establishing a Canada Health Access Fund for a "safety valve" to help Canadians access care elsewhere when necessary. Details on how this Strategy would work are attached. The point is that this Strategy is necessary to assure Canadians that they get the care they need when they need it. Recommendation 1. The federal government advance the remaining $1 billion from the 2004 First Ministers Accord that was originally intended to augment the Wait Times Reduction Fund (2010-2014) to support a Canada Health Access Strategy by: (a) expanding provincial surge capacity : $500 million to be flowed immediately to provinces on a per capita basis in return for agreement to accelerate the timetable for bringing down wait times, as was promised in the recent federal election campaign; (b) improving national coordination of wait time management: $250 million to support creation of regional and/or national referral networks, a more coordinated approach to health human resource planning, expansion of information technology solutions to wait time management and facilitation of out-of-country referrals; and (c) establishing a Canada Health Access Fund: $250 million initial investment in an alternative patient recourse system or "safety valve" when and if clinically-indicated maximum wait time benchmarks as agreed to by provinces/territories last December are exceeded. Addressing Shortfalls in Health Human Resources As identified by Minister Clement in a recent speech at the "Taming of the Queue III" wait-time conference, addressing shortages in health human resources is a key element of any strategy for reducing lengthy wait-times. Unfortunately, we face serious physician shortages, starting with family physicians. The bad news is that it can take several years to educate and train the necessary professionals. The good news is that there are some strategies that can be undertaken to address the situation in the short term. 2. VISA POSITION BUYBACK FUND One such strategy is our Visa Position Buyback proposal that would eliminate the backlog of 1,200 qualified international medical graduates (IMGs) over the next five to seven years. Currently, these qualified IMGs, who are either Canadian citizens or landed immigrants, are unable to access the necessary residency training. One existing source for training capacity exists with the positions purchased by foreign governments for visa trainees. We estimate that there are over 900 current visa trainees at all rank levels. By implementing the Visa Position Buyback program, the government is able to take an immediate step that will produce tangible results as soon as a two to four years from now. This initiative would be part of a longer term plan to fully address the shortages in health human resources and help the government meet its commitment to implement a properly functioning patient wait-time guarantee. Recommendation 2a. The federal government allocate $381.6 million toward the training of up to 1,200 IMGs through to practice over the 2007/08 to 2015/16 period. Funding would be made available in two installments: an immediate investment of $240 million and the remaining $140 million subject to a satisfactory progress report at the end of five years. Repatriate Health Professionals Working in the United States Fortunately, another short-term source of health professionals exists that Canada should pursue. Thousands of health care professionals are currently working in the United States including approximately 9,000 Canadian trained physicians. We know that many of the physicians who do come back to Canada are of relatively young age meaning that they have significant practice life left. While a minority of these physicians do come back on their own, many more can be repatriated in the short-term through a relatively small but focussed effort by the federal government led by a secretariat within Health Canada. Recommendation 2b. The federal government should establish a secretariat within Health Canada that would provide funding to national professional associations to conduct targeted campaigns to encourage the repatriation of Canadian health professionals working in the United States, and act as a clearinghouse on issues associated with returning to Canada (e.g., citizenship, taxation, etc.). 3. PUBLIC HEALTH INFRASTRUCTURE RENEWAL The CMA remains concerned about the state of Canada's public health system. Public health, including the professionals providing public health services, constitutes our front line against a wide range of threats to the health of Canadians. While there is much talk about the arrival of possible pandemics, Canada's public health system must be ready to take on a broad range of public health issues. The CMA has been supportive of the Naylor report which provides a blue print for action and reinvestment in the public health system for the 21st century. While this will take several years to achieve, there are some immediate steps that can be taken which will lessen the burden of disease on Canadians and our health care system. These steps include establishing a Public Health Partnership Program with provincial and territorial governments to build capacity at the local level and to advance pandemic planning. In addition, we call on the government to continue its funding of immunization programs under its National Immunization Strategy. Recommendation 3a. The federal government should establish a Public Health Infrastructure Renewal Fund in the amount of $350 million annually to establish a Public Health Partnership Program with the provincial/territorial governments for the purposes of building capacity at the local level and advancing pandemic planning. In addition, the $100 million per year for immunization programs under the National Immunization Strategy should be continued. 4. A REMEDY FOR GST-RELATED DISTORTIONS IN THE HEALTH SYSTEM The CMA and many other national health organizations are concerned about the increasing, unintended and negative consequences the GST is having on health care. For example, the 83% rebate originally provided for under the so-called "MUSH" formula is no longer tax neutral and is acting as a deterrent in some cases toward increased use of ambulatory care services such as day surgeries. Over the past 15 years the physicians of Canada have faced a large and growing unfair tax burden due to the GST. Since physicians' services are tax exempt under the law, physicians are unable to either claim input tax credits or pass on the tax because of the prohibition under the Canada Health Act of billing patients directly. This puts physicians in a unique and patently unfair catch 22 that now amounts to over $65 million per year, which further acts as a deterrent to repatriating or retaining Canadian physicians. Recommendation: 4a. That the federal government, in the course of reducing the GST from 7% to 5% further to its campaign commitments, remove the large and growing deterrent effects of the GST on the efficient and effective delivery of health care in Canada. In summary, the CMA is providing you with recommendations on strategic investments to help your government honour its commitment to timely access to care and to improve the health of Canadians. Our recommendations are financially reasonable, making good use of Canadians' tax dollars. We look forward to meeting with you on April 19 to discuss our proposals with you. Sincerely, Ruth L. Collins-Nakai, MD, MBA, FRCPC, MACC President c.c. The Honourable Tony Clement, Health Minister
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Maintaining Ontario’s leadership on prohibiting the use of sick notes for short medical leaves

https://policybase.cma.ca/en/permalink/policy13934
Date
2018-11-15
Topics
