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Policies that advocate for the medical profession and Canadians


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Adoption and implementation of sustainable funding framework for medicare

https://policybase.cma.ca/en/permalink/policy1518
Last Reviewed
2017-03-04
Date
2004-08-18
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Resolution
GC04-85
The Canadian Medical Association advocates for the adoption and implementation of a sustainable funding framework for medicare based on the policy objectives set out in the Canada Health Access Fund.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
2004-08-18
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Resolution
GC04-85
The Canadian Medical Association advocates for the adoption and implementation of a sustainable funding framework for medicare based on the policy objectives set out in the Canada Health Access Fund.
Text
The Canadian Medical Association advocates for the adoption and implementation of a sustainable funding framework for medicare based on the policy objectives set out in the Canada Health Access Fund.
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Advancing Inclusion and quality of life for seniors

https://policybase.cma.ca/en/permalink/policy13729
Date
2017-10-26
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2017-10-26
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Text
Canadians are living longer, healthier lives than ever before. The number of seniors expected to need help or care in the next 30 years will double, placing an unprecedented challenge on Canada’s health care system. That we face this challenge speaks to the immense success story that is modern medicine, but it doesn’t in any way minimize the task ahead. Publicly funded health care was created about 50 years ago when Canada’s population was just over 20 million and the average life expectancy was 71. Today, our population is over 36 million and the average life expectancy is 10 years longer. People 85 and older make up the fastest growing age group in our country, and the growth in the number of centenarians is also expected to continue. The Canadian Medical Association is pleased that the House of Commons Standing Committee on Human Resources, Skills and Social Development and the Status of Persons with Disabilities is studying ways Canada can respond to these challenges. Here, for your consideration, we present 15 comprehensive recommendations that would help our seniors remain active, contributing citizens of their communities while improving the quality of their lives. These range from increasing capital investment in residential care infrastructure, to enhancing assistance for caregivers, to improving the senior-friendliness of our neighbourhoods. The task faced by this committee, indeed the task faced by all of Canada, is daunting. That said, it is manageable and great advances can be made on behalf of seniors. By doing so, we will ultimately deliver both health and financial benefits to all Canadians. Dr. Laurent Marcoux, CMA President The Canadian Medical Association (CMA) is pleased to submit this brief to the Standing Committee on Human Resources, Skills and Social Development and the Status of Persons with Disabilities as part of its study regarding how the Government can support vulnerable seniors today while preparing for the diverse and growing seniors population of tomorrow. This brief directly addresses the three themes considered by this Committee:
How the Government can improve access to housing for seniors including aging in place and affordable and accessible housing;
How the Government can improve income security for vulnerable seniors; and
How the Government can improve the overall quality of life and well-being for seniors including community programming, social inclusivity, and social determinants of health. Improving access to housing for seniors As part of a new National Housing Strategy, the federal government announced in the 2017 Budget that it will invest more than $11.2 billion in a range of initiatives designed to build, renew, and repair Canada’s stock of affordable housing and help to ensure that Canadians have adequate and affordable housing that meets their needs. While a welcome step, physicians continue to see the problems facing seniors in relation to a lack of housing options and supports — problems that cascade across the entire health care system. A major hindrance to social equity in health care delivery and a serious cause of wait times is the inappropriate placement of patients, particularly seniors, in hospitals. Alternate level of care (ALC) beds are often used in acute care hospitals to accommodate patients — most of whom are medically stable seniors — waiting for appropriate levels of home care or access to a residential care home/facility. High rates of ALC patients in hospitals affect all patients by contributing to hospital overcrowding, lengthy waits in emergency departments, delayed hospital admissions, cancelled elective surgeries, and sidelined ambulance services waiting to offload new arrivals (often referred to as code gridlock).1 Moreover, unnecessarily long hospital stays can leave patients vulnerable to hospital-acquired illnesses and disabilities such as delirium, deconditioning, and falls. Daily costs - Ontario $842: acute care hospital, per patient $126: long-term care residence, per patient $42: home care, per patient # of acute care hospital beds = 18,571 14% waiting for placement = 2,600 beds Providing more cost-effective and appropriate solutions will optimize the use of health care resources. It has been estimated that it costs $842 per day for a hospital bed versus $126 per day for a long-term care bed and $42 per day for care at home.2 An investment in appropriate home or residential care, which can take many forms, will alleviate inappropriate hospital admissions and facilitate timely discharges. The residential care sector is facing significant challenges because of the rising numbers of older seniors with increasingly complex care needs. The demand for residential care will increase significantly over the next several years because of the growing number of frail elderly seniors requiring this service. New facilities will need to be constructed and existing facilities will need to be upgraded to comply with enhanced regulatory requirements and respond to residents’ higher care needs. The Conference Board of Canada has produced a residential care bed forecast tied to population growth of age cohorts. It is estimated that Canada will require an average of 10,500 new beds per year over the next 19 years, for a total of 199,000 new beds by 2035. This forecast does not include the investments needed to renovate and retrofit existing long-term care homes.3 A recent report by the Canadian Institute for Health Information indicated that residential care capacity must double over the next 20 years (assuming no change in how care is currently provided), necessitating a transformation in how seniors care is provided across the continuum of care.4 These findings provide a sense of the immense challenges Canada faces in addressing the residential care needs of older seniors. Investments in residential care infrastructure and continuing care will improve care for seniors while significantly reducing wait times in hospitals and across the system, benefiting all patients. Efforts to de-hospitalize the system and address the housing and residential care options for Canada’s aging population are key. The federal government can provide significant pan-Canadian assistance by investing in residential care infrastructure. RECOMMENDATION 1 The CMA recommends that the federal government include capital investment in residential care infrastructure, including retrofit and renovation, as part of its commitment to invest in social infrastructure. Improving income security for vulnerable seniors Income is a key factor impacting the health of individuals and communities. Higher income and social status are linked to better health.5 Adequate Income: Poverty among seniors in Canada dropped sharply in the 1970s and 1980s but it has been rising in recent years. In 2012, the incidence of low income among people aged 65 years and over was 12.1%. This rate was considerably higher for single seniors at 28.5%.6 Incidence of low income (2012) Seniors overall: 12.1% Single seniors: 28.5% Most older Canadians rely on Old Age Security (OAS), the Canada Pension Plan (CPP), and their personal pensions or investments to maintain their basic standard of living in retirement. Some seniors are also eligible for a Guaranteed Income Supplement (GIS) to improve their financial security. The CMA recognizes the federal government’s actions to strengthen these programs and initiatives to ensure their viability and to provide sustainable tax relief. These measures must continue and evolve to support aging Canadians so they can afford to live at home or in age-friendly communities as they get older. The government’s actions to ensure adequate income support will also assist aging Canadians to take care of their health, maintain independence, and continue living safely without the need for institutional care. On the topic of seniors’ income security, the financial abuse of seniors cannot be overlooked. Elder abuse can take many forms: financial, physical, psychological, sexual, and neglect. Often the abuser is a family member, friend, or other person in a position of trust. Researchers estimate that 4 to 10% of Canadian seniors experience abuse or neglect, but that only a small portion of this is reported. The CMA supports public awareness initiatives that bring attention to elder abuse, as well as programs to intervene with seniors who are abused and with their abusers. RECOMMENDATION 2 The CMA recommends that the federal government take steps to provide adequate income support for older Canadians, as well as education and protection from financial abuse. Improving the overall quality of life and well-being for seniors Improving how we support and care for Canada’s growing seniors population has been a priority for CMA over the past several years. For the first time in Canada’s history, persons aged 65 years and older outnumber those under the age of 15 years.7 Seniors are projected to represent over 20% of the population by 2024 and up to 25% of the population by 2036.8 People aged 85 years and over make up the fastest growing age group in Canada — this portion of the population grew by 127% between 1993 and 2013.9 Statistics Canada projects, on the basis of a medium-growth scenario, that there will be over 11,100 Canadians aged 100 years and older by 2021, 14,800 by 2026 and 20,300 by 2036.7 Though age does not