Physician practice/ compensation/ forms
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2018-11-15
Topics
Physician practice/ compensation/ forms
Health systems, system funding and performance
Text
The Canadian Medical Association (CMA) submits this brief to the Standing Committee on Finance and Economic Affairs for consideration as part of its study on Bill 47, Making Ontario Open for Business Act, 2018. The CMA unites physicians on national, pan-Canadian health and medical matters. As the national advocacy organization representing physicians and the medical profession, the CMA engages with provincial/territorial governments on pan-Canadian health and health care priorities. As outlined in this submission, the CMA supports the position of the Ontario Medical Association (OMA) in recommending that Schedule 1 of Bill 47 be amended to strike down the proposed new Section 50(6) of the Employment Standards Act, 2000. This section proposes to reinstate an employer’s ability to require an employee to provide a sick note for short leaves of absence because of personal illness, injury or medical emergency. Ontario is currently a national leader on sick notes In 2018, Ontario became the first jurisdiction in Canada to withdraw the ability of employers to require employees to provide sick notes for short medical leaves because of illnesses such as a cold or flu. This legislative change aligned with the CMA’s policy position1 and was strongly supported by the medical and health policy community. An emerging pan-Canadian concern about the use of sick notes As health systems across Canada continue to grapple with the need to be more efficient, the use of sick notes for short leaves as a human resources tool to manage employee absenteeism has drawn increasing criticism in recent years. In addition to Ontario’s leadership, here are a few recent cases that demonstrate the emerging concern about the use of sick notes for short leaves:
In 2016, proposed legislation to end the practice was tabled in the Manitoba legislature.2
The Newfoundland and Labrador Medical Association and Doctors Nova Scotia have been vocal opponents of sick notes for short leaves, characterizing them as a strain on the health care system.3,4
The University of Alberta and Queen’s University have both formally adopted “no sick note” policies for exams.5,6
The report of Ontario’s Changing Workplaces Review summarized stakeholder comments about sick notes, describing them as “costly, very often result from a telephone consultation and repeat what the physician is told by the patient, and which are of very little value to the employer.”7 Ontario’s action in 2018 to remove the ability of employers to require sick notes, in response to the real challenges posed by this practice, was meaningful and demonstrated leadership in the national context. The requirement to obtain sick notes negatively affects patients and the public By walking back this advancement, Ontario risks reintroducing a needless inefficiency and strain on the health system, health care providers, their patients and families. For patients, having to produce a sick note for an 4 employer following a short illness-related leave could represent an unfair economic impact. Individuals who do not receive paid sick days may face the added burden of covering the cost of obtaining a sick note as well as related transportation fees in addition to losing their daily wage. This scenario illustrates an unfair socioeconomic impact of the proposal to reinstate employers’ ability to require sick notes. In representing the voice of Canada’s doctors, the CMA would be remiss not to mention the need for individuals who are ill to stay home, rest and recover. In addition to adding a physical strain on patients who are ill, the requirement for employees who are ill to get a sick note, may also contribute to the spread of viruses and infection. Allowing employers to require sick notes may also contribute to the spread of illness as employees may choose to forego the personal financial impact, and difficulty to secure an appointment, and simply go to work sick. Reinstating sick notes contradicts the government’s commitment to end hallway medicine It is important to consider these potential negative consequences in the context of the government’s commitment to “end hallway medicine.” If the proposal to reintroduce the ability of employers to require sick notes for short medical leaves is adopted, the government will be introducing an impediment to meeting its core health care commitment. Reinstating sick notes would increase the administrative burden on physicians Finally, as the national organization representing the medical profession in Canada, the CMA is concerned about how this proposal, if implemented, may negatively affect physician health and wellness. The CMA recently released a new baseline survey, CMA National Physician Health Survey: A National Snapshot, that reveals physician health is a growing concern.8 While the survey found that 82% of physicians and residents reported high resilience, a concerning one in four respondents reported experiencing high levels of burnout. How are these findings relevant to the proposed new Section 50(6) of the Employment Standards Act, 2000? Paperwork and administrative burden are routinely found to rank as a key contributor to physician burnout.9 While a certain level of paperwork and administrative responsibility is to be expected, health system and policy decision-makers must avoid introducing an unnecessary burden in our health care system. Conclusion: Remove Section 50(6) from Schedule 1 of Bill 47 The CMA appreciates the opportunity to provide this submission for consideration by the committee in its study of Bill 47. The committee has an important opportunity to respond to the real challenges associated with sick notes for short medical leaves by ensuring that Section 50(6) in Schedule 1 is not implemented as part of Bill 47. 5 1 Canadian Medical Association (CMA). Third-Party Forms (Update 2017). Ottawa: The Association; 2017. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD17-02.pdf (accessed 2019 Nov 13). 2 Bill 202. The Employment Standards Code Amendment Act (Sick Notes). Winnipeg: Queen’s Printer for the Province of Manitoba; 2016. Available: https://web2.gov.mb.ca/bills/40-5/pdf/b202.pdf (accessed 2019 Nov 13). 3 CBC News. Sick notes required by employers a strain on system, says NLMA. 2018 May 30. Available: www.cbc.ca/news/canada/newfoundland-labrador/employer-required-sick-notes-unnecessary-says-nlma-1.4682899 4 CBC News. No more sick notes from workers, pleads Doctors Nova Scotia. 2014 Jan 10. Available: www.cbc.ca/news/canada/nova-scotia/no-more-sick-notes-from-workers-pleads-doctors-nova-scotia-1.2491526 (accessed 2019 Nov 13). 5 University of Alberta University Health Centre. Exam deferrals. Edmonton: University of Alberta; 2018. Available: www.ualberta.ca/services/health-centre/exam-deferrals (accessed 2019 Nov 13). 6 Queen’s University Student Wellness Services. Sick notes. Kingston: Queen’s University; 2018. Available: www.queensu.ca/studentwellness/health-services/services-offered/sick-notes (accessed 2019 Nov 13). 7 Ministry of Labour. The Changing Workplaces Review: An Agenda for Workplace Rights. Final Report. Toronto: Ministry of Labour; 2017 May. Available: https://files.ontario.ca/books/mol_changing_workplace_report_eng_2_0.pdf (accessed 2019 Nov 13). 8 Canadian Medical Association (CMA). One in four Canadian physicians report burnout [media release]. Ottawa: The Association; 2018 Oct 10. Available: www.cma.ca/En/Pages/One-in-four-Canadian-physicians-report-burnout-.aspx (accessed 2019 Nov 13). 9 Leslie C. The burden of paperwork. Med Post 2018 Apr.
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Meeting the demographic challenge: Investments in seniors care

https://policybase.cma.ca/en/permalink/policy13924
Date
2018-08-03
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Date
2018-08-03
Topics
Population health/ health equity/ public health
Text
Recommendation: That 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. The Canadian Medical Association unites 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. Introduction The Canadian Medical Association (CMA) is pleased to provide the House of Commons Standing Committee on Finance this pre-budget submission, focused on the major challenges confronting seniors care in Canada. As Canada’s demographic shift advances, the challenge of ensuring quality seniors care will only become more daunting unless governments make critical investments in our health care system today. This is a national issue that will affect all provinces and territories (PTs). However, not all PTs will bear the costs equally. The current federal health transfer system does not take demographics into account. The CMA proposes the federal government fund a share of the health care costs associated with our aging population by means of a new “demographic top-up” to the Canada Health Transfer (CHT). Recommendation: That 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. Seniors Care: Challenges and Opportunities Canada, like most OECD economies, is grappling with the realities of a rapidly aging population. The population of seniors over the age of 65 in Canada has increased by 20% since 2011 and it has been projected that the proportion of Canada’s total population over 65 will exceed one-third by 2056 with some provinces like Newfoundland and Labrador reaching that point as soon as the mid-2030s.1 Census figures also show that the fastest growing demographic in Canada between 2011 and 2016 was individuals over 90, growing four times the rate of the overall population during this period.2 These demographic changes have a number of major implications for the future of Canadian society. Chief among them is the new pressure they add to our health care system. As the population ages, it is expected that health care costs will grow at a significantly faster rate than in previous years. As demonstrated in Chart 1 below, population aging will be a top contributor to rising health care costs over the decade ahead. By 2026–27, these increases will amount to $19 billion in additional annual health care costs associated with population aging, as shown in Chart 2. Many seniors experience varying degrees of frailty, which the Canadian Frailty Network (CFN) defines as “a state of increased vulnerability, with reduced physical reserve and loss of function across multiple body systems” that “reduces ability to cope with normal or minor stresses, which can cause rapid and dramatic changes in health.”3 About 75% to 80% of seniors report having one or more chronic conditions.4 It is primarily the care associated with management of these conditions as well as increased residential care needs that drive the higher costs associated with seniors care. The average annual per capita provincial/territorial health spending for individuals age 15 to 64 is $2,700 compared with $12,000 for seniors age 65 and over.5 Our medicare system, which was established over half a century ago, is not designed or resourced to deal with this new challenge. The median age of Canadians at the time of the Medical Care Act’s enactment in 1966 was 25.5 years. It is now 40.6 years and is expected to rise to 42.4 years in the next decade.5 While past governments have placed significant focus on hospital care (acute and sub-acute), transitional care, community supports such as home care and long-term care (LTC) have been largely underfunded. Demographic changes have already begun to place pressure on our health care system, and the situation will only become worse unless funding levels are dramatically raised. Chart 1: Major contributors to rising health care costs (forecast average annual percentage increase, 2017–26)5 Chart 2: Provincial/terrioritial health care costs attributable to population aging ($ billions, all PTs relative to 2016–17 demographics)5 Individuals in Ontario wait a median of 150 days for placement in a LTC home.6 In many communities across the country acute shortages in residential care infrastructure mean that seniors can spend as long as three years on a wait list for LTC.7 Seniors from northern communities are often forced to accept placements hundreds of kilometres from their families.8 The human and social costs of this are self-evident but insufficient spending on LTC also has important consequences for the efficiency of the system as a whole. When the health of seniors stabilizes after they are admitted to hospital for acute care, health care professionals are often confronted with the challenge of finding better living options for their patients. These patients are typically assigned Alternate Level of Care (ALC) beds as they wait in hospital for appropriate levels of home care or access to a residential care home/facility. In April 2016, ALC patients occupied 14% of inpatient beds in Ontario while in New Brunswick, 33% of the beds surveyed in two hospitals were occupied by ALC patients.9 The average length of hospital stay of all ALC patients in Canada is an unacceptable 380 days. Not only does ALC care lead to generally worse health outcomes and patient satisfaction than both LTC and home care, but it is also significantly more expensive. The estimated daily cost of a hospital bed used by a patient is $842, compared with $126 for a LTC bed and $42 per day for care at home.10 Moreover, high rates of ALC patients can contribute to hospital overcrowding, lengthy emergency wait times and cancelled elective surgeries.11 Committing more funding to LTC infrastructure would lead to system-wide improvements in wait times and quality of care by helping to alleviate the ALC problem. A recent poll found that only 49% of Canadians are confident that the health care system will be able to meet senior care needs and that 88% of Canadians support new federal funding measures.12 Fortunately, there have been some signs at both the provincial and federal levels that seniors care has become an issue of increasing importance. New Brunswick recently introduced a caregiver’s benefit while the Ontario government has recently committed to building 15,000 LTC beds over the next decade. The federal government highlighted home care as a key investment area in the most recent Health Accord bilateral agreements and has made important changes to both the Canada Pension Plan (CPP) and Old Age Security (OAS) programs. The Demographic Top-Up: Modernizing the CHT Despite these recent and important initiatives by governments in Canada, additional policy and fiscal measures will be needed to address the challenges of an aging population. Many provincial governments have shown a clear commitment to the issue, but the reality is that their visions for better seniors care will not come to fruition unless they are backed up by appropriate investments. This will not be possible unless the federal government ensures transfers are able to keep up with the real cost of health care. Current funding levels clearly fail to do so. Projections in a recent report by the Conference Board of Canada, commissioned by the CMA, indicate that health transfers are expected to rise by 3.6% while health care costs are expected to rise by 5.1% annually over the next decade.3 Over the next decade, unless changes are made, provinces/territories will need to assume an increasingly larger share of health care costs. If federal health transfers do not account for population aging, the federal share of health care spending will fall below 20% by 2026.5 Aging will affect some provinces more than others, as demonstrated in Figure 1 below. The overall cost of population aging to all of the provinces and territories is projected to be $93 billion over the next decade.5 The absence of demographic considerations in transfer calculations therefore indirectly contributes to regional health inequality as provinces will not receive the support they need to ensure that seniors can count on quality care across Canada. Figure 1: Increases in health care costs associated with population aging, 2017 to 2026 ($ billions)5 The CMA recommends that the federal government address the health costs of population aging by introducing a “demographic top-up” to the Canada Health Transfer. One model for this would require the federal government to cover a share of the costs projected to be added by population aging in each province/territory (see above) equal to the federal share of total health costs covered now (22%). The Conference Board of Canada estimates that the overall cost of such a change would be $21.1 billion over the next decade (see Table 1). This funding would greatly enhance the ability of the provinces and territories to make much-needed investments in