automatically mean ill health or disability, the risk of both increases with age. Approximately 75 to 80% of Canadian seniors report having one or more chronic conditions.10 Because of increasing rates of disability and chronic disease, the demand for health services is expected to increase as Canada’s population ages. The Conference Board of Canada has estimated 2.4 million Canadians 65 years and older will need continuing care, both paid and unpaid, by 2026 — a 71% increase since 2011.11 When publicly funded health care was created about 50 years ago, Canada’s population was just over 20 million and the average life expectancy was 71. Today, our population is over 36 million and the average life expectancy is 10 years longer. The aging of our population is both a success story and a pressing health policy issue. National seniors strategy Canada needs a new approach to ensure that both our aging population and the rest of Canadians can get the care they need, when and where they need it. The CMA believes that the federal government should invest in seniors care now, guided by a pan-Canadian seniors strategy. In doing so, it can help aging Canadians be as productive as possible — at work, in their communities, and in their homes. The CMA is pleased with the June 2017 Report of the Standing Senate Committee on National Finance that called for the federal government to develop, in collaboration with the provinces and territories and Indigenous partners, a national seniors strategy in order to control spending growth while ensuring appropriate and accessible care.12 The CMA is also pleased that MP Marc Serré (Nickel Belt) secured support for his private members’ motion calling for the development of a national seniors strategy. Over 50,000 Canadians have already lent their support to this cause (see www.DemandaPlan.ca). RECOMMENDATION 3 The CMA recommends that the federal government provide targeted funding to support the development of a pan-Canadian seniors strategy to address the needs of the aging population. Improving assistance for home care and Canada’s caregivers Many of the services required by seniors, in particular home care and long-term care, are not covered by the Canada Health Act. Funding for these services varies widely from province to province. The disparity among the provinces in terms of their fiscal capacity in the current economic climate will mean improvements in seniors care will advance at an uneven pace. The funding and delivery of accessible home care services will help more aging Canadians to recover from illness, live at home longer, and contribute to their families and communities. Multi-year funding arrangements to reinforce commitment to and financial investment in home care should be carefully considered.13 The development of innovative partnerships and models to help ensure services and resources for seniors’ seamless transition across the continuum of care are also important. RECOMMENDATION 4 The CMA recommends governments work with the health and social services sectors, and with private insurers, to develop a framework for the funding and delivery of accessible and sustainable home care and long-term care services. Family and friend caregivers are an extremely important part of the health care system. A 2012 Statistics Canada study found that 5.4 million Canadians provided care to a senior family member or friend, and 62% of caregivers helping seniors said that the care receiver lived in a private residence separate from their own.14 According to a report by Carers Canada, the Canadian Home Care Association, and the Canadian Cancer Action Network, caregivers provide an array of services including personal and medical care, housekeeping, advocacy, financial management, and social/emotional support. The report also indicated that caregivers contribute $25 billion in unpaid labour to our health system.15 Given their enormous contributions, Canada’s caregivers need support in the form of financial assistance, education, peer support, and respite care. A pan-Canadian caregiver strategy is needed to ensure caregivers are provided with the support they require.15 Caregivers provide... Personal and Medical Care Housekeeping worth $25 billion in Advocacy unpaid labour Financial Managemen Social-emo ional Suppor RECOMMENDATION 5 The CMA recommends that the federal government and other stakeholders work together to develop and implement a pan-Canadian caregiver strategy, and expand the support programs currently offered to informal caregivers. Canadians want governments to do more to help seniors and their family caregivers.16 The federal government’s new combined Canada Caregiver Credit (CCC) is a non-refundable credit to individuals caring for dependent relatives with infirmities (including persons with disabilities). The CCC will be more accessible and will extend tax relief to more caregivers by including dependent relatives who do not live with their caregivers and by increasing the income threshold. Making the new CCC a refundable tax credit for caregivers whose tax owing is less than the total credit would result in a refund payment to provide further financial support for low-income families. RECOMMENDATION 6 The CMA recommends that the federal government improve awareness of the new Canada Caregiver Credit and amend it to make it a refundable tax credit for caregivers. The federal government’s