seniors care and the health care system as a whole. It could be used to support the provinces’ and territories’ efforts to address shortages in LTC, to expand palliative care and home care supports and to support further innovation in the realm of seniors care. Table 1: Cost of demographic top-Up by province in $ millions5 Conclusion The evidence that our health care systems are not prepared or adequately funded to ensure appropriate and timely access to seniors care, across the continuum of care, is overwhelming. Wait times for LTC and home care are unacceptably high and complaints about lack of availability in Northern and rural communities are becoming increasingly common. Health care providers in the LTC sector regularly raise concern about overstretched resources and a lack of integration with the rest of the health care system. By introducing a new demographic top-up to the Canada Health Transfer, the federal government would demonstrate real leadership by ensuring that all provinces/territories are able to adapt to an aging population without eroding quality of care. Furthermore, improvements in how we care for our seniors will lead to improvements for patients and caregivers of all ages through greater system efficiencies (e.g., shorter wait times for emergency care and elective surgeries) and more coordinated care. The CMA has been, and will continue to be, a tireless advocate for improving seniors care in Canada. The CMA would welcome opportunities to provide further information on the recommendation outlined in this brief. References 1Statistics Canada. Age and sex, and type of dwelling data: key results from the 2016 Census. Ottawa: Statistics Canada; 2017. Available: https://www150.statcan.gc.ca/n1/daily-quotidien/170503/dq170503a-eng.htm 2Ministry of Finance Ontario. 2016 Census highlights, fact sheet 3. Toronto: Office of Economic Policy, Labour Economics Branch; 2017. Available: www.fin.gov.on.ca/en/economy/demographics/census/cenhi16-3.html. 3Canadian Frailty Network. What is frailty? Kingston: The Network; 2018. Available: www.cfn-nce.ca/frailty-in-canada/ 4Canadian Institute for Health Information (CIHI). Health care in Canada, 2011: a focus on seniors and aging. Available: https://secure.cihi.ca/free_products/HCIC_2011_seniors_report_en.pdf 5The Conference Board of Canada. Meeting the care needs of Canada’s aging population. Ottawa: The Conference Board; 2018. Available: www.cma.ca/En/Lists/Medias/Conference%20Board%20of%20Canada%20-%20Meeting%20the%20Care%20Needs%20of%20Canada%27s%20Aging%20Population.PDF 6Health Quality Ontario. Wait times for long-term care homes. Available: www.hqontario.ca/System-Performance/Long-Term-Care-Home-Performance/Wait-Times 7Crawford B. Ontario’s long-term care problem: seniors staying at home longer isn’t a cure for waiting lists. Ottawa Citizen 2017 Dec 22. Available: https://ottawacitizen.com/news/local-news/ontarios-long-term-care-problem-seniors-staying-at-home-longer-isnt-a-cure-for-waiting-lists 8Sponagle J. Nunavut struggles to care for elders closer to home. CBC News 2017 Jun 5. Available: www.cbc.ca/news/canada/north/nunavut-seniors-plan-1.4145757 9McCloskey R, Jarrett P, Stewart C, et al. Alternate level of care patients in hospitals: What does dementia have to do with this? Can Geriatr J. 2014;17(3):88–94. 10Home Care Ontario. Facts and figures – publicly funded home care. Hamilton: Home Care Ontario; n.d. Available: www.homecareontario.ca/home-care-services/facts-figures/publiclyfundedhomecare 11Simpson C. Code gridlock: why Canada needs a national seniors strategy. Ottawa: Canadian Medical Association; 2014. Available: www.cma.ca/En/Lists/Medias/Code_Gridlock_final.pdf 12Ipsos Public Affairs. Just half of Canadians confident the healthcare system can meet the needs of seniors. Toronto: Ipsos; 2018. Available: www.ipsos.com/en-ca/news-polls/Canadian-Medical-Association-Seniors-July-17-2018
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Presentation to the House of Commons Standing Committee on Environment and Sustainable Development

https://policybase.cma.ca/en/permalink/policy2044
Last Reviewed
2013-03-02
Date
2006-06-12
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2013-03-02
Date
2006-06-12
Topics
Population health/ health equity/ public health
Text
My name is Dr. Isra Levy, and as a public health physician and the Chief Medical Officer and Director in the Canadian Medical Association's Office for Public Health, I am pleased to be participating in your roundtable today. With me is Mr. John Wellner, Director, Health Policy at our sister organization the Ontario Medical Association. CEPA is, of course, a key piece of Environmental Legislation, but we at the CMA see it to be primarily about health. Similarly, Canada's doctors see the topic of today's hearings, "Measuring CEPA's Success" in terms of the impacts on our medical practices and, more particularly, on our patients. To us the measurement of success that matters is good health in our patients. And unfortunately I must tell you that we still see the negative impacts of environmental degradation on our vulnerable patients every day. We are pleased to participate in this review of CEPA, because for us, the measure of health benefits and health outcomes, over the short or long-term that stem from reduced exposure to environmental contaminants is an important measure of our health as a nation. The Canadian Medical Association, first founded in 1867, currently represents more than 63,000 physicians across the country. Our mission includes advocating for the highest standard of health and care for all Canadians and we are committed to activities that will result in healthy public policy. The environment, as a determinant of health, is a major concern for the general public as well as health care providers. And health outcomes are directly linked to the physical environment in many, many ways. We know from the crises in Walkerton, Collingwood, North Battleford and many First Nations communities, the devastating effects that contaminated water can have on individuals and families. We know from the smog health studies undertaken by the OMA, Health Canada and others, about the public health crisis of polluted air in many parts of Canada. And it is a crisis. We are now in a position where science allows us to more clearly show the long-term, lifetime burden of morbidity caused by some of these pollutants; we now know that there are thousands more premature deaths caused by air pollution in Canada than has previously been appreciated. We are learning that central Canada is not the only place that has a smog problem. The OMA has shown, through its Illness Costs of Air Pollution model, that it is plausible to think in terms of substantial costs to the health and pocketbooks of Canadians because of environmental risks across the country. The CMA has developed many environmental policies that are pertinent to our CEPA discussion today. * Prior to Canada's ratification of the Kyoto Protocol, the CMA urged the Prime Minister 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. We realize that pollution prevention initiatives can have many health benefits and that pollution sources seldom emit contaminants in isolation. The smoke that you see, and often emissions that you can't see, represent a cocktail of potentially harmful substances. * The CMA has committed to working with the federal Ministers of health and the Environment to develop national strategies to reduce the unacceptably high levels of persistent organic pollutants amongst the peoples of the Arctic coast. * We have asked Environment Canada and Health Canada to initiate a review of the current Canadian one hour guideline for maximal exposure level to both indoor and outdoor NO2 and recommend 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. Let me return to the issue of measuring success though - Doctors understand the concept that success from an intervention can be nuanced. In the case of disease, physicians know and accept that the benefit of treatment is not always cure of a patient. 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 urge you to commit to measures of success in terms of real improvement, rather than merely accepting slight curtailments in the "inevitable increase" of environmental contamination. The issue of greenhouse gas reduction is one that illustrates this point. Just as slowing the progression of a disease can never be considered a cure, referring to an "inevitable increase" in emissions and attempting only to limit the growth of those emissions, cannot result in true success by any measure. We have seen 'good news' press releases on environmental initiatives from various federal and provincial governments, but the news isn't always worthy of praise. Although there have been some great environmental successes that Canadians should be proud of, the measure of overall success - on all contaminants of concern - has only been incremental at best. For example, when policy makers speak about industrial emission reductions of any kind, they often refer to "emissions intensity" - the emissions per unit of production, rather than total, overall emissions. To be health-relevant, the only meaningful way to report emissions reductions is to present them as "net" values, rather than the all-to-common "gross" valuation. 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. This issue becomes especially tricky with regional pollutants like smog precursors, because you may have to take the whole air shed into account. For this reason, cross- jurisdictional pollution control initiatives are very important in Canada - and that means federal oversight. In fact, to our understanding, that is what CEPA does, it gives the federal government jurisdictional authority, and, dare I say, obligation to act to protect the health of Canadians. To the CMA, and we believe to most Canadians, the real measure of success is a reduction in the illnesses associated with pollution. It is not just important how we measure this ultimate success, but how we measure our progress towards it. 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 CEPA comes in. This is where your role 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, water and foods. Canada has historically relied only on guidelines for contaminants of concern, memoranda of understanding with polluters and voluntary goals and targets. Our American neighbours prefer legally binding standards, strict emission monitoring, and pollution attainment designations. While there may be some benefit to the Canadian approach, we are clearly behind in this area. In many parts of the U.S., counties try desperately to avoid "non-attainment" designations based on the ambient air pollution target levels. If they are designated to be a non-attainment zone they risk loss of federal infrastructure transfer payments. In Canada, we have Canada-Wide smog Standards for 2010 - but of course these are non-binding, have no penalties for non-attainment, provide loopholes for any jurisdictions claiming cross-border pollution influences and allow provinces to opt-out with a mere three months notice. We must be more forceful. Indeed sufficient evidence exists on the health effects of a wide-range of CEPA-Toxic substances (smog precursors, for example) to justify more forceful action to reduce exposures. And there are many more chemicals of concern, for which all the evidence may perhaps not yet be in, but which require a precautionary approach in order to prevent potential human harm. So, although the presentation of environmental information (e.g., ambient pollution levels in a State of the Environment report, or a health-based Air Quality Index) is beneficial and may provide information that enables Canadians to reduce their exposures, ultimately this is not enough. The CMA believes that although enhanced environmental monitoring or pollutant exposure studies are important to our understanding of some contaminants, such studies in and of themselves will not improve the health of our patients. The true measure of success would go beyond reporting the danger, to actually reducing the danger. The CMA believes that is the purpose of CEPA. We look forward to working with you to improve CEPA and ensure that the measures of CEPA's success will benefit the health of our patients across Canada. Canadian Medical Association Ottawa, June 12, 2006
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Presentation to the Standing Committee on Human Resources, Social Development and the Status of Persons with Disabilities

https://policybase.cma.ca/en/permalink/policy8564
Last Reviewed
2019-03-03
Date
2006-09-21
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2019-03-03
Date
2006-09-21
Topics
Population health/ health equity/ public health
Text
While my remarks today will focus on the recognition of foreign credentials, mainly with reference to the medical profession with which I am most familiar, I want to emphasize that this is just one element of assuring a sustainable health workforce in Canada as my colleagues will be amplifying in greater detail. I want to impress upon Members of the Committee that the CMA does not test, credential, license or discipline physicians, nor is it empowered to act on complaints made by patients - this is the purview of the provincial/territorial licensing bodies. We are not directly involved in provincial or territorial benefit negotiations for physicians - this is the responsibility of our provincial/territorial Divisions. Nor do we control medical school enrolment or conduct clinical research. What we do, is carry out research and advocacy on short, medium and long term health and health care issues to ensure we can meet the current and emergent needs of Canadians. CONTRIBUTIONS OF INTERNATIONAL MEDICAL GRADUATES TO CANADA I would like to begin by dispelling the popular myth that Canada is a "closed shop" to persons with international medical credentials. In fact Canada has always relied on International Medical Graduates to make up a significant proportion of the medical workforce; this proportion has remained fairly steady at about one in four physicians for the past few decades. (Currently 23%). Our best estimate is that some 400 IMGs are newly licensed to practice in Canada each year. In fact, the College of Physicians and Surgeons of Ontario, has for the past two years licensed more IMGs that Ontario medical graduates. A corollary of this myth is that IMGs are unable to access the postgraduate medical training system to complete any supplementary training they might need. In the Fall 2005, of the some 7,800 postgraduate trainees in Canada just over 900 or 12% were IMGs. Many more are participating in special assessment/supervised practice programs in the community. The fact of the matter is that Canada has historically trained fewer physicians than we need to meet our population needs. This can be clearly demonstrated by looking at relative opportunity to enter medical school. In the most recent year (2005/2006) Canada had 7.1 first year medical school places per 100,000 population. This level is just over one-half of that of the United Kingdom, with its 12.9 places per 100,000 population. While the United States has the same ratio of medical school places per 100,000 population as Canada - it has 1.5 first year postgraduate places per medical graduate and relies on bringing large numbers of IMGs in to fill these places and supplement production in this manner. Not only is Canadian undergraduate medical education capacity inadequate, but postgraduate medical training capacity is similarly insufficient to meet the demands of training Canadian medical graduates, providing training to IMGs, and permitting Canadians to retrain in specialties. In 2006 of the 932 IMGs registered in the second iteration run by the Canadian Resident Matching Service, just 111 or 12% were successful in obtaining a training position. There is clearly a backlog of IMGs who are eligible to receive the supplementary training they need to become eligible for licensure to practice in Canada should sufficient capacity be available. For those who are not eligible, opportunities should be provided to achieve credentials in other health professions such as physician assistants or paramedics. A recent pilot project in Ontario was funded to allow IMGs to qualify and work as physician assistants in supervised practice settings. Against this backdrop, it is no small wonder that Canada ranks 26th out of 29 OECD countries in the ratio of physicians per 1,000 population. For the past decade Canada's ratio has stood at 2.1 physicians per 1,000 population - one-third below the OECD average of 3.0 in 2003. NATIONAL STANDARDS Over the years, medicine has worked hard to promote national standards for medical education and the practice of medicine in Canada. Since 1912 the Medical Council of Canada (MCC) has been responsible for promoting a uniform standard qualification to practice medicine for all physicians across Canada. This qualification, known as the Licentiate of the Medical Council of Canada (LMCC) is obtained by being successful on a two-part Qualifying Examination. While licensure of physicians is a provincial/territorial responsibility, there is a national standard for portable eligibility for licensure that was adopted in 1992 by the Federation of Medical Licensing (now Regulatory) Authorities of Canada (FMRAC), the Association of Canadian Medical Colleges (now Association of Faculties of Medicine of Canada) (AFMC) and the MCC. The basis of this standard is that "in all provinces except Quebec the basis for licensure for most trainees will be the successful completion of the two-part Qualifying Examination of the Medical Council of Canada plus certification by either the College of Family Physicians of Canada (CFPC) or the Royal College of Physicians and Surgeons of Canada (RCPSC)". A similar standard is applied by the Collège des médecine du Quèbec. This standard also applies to IMGs, although the provincial/territorial licensing bodies have the ability to grant exemptions in particular