recent commitment to provide $6 billion over 10 years to the provinces and territories for home care, including support for caregivers, is a welcome step toward improving opportunities for seniors to remain in their homes. As with previous bilateral funding agreements, it is important to establish clear operating principles between the parties to oversee the funding implementation and for the development of clear metrics to measure performance. RECOMMENDATION 7 The CMA recommends that the federal government develop explicit operating principles for the home care funding that has been negotiated with the provinces and territories to recognize funding for caregivers and respite care as eligible areas of investment. The federal government’s recent funding investments in home care and mental health recognize the importance of these aspects of the health care system. They also signal that Canada has under-invested in home and community-based care to date. Other countries have more supportive systems and programs in place — systems and programs that Canada should consider. RECOMMENDATION 8 The CMA recommends the federal government convene an all-party parliamentary international study that includes stakeholders to examine the approaches taken to mitigate the inappropriate use of acute care for elderly persons and provide support for caregivers. Programs and supports to promote healthy aging The CMA believes that governments at all levels should invest in programs and supports to promote healthy aging, a comprehensive continuum of health services to provide optimal care and support to older Canadians, and an environment and society that is “age friendly”.17 The Public Health Agency of Canada (PHAC) defines healthy aging as “the process of optimizing opportunities for physical, social and mental health to enable seniors to take an active part in society without discrimination and to enjoy independence and quality of life.”18 It is believed that initiatives to promote healthy aging and enable older Canadians to maintain their health will help lower health care costs by reducing the overall burden of disability and chronic disease. Such initiatives should focus on physical activity, good nutrition, injury (e.g. falls) prevention, and seniors’ mental health (including depression). RECOMMENDATION 9 The CMA recommends that governments at all levels support programs to promote physical activity, nutrition, injury prevention, and mental health among older Canadians. For seniors who have multiple chronic diseases or disabilities, care needs can be complex, and they may vary greatly from one person to another and involve many health care providers. Complex care needs demand a flexible and responsive health system. The CMA believes that quality health care for older Canadians should be delivered on a continuum from community-based health care (e.g. primary health care, chronic disease management programs), to home care (e.g. visiting health care workers to give baths and foot care), to long-term care and palliative care. Ideally, this continuum should be managed so that the senior can remain at home and out of emergency departments, hospitals, and long-term care unless appropriate; easily access necessary care; and make a smooth transition from one level of care to another when necessary. RECOMMENDATION 10 The CMA recommends governments and other stakeholders work together to develop and implement models of integrated, interdisciplinary health service delivery for older Canadians. Every senior should have the opportunity to have a family physician or to be part of a family practice that serves as a medical home. This provides a central hub for the timely provision and coordination of the comprehensive menu of health and medical services. A medical home should provide patients with access to medical advice and the provision of, or direction to, needed care 24 hours a day, seven days a week, 365 days a year. Research in 2014 by the Commonwealth Fund found that the percentage of Canadian seniors who have a regular family physician or place of care is very high (98%); however, their ability to get timely access based on same-day or next-day appointments was among the lowest of 11 nations.19 Compared to seniors in most other countries surveyed, Canadian seniors were also more likely to use the emergency department and experience problems with care coordination. RECOMMENDATION 11 The CMA recommends governments continue efforts to ensure that older Canadians have access to a family physician, supported by specialized geriatric services as appropriate. Prescription drugs represent the fastest-growing item in the health budget and the second-largest category of health expenditure. As the population of seniors grows, there will be an ongoing need for detailed information regarding seniors’ drug use and expenditure to support the overall management of public drug programs.20 Despite some level of drug coverage for seniors in all provinces and territories, some seniors still skip doses or avoid filling prescriptions due to cost, and more research into the extent of this problem is required.21 The CMA supports the development of an equitable and comprehensive pan-Canadian pharmacare program. As a step toward comprehensive, universal coverage, the CMA has repeatedly called on the federal government to implement a system of catastrophic coverage for prescription