circumstances. SHORT, MEDIUM AND LONG TERM STRATEGY The CMA has advocated a short, medium and longer term strategy for integrating more IMGs into the Canadian medical workforce. In the short term the federal government should provide funding to clear the backlog of qualified physicians and other health professionals eligible to pursue supplementary training. In the medium term the federal government needs to work with the provincial and territorial governments and key stakeholders in the development of sufficient health professional education and training opportunities to accommodate: * Canadians who want to pursue careers as health professionals; * Currently practising health professionals who require supplementary training or who wish to retrain; * Internationally trained health professionals who are permanent residents and citizens of Canada who require supplementary training; and * International trained health professionals, non-residents of Canada who wish to pursue postgraduate training as visa trainees. In the long term Canada needs to adopt a policy commitment of increased self-sufficiency in the education and training of health professionals in Canada. In progressing these strategies I would stress the importance of the need for the federal government to engage the national health professional associations, as this is critical in moving the agenda forward. I would cite as one success story the outcomes of the multi-partite Canadian Task Force on Licensure of International Medical Graduates, which brought together federal and provincial/territorial governments and key medical organizations. Several initiatives are underway in follow-up to its 2004 report. An IMG database is being developed by the Canadian post-MD Education Registry of AFMC, sponsored by the federal government's Foreign Credential Recognition Program. The Physician Credentials Registry of Canada (PCRC) which is being developed under the leadership of the Medical Council of Canada (MCC) and the Federation of Medical Regulatory Authorities of Canada (FMRAC) will reduce duplication and increase the efficiency of data collection by providing a centralized uniform process to obtain primary source verification of a physician's diploma and other core medical credentials. Several provinces have greatly enhanced their ability to integrate IMGs, including supervised assessment programs in the community. We look forward to seeing results from a similar task force that is underway for nursing. CANADIAN AGENCY FOR ASSESSMENT AND RECOGNITION OF FOREIGN CREDENTIALS In conclusion, I would like to offer some ideas for the implementation of the Canadian Agency for the Assessment and Recognition of Foreign Credentials that was included in the 2006 federal budget. The Constitution Act 1867 clearly assigns the majority of responsibility for the delivery of health care to the provinces. On this basis, the licensure of physicians and other health professionals should continue to be a matter of provincial/territorial jurisdiction. In the case of medicine however, Canada has been well-served by the national standard for medical licensure that has been promoted by the MCC in concert with the national certification standards that are set by the RCPSC and CFPC. Based on the foregoing, it is proposed that the broad mandate for the Canadian agency is to promote and facilitate the adoption and awareness of national standards for certification and licensure with clearly articulated procedures for the assessment of the credentials of internationally trained professionals and pathways to licensure to practice in Canada. This might include the following activities: * promote understanding among educational institutions and professional organizations about the implications of the various international agreements that Canada is party to (e.g., NAFTA, WTO); * promote a sharing of leading practices between different disciplines; * facilitate international exchanges with regulatory bodies, within and between disciplines; * develop an evaluation framework that can assess the extent to which processes for the assessment of foreign credentials are fair, accessible, coherent, transparent and rigorous; * develop template materials that will help promote international sharing of information about career prospects in Canada for various occupations; * fund development and pilot projects on the application of information technology solutions; and * serve as a focal point for federal/provincial/territorial administrative requirements. I would stress that this will only be effective if representatives from the education and regulatory authorities and the practising community are at the table. Canadian Medical Association Ottawa, September 21, 2006
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Registered retirement savings plans : Presentation to the House of Commons Standing Committee on Finance

https://policybase.cma.ca/en/permalink/policy1996
Last Reviewed
2019-03-03
Date
1994-11-17
Topics
Physician practice/ compensation/ forms
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2019-03-03
Date
1994-11-17
Topics
Physician practice/ compensation/ forms
Text
Millions of Canadians are planning for their retirement relying on Registered Retirement Savings Plans (RRSPs) and private pension plans, either as their only future retirement income or to supplement the Canada Pension Plan (CPP) and Quebec Pension Plan (QPP). Approximately 5 million contribute to RRSPs. Another 3.7 million participate in registered pension plans (RPPs). Some are independent business people, others work in family businesses. Some are self-employed or work for organizations that have opted for RRSPs instead of RPPs. Our Alliance is representative of this Canadian diversity. The objective of the Alliance is to maintain the current provisions of the Income Tax Act (the Act) and Income Tax Regulations (the Regulations) governing retirement savings. The current system is fundamentally good for the economy of Canada, and any changes made for short term deficit reduction will ultimately harm the economy in general and small and medium-sized business, in particular. Research shows that RRSPs are an important tool for small business retirement planning. Only in recent years have limits been adjusted to bring similar protection to those afforded under RPPs. We have only just started to achieve a measure of equitable treatment for the retirement savings of the self-employed and employees not protected by employer pension plans. The current system provides for the harmonization of all tax-assisted retirement savings arrangements, which will only be achieved when the limits on money-purchase arrangements (including RRSPs) attain the equivalent limits already set for defined-benefit arrangements, such as employer pension plans. Changes to RRSPs alone will discriminate against the self-employed and against employees without employer pension plans. These Canadians form the majority of the workforce now and in the future. Arguments in favour of changes to the current system are based on two assumptions: firstly, that Canadians are saving sufficient income for their retirement and will continue to do so regardless of tax increases; and secondly, that the cost to the Government in lost tax revenues is enormous. Neither of these assumptions is valid. Background The fiscal theory underlying retirement savings is decades old. Contributions to registered plans are deductible and all earnings are exempt from tax until benefits are paid out from those plans. In essence the retirement savings system consists of a deferral of tax on contributions and earnings. The pension tax reform of 1989-1990 does not change the underlying fiscal theory. It aims to achieve equity between the employed and the self-employed and between defined benefit arrangements and money-purchase arrangements (including RRSPs). That equity was achieved by phasing in a higher contribution limit for money-purchase arrangements so that they could, in the future, provide a retirement income comparable to that furnished by a defined benefit arrangement. This objective of achieving equivalence permeates the Act and the Regulations and has resulted in a substantial and continuing realignment of retirement savings arrangements in Canada. That realignment, with its attendant compliance costs, borne by employers and employees, was based on the acceptance of the premises behind pension tax reform, which acceptance Canadians have demonstrated. This realignment had a gestation period of over 5 years. 1 From the 1984 federal budget, which sought complete equity but with massive compliance costs, to the 1985 federal budget, which sought lesser compliance costs but with diminished equity, there issued pension tax reform, which yields substantial equity with substantial compliance costs. The Auditor General, in his 1988 report, estimated that pension tax reform would necessitate $330 million in start-up costs and $15 million in annual reporting costs. The Department of Finance disagreed and estimated that start-up costs would be from $60 to $70 million and that the annual reporting costs would be between $10 and $15 million. The independent consultant's report, upon which the Auditor General's report was based, had said that the start-up costs would be $395 million. Accordingly, Canadians have already borne many of the costs of retooling the retirement savings system and will continue to do so. Having paid those costs, surely Canadians are entitled to the measure of equity that the system promises. Governing Principles There are disquieting rumours about possible changes to the current retirement savings system. As yet, the government has said little on this issue, other than to say that the retirement system is not inviolable. The Alliance seeks to maintain the status quo. We should, therefore, deal with the principles that underlie the current system, and which continue to hold true: internal fairness and the accumulation of sufficient retirement income. Internal Fairness The current system was reformed to deliver internal fairness - if not quite yet, by 1996. It allows individuals to accumulate a pre-determined amount of private retirement savings. Taxpayers may, on a tax-assisted basis, earn a lifetime pension at the rate of $1,722 per year. In other words, an employee with 35 years of service may be entitled, on retirement, to an annual lifetime pension of $60,270. That level of tax assistance has been available to members of defined benefit plans since 1977. It has been frozen at that level since that time and will remain frozen until 1996. The money purchase limits, including RRSP limits, have been phased in to eventually provide equivalent benefits. Accordingly, the annual RRSP limits, when fully instituted in 1996, will allow the self-employed to accumulate retirement savings equivalent to those of members of defined benefit plans. Thus, one of the rationales underlying the current retirement savings structure is to eliminate the earlier discrimination against the self-employed. The self-employed will now be allowed to achieve retirement savings equivalent to those available to employees. RRSPs are not an isolated program under the Act, but rather an integral component of an indissoluble whole. Accumulation of Sufficient Retirement Income The limits set by pension tax reform are intended to provide a level of retirement income that will allow retired individuals to maintain their standard of living. It is generally felt that a retirement income equal to about 60-70 percent of pre-retirement income should not result in a marked change in one's standard of living. Increasingly, it appears that individual taxpayers will need to rely more on private retirement savings and less on public programmes. It is important, therefore, that the tax system permit the accumulation of retirement savings sufficient to allow taxpayers to maintain their pre-retirement standard of living. Indeed, it does not appear possible for money-purchase arrangements to reach, in most cases, the replacement ratio of 60 to 70 percent. Consider the following example. 2 Let us consider two taxpayers earning $50,000 and $100,000 respectively, in 1993 who maximize their contributions to RRSPs. What replacement income ratio can these taxpayers attain? Assume that the taxpayers are married and that the annuity to be purchased from the RRSP, at retirement, has the following characteristics: post-retirement indexation at 3% per annum with a spousal survivor benefit of two-thirds. 3 The results of this hypothetical are: [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] RRSP as a percentage of final year's salary at a 1993 salary of $50,000 ($100,000) Retirement Age Savings Start Age 25 35 45 55 41.0% (31.6%) 24.7% (19.0%) 11.2% (8.6%) 60 54.4% (41.9%) 35.1% (26.7%) 19.0% (14.6%) 65 72.2% (55.7%) 48.8% (37.6%) 29.4% (22.6%) [TABLE END] The above table indicates, for example, that a 35-year old earning $50,000 in 1993 can, at most, earn a pension from an RRSP equal to 48.8% of his final year's income, if his retirement commences at age 65. In other words, after 30 years of working and saving, that individual will have a retirement income of less than half of his pre-retirement income. This is below the income replacement threshold assumed by pension tax reform itself. For the taxpayer earning $100,000 in 1993, his RRSP pension will be 37.6% of this pre-retirement income. The only individual who attains an adequate replacement ratio, on these assumptions, is the 25-year old who saves for 40 years. It follows that, although the pension tax system espouses equivalence with the defined benefit pension plan, it does not attain it in practice. Inequities in the Current System In the current North American context, the limits of Canadian tax assistance for retirement savings are not generous. The equivalent money purchase and defined benefit limits for the United States, for example, are more than twice as generous as the Canadian limits. In addition, the Canadian system does not provide for deferrals of salary, as does the United States system. Furthermore, inequities exist in the provision of supplementary retirement benefits. Supplementary benefits are those in excess of the $60,270 benchmark pension discussed above. They also include benefits that the Regulations, and the Department of National Revenue, do not allow to be paid from a registered pension plan. Servants of the people, such as Members of Parliament and Members of Provincial Legislatures, benefit from the privileged status of the payor of the pension, in that security of the pension promise is not an issue. Self-employed individuals and ordinary employees, on the other hand, must be concerned with the funding of their pension promise. Requirement for Informed and Thoughtful Debate In the early 1990s, annual contributions to RRSPs and RPPs exceeded $33 billion. Trusteed pensions, not including consolidated revenue fund plans, held $235 billion in assets at the end of 1992. The book value of the assets of such plans stood at $268 billion at the end of the first quarter of 1994. RRSP assets, not including self-directed plans, totalled $147 billion at the end of 1992. In his discussion paper entitled Creating a Healthy Fiscal Climate: The Economic and Fiscal Update, released October 18, 1994, the Minister of Finance has indicated that the tax expenditure associated with all retirement savings for 1991 was $14.9 billion. It is not surprising, therefore, that the Department of Finance should cast a covetous eye at the retirement savings system. We are concerned that a search for easy sources of revenue might prompt the government to change the existing rules in the Act governing retirement savings. It is submitted, however, that changes to the system, although fiscally attractive in the short term, would be detrimental to Canadian taxpayers in the long run. Deficit reduction should not be the sole motivating factor for change to the retirement savings system. The existing complex web of rules governing retirement savings should only be touched if there are compelling reasons, unrelated to immediate deficit reduction, to effect change. This is particularly so given the recent and unfinished reform of retirement savings arrangements in this country. It is clear that this debate has not yet begun and cannot be completed before the next federal budget. The prudent approach, therefore, is to defer any change to the retirement savings system until that debate has taken its course. A Framework for the Debate The following parameters should govern any consideration of the changes to the retirement savings system. 1. The Principle of Even-Handedness It is clear that all components of the retirement savings structure are interrelated. As a result, it would be unfair to single out RRSPs for detrimental treatment. RRSP savings are no different from other forms of retirement savings. 2. A Tax Increase According to a recent study of the Canada Tax Foundation, 3.7 million Canadians contributed to RPPs, and 4.8 million Canadians contributed to RRSPs, in the 1992 taxation year. 4 In that year, 69.7 percent of contributors to RPPs and 60.5 percent of contributors to RRSPs were in the middle income range ($25,000 to $60,000). Obviously, the participation rate by Canadians in retirement savings arrangements is quite high. A change to the retirement savings regime, by limiting deductibility of contributions for example, would be viewed as a tax increase by users of these arrangements. Indeed, for those individuals, any negative change to the retirement savings arrangement will have the same effect as a tax increase. 3. Job Creation The quest for deficit reduction should not obscure the important role that government can play in creating an environment conducive to increasing employment opportunities. As the government has previously stated, the bulk of job creation must come from small and medium-sized businesses. As a result, the current retirement savings regime, and in particular RRSP investments, should be viewed as an asset, and not a liability. The ability to deduct savings for retirement has the effect of increasing aggregate private savings as a source of funds for capital investment. 