medication to reduce cost barriers of treatment and ensure Canadians do not experience undue financial hardship. Moreover, with more drugs available to treat a large number of complex and chronic health conditions, the CMA supports the development of a coordinated national approach to reduce polypharmacy among the elderly. RECOMMENDATION 12 The CMA recommends governments and other stakeholders work together to develop and implement a pan-Canadian pharmaceutical strategy that addresses both comprehensive coverage of essential medicines for all Canadians, and programs to encourage optimal prescribing and drug therapy. Optimal care and support for older Canadians also depends on identifying, adapting, and implementing best practices in the care of seniors. PHAC’s Best Practices Portal22 is one noteworthy initiative, and the system needs to spread and scale best practices by leveraging and enhancing pan-Canadian resources that build capacity and improve performance in home care and other sectors.13 RECOMMENDATION 13 The CMA recommends that governments and other stakeholders support ongoing research to identify best practices in the care of seniors, and monitor the impact of various interventions on health outcomes and costs. An environment and society that is “age friendly” One of the primary goals of seniors policy in Canada is to promote the independence of older Canadians, avoiding costly institutionalization for as long as feasible. To help older Canadians successfully maintain their independence, governments and society must keep the social determinants of health in mind when developing and implementing policy that affects seniors. It is also important to eliminate discrimination against seniors and promote positive messaging around aging. An age-friendly society respects the experience, knowledge, and capabilities of its older members and accords them the same worth and dignity as it does other citizens. Employment is also important for seniors who need or desire it. Many seniors are choosing to remain active in the workplace for a variety of reasons, such as adding to their financial resources or staying connected to a social network.23 The CMA recognizes the federal government’s support for seniors who opt to continue working. And, while many employers encourage older workers and accommodate their needs, employment may be difficult to find in workplaces that are unwilling to hire older workers. RECOMMENDATION 14 The CMA recommends that governments at all levels and other partners give older Canadians access to opportunities for meaningful employment if they desire. The physical environment, including the built environment, can help to promote seniors’ independence and successful, healthy aging. The World Health Organization defines an “age-friendly environment” as one that fosters health and well-being and the participation of people as they age.24 Age-friendly environments are accessible, equitable, inclusive, safe and secure, and supportive. They promote health and prevent or delay the onset of disease and functional decline. They provide people-centered services and support to enable recovery or to compensate for the loss of function so that people can continue to do the things that are important to them.24 These factors should be taken into consideration by those who design and build communities. For example, buildings should be designed with entrance ramps and elevators; sidewalks could have sloping curbs for walkers and wheelchairs; and frequent, accessible public transportation should be provided in neighbourhoods with large concentrations of seniors. RECOMMENDATION 15 The CMA recommends that governments and communities take the needs of older Canadians into account when designing buildings, walkways, transportation systems, and other aspects of the built environment. Conclusion The CMA recognizes the federal government’s commitment to support vulnerable seniors today while preparing for the diverse and growing seniors’ population of tomorrow. The CMA’s recommendations in this submission can assist the government as it seeks to improve access to housing for seniors, enhance income security for vulnerable seniors, and improve the overall quality of life for seniors in ways that will help to advance inclusion, well-being, and the health of Canada’s aging population. To maximize the health and well-being of older Canadians, and ensure their active engagement and independence for as long as possible, the CMA believes that the health care system, governments, and society should work with older Canadians to promote healthy aging, provide quality patient-centred health care and support services, and build communities that value Canadians of all ages. References 1 Simpson C. Code Gridlock: Why Canada needs a national seniors strategy. Address to the Canadian Club of Ottawa by Dr. Christopher Simpson, President, Canadian Medical Association; 2014 Nov. 18; Ottawa, Ontario. Available: https://www.cma.ca/En/Lists/Medias/Code_Gridlock_final. pdf#search=code%20gridlock (accessed 2016 Sep 22). 2 North East Local Health Integration Network. HOME First shifts care of seniors to HOME. LHINfo Minute, Northeastern Ontario Health Care Update. Sudbury: The Network; 2011. Cited by Home Care Ontario. Facts & figures - publicly funded home care. Hamilton: Home Care Ontario; 2017 Jun. Available: http://www.homecareontario.ca/home-care-services/facts-figures/publiclyfundedhomecare (accessed 2016 Sep 22). 