5 Reducing the tax incentive for retirement savings could have the effect of reducing the amount of "pooled" capital funds that could be made available for entrepreneurial activities. It would also add to the cost of doing business in Canada and stifle future employment opportunities. The rules in the Income Tax Act that permit RRSP contributors to put investments in small businesses are insufficient at present and must be strenghtened if the government wants to encourage job creation. Canada's Economic Challenges 6 shows that small business is playing an increasing role in the economy. Any reduction in the existing schedule of limits will hurt the ability of small business to create jobs. Indeed, the government should consider measures to increase the access by small and medium businesses to the retirement savings capital pool. The latest report of the House of Commons Industry Committee makes the point well: Ottawa should use tax incentives to help improve the competitiveness of the Canadian small business sector...One way the government can increase small business access to capital would be to permit owners, operators and other major shareholders to use funds from their registered retirement savings plans to buy equity in their business...that would increase the availability of such "love capital". 7 4. The Tax Expenditure Calculation As indicated earlier, it is said that the tax expenditure for all retirement savings for 1991 was $14.9 billion. That number suggests that the Government of Canada bears a high cost for its retirement savings system. However, it is our view that the calculation of that cost is not correct, with the result that the number is inflated. The Department of Finance's calculation of the tax expenditure cost is arrived at by adding the value of deductions associated with contributions and the value of the tax shelter on earnings. From that result is subtracted the revenue generated from withdrawals. For example, for the 1991 taxation year, the $14.9 billion number noted above is calculated as follows: Tax expenditure (RRSP) = value of deductions + value of tax shelter - taxes on withdrawals = $3.310 billion + $2.960 billion - .735 million = $5.535 billion Tax expenditure (RPP) = value of deductions + value of tax shelter - taxes on withdrawals = $4.460 billion + $8.950 billion - 4.030 billion = $9.38 billion Tax expenditure (RRSP + RPP) = $5.535 billion + $9.38 billion = $14.915 billion. The Government of Canada has itself admitted that its calculation of tax expenditures is subjective. In the case of tax deferrals, it has further stated that: Estimating the cost of tax deferrals presents a number of methodological difficulties since, even though the tax is not currently received, it may be collected at some point in the future. 8 The government has also specifically commented on tax expenditures associated with retirement savings: It should be noted that the RRSP/RPP tax expenditure estimates do not reflect a mature system because contributions currently exceed withdrawals. Assuming a constant tax rate, if contributions equalled withdrawals, only the non-taxation of investment would contribute to the net tax expenditure. As time goes by and more retired individuals have had the opportunity to contribute to RRSPs throughout their lifetime, the gap between contributions and withdrawals will shrink and possibly even become negative. An upward bias in the current estimates can therefore be expected to decline. 9 The method used to calculate the tax expenditure costs associated with retirement savings is based on the "current cash-flow" model. In effect, the calculation takes a snapshot of a given year and does not take into account future income flows. As indicated above, the calculation adds the value in a year of tax deductions to the lost tax on earnings, and subtracts the tax generated from withdrawals. We argue that that model is flawed. Current demographics show that the system is not yet mature since contributions will exceed withdrawals for some time. Once the baby boom generation begins to retire, withdrawals will exceed contributions. Substantial revenues will be generated for the fisc, revenues necessary to support government programs of the day. The value of the tax on those withdrawals is totally ignored in the static model adopted by the Department of Finance. Statistics Canada projects that the proportion of the Canadian population aged 70 and over will increase from 7.84% in 1991 to 10.6% in 2010. The numbers of such individuals will increase from 2.102 million in 1991, to 3.355 million in 2010, a 59.6 percent increase. Those individuals will be drawing pensions, both from RRSPs and RPPs. Those pensions will be taxed and will benefit the fisc. Furthermore, there is evidence to suggest that the calculation adopted by the Government greatly over-values the cost to the fisc. A US commentator has suggested that government also gains "additional corporate tax revenue on the extra capital stock that results from higher savings. The government's official revenue estimates ignore this increase in corporate tax receipts." 10 To restate the position, the tax expenditure calculation adopts a static approach, both by considering only the current year's cash flows and by ignoring any secondary effects of the retirement savings pool. Until the true cost of the retirement savings system can be ascertained, the current estimates cannot be relied upon to justify change to the tax rules governing retirement savings. Trade-Offs While the Alliance recognizes the need for the Government to get its fiscal house in order, with a particular emphasis on the expenditure side of the equation, a proper balance must be struck between short-term solutions and longer-term consequences. One important consideration is the long-term pain that would result from Canadians having less financial flexibility to properly plan for their retirement. This long-term consequence must be measured against the short-term gain in revenues that would result from a freeze or reduction in the contributions to RRSPs and RPPs. At a time when the Government is encouraging greater self-reliance in matters of finance, further limiting Canadians' ability to adequately plan for their retirement would serve to aggravate the public future dependence on government programs. Looking at current demographic trends, it is important to ensure that all Canadians have an opportunity to set aside necessary financial resources that will be drawn upon (and taxed) at the time of retirement. If the government is looking to become more efficient in its delivery of public sector programs, it should also ensure that the private sector is allowed sufficient flexibility to meet its needs. In this context, the current retirement savings plans should be considered an investment in the future and should not be tampered with or diminished. Recommendations I THE ALLIANCE RECOMMENDS THAT THE FEDERAL GOVERNMENT CONSIDER THE TOTAL COST OF THE RETIREMENT SAVINGS SYSTEM BEFORE MAKING ANY CHANGES TO THE INCOME TAX ACT. II THE ALLIANCE RECOMMENDS THAT THE EQUITY ESTABLISHED DURING PENSION REFORM NOT BE DISTURBED BY DISCRIMINATORY CHANGES AND THAT ANY FUNDAMENTAL CHANGES TO THE SYSTEM SHOULD INVOLVE A PROCESS OF INFORMED AND THOUGHTFUL INQUIRY AND DEBATE. III THE ALLIANCE RECOMMENDS THAT THE FEDERAL GOVERNMENT FOSTER ECONOMIC DEVELOPMENT BY TREATING RRSP CONTRIBUTIONS AS ASSETS RATHER THAN LIABILITIES AND BY EXPLORING THE REGULATORY CHANGES NECESSARY TO ENSURE INCREASED ACCESS TO SUCH FUNDS BY SMALL AND MEDIUM-SIZED BUSINESSES. _______________________ 1 Appendix A to this submission details the historical development of pension tax reform. 2 Taken from Sylvain Parent, FSA, FCIA, RRSP income replacement levels: a case study, 1993 Pension & Tax Reports; 4:93-94. 3 Further assumptions are as follows: rate of return is 7.5% per annum; yearly salary increases are 5.5% per annum; mortality is 80% of the average of the 1983 Group Annuity Mortality rates for males and females. 4 Perry, David B, Everyone's Tax Shelter At Risk, Canadian Tax Highlights, Volume 2, number 10, October 19, 1994; p. 75. 5 Andrews and Bradford, Savings Incentives in a Hybrid Income Tax, Studies of Government and Finance, The Brookings Institution, Washington, DC; February, 1988. 6 Department of Finance, January, 1994, p. 30. 7 Special Report, The Public Sector, October 24, 1994. 8 Government of Canada, Personal and corporate income tax expenditures, December 1993, p.4. 9 Ibid., p.53. 10 Feldstein, Martin. The Effects of Tax-Based Incentives on Government Revenue and National Saving, NBER Working Paper #4021, March 1992. This position has been dismissed, out of hand and with no reasons, by two Canadian commentators: Ingerman, Sid and Rowley, Robin, Tax Losses and Retirement Savings, Canadian Business Economics, Vol. 2, No. 4, Summer 1994, pp. 46-54.
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