3 Conference Board of Canada. A cost-benefit analysis of meeting the demand for long-term care beds. Ottawa: Conference Board of Canada; Manuscript submitted for publication. 4 Canadian Institute for Health Information (CIHI). Seniors in transition: exploring pathways across the care continuum. Ottawa: The Institute; 2017. Available: https://www.cihi.ca/sites/default/files/document/seniors-in-transition-report-2017-en.pdf (accessed 2017 Jun 30). 5 World Health Organization. Health Impact Assessment (HIA). The determinants of health. Available: http://www.who.int/hia/evidence/doh/en/ (accessed 2017 Oct 23). 6 Statistics Canada. Persons in low income (after-tax low income measure), 2012. The Daily. Ottawa: Statistics Canada; 2014 Dec 10. Available: http://www.statcan.gc.ca/daily-quotidien/141210/t141210a003-eng.htm (accessed 2017 Oct 17). 7 Statistics Canada. Population projections: Canada, the provinces and territories, 2013 to 2063. The Daily. Ottawa: Statistics Canada; 2014 Sep 17. Available: http://www.statcan.gc.ca/daily-quotidien/140917/dq140917a-eng.pdf (accessed 2016 Sep 19). 8 Statistics Canada. Canada Year Book 2012, seniors. Ottawa: Statistics Canada; 2012. Available: https://www.statcan.gc.ca/pub/11­ 402-x/2012000/chap/seniors-aines/seniors-aines-eng.htm (accessed 2017 Oct 18). 9 Public Health Agency of Canada. The Chief Public Health Officer’s report on the state of public health in Canada, 2014: public health in the future. Ottawa: Public Health Agency of Canada; 2014. Available: https://www.canada.ca/content/dam/phac-aspc/migration/phac-aspc/ cphorsphc-respcacsp/2014/assets/pdf/2014-eng.pdf (accessed 2016 Sep 19). 10 Canadian Institute for Health Information (CIHI). Health Care in Canada, 2011: A Focus on Seniors and Aging. Ottawa: The Institute; 2014 Nov. Available: https://secure.cihi.ca/free_products/HCIC_2011_seniors_report_en.pdf (accessed 2016 Sept 19). 11 Stonebridge C, Hermus G, Edenhoffer K. Future care for Canadian seniors: a status quo forecast. Ottawa: Conference Board of Canada; 2015. Available: http://www.conferenceboard.ca/e-library/abstract.aspx?did=7374 (accessed 2016 Sep 20). 12 Report of the Standing Senate Committee on National Finance. Getting ready: For a new generation of active seniors. Ottawa: The Committee; 2017 Jun. Available: https://sencanada.ca/content/sen/committee/421/NFFN/Reports/NFFN_Final19th_Aging_e.pdf (accessed 2017 Oct 18). 13 Canadian Home Care Association, The College of Family Physicians of Canada, Canadian Nurses Association. Better Home Care in Canada: A National Action Plan. 2016. Ottawa: Canadian Home Care Association, The College of Family Physicians of Canada, Canadian Nurses Association; 2016. Available: http://www.thehomecareplan.ca/wp-content/uploads/2016/10/Better-Home-Care-Report-Oct-web.pdf (accessed 2017 Oct 23). 14 Turcotte M, Sawaya C. Senior care: differences by type of housing. Insights on Canadian society. Cat. No. 75-006-X. Ottawa: Statistics Canada; 2015 Feb 25. Available: http://www.statcan.gc.ca/pub/75-006-x/2015001/article/14142-eng.pdf (accessed 2016 Sep 22). 15 Carers Canada, Canadian Home Care Association, Canadian Cancer Action Network. Advancing Collective Priorities: A Canadian Carer Strategy. 2017. Mississauga: Canadian Home Care Association, Canadian Cancer Action Network; 2017. Available: http://www.cdnhomecare.ca/media. php?mid=4918 (accessed 2017 Oct 23). 16 Ipsos Public Affairs, HealthCareCAN, Canadian College of Health Leaders. National Health Leadership Conference report. Toronto: Ipsos Public Affairs; 2016 Jun 6. Available: http://www.nhlc-cnls.ca/assets/2016%20Ottawa/NHLCIpsosReportJune1.pdf (accessed 2016 Jun 06). 17 Canadian Medical Association. Health and Health Care for an Aging Population. Ottawa: The Association; December 2013. Available: https:// www.cma.ca/Assets/assets-library/document/en/advocacy/policy-research/CMA_Policy_Health_and_Health_Care_for_an_Aging-Population_ PD14-03-e.pdf (accessed 2017 Oct 20). 18 Government of Canada. The Chief Public Health Officer’s Report on the State of Public Health in Canada 2010 – Canada’s experience in setting the stage for healthy aging. Ottawa: Government of Canada; 2014. Available: https://www.canada.ca/en/public-health/corporate/publications/ chief-public-health-officer-reports-state-public-health-canada/annual-report-on-state-public-health-canada-2010/chapter-2.html (accessed 2017 Oct 23). 19 Commonwealth Fund. 2014 International Health Policy Survey of Older Adults in Eleven Countries. 2014. New York: Commonweath Fund; 2014. Available: http://www.commonwealthfund.org/~/media/files/publications/in-the-literature/2014/nov/pdf_1787_commonwealth_fund_2014_intl_ survey_chartpack.pdf (accessed 2017 Oct 23). 20 Canadian Institute for Health Information. Drug Use among Seniors on Public Drug Programs in Canada, 2002 to 2008. (2010). Ottawa: The Institute; 2010. Available: https://secure.cihi.ca/free_products/drug_use_in_seniors_2002-2008_e.pdf (accessed 2017 Oct 23). 21 Law MR, Cheng L, Dhalla IA, Heard D, Morgan SG. The effect of cost on adherence to prescription medications in Canada. CMAJ. 2012 Feb21;184(3):297-302. Available: http://www.cmaj.ca/content/184/3/297.short. (accessed 2017 Oct 23). 22 Public Health Agency of Canada. Canadian Best Practices Portal. Ottawa: Public Health Agency of Canada; 2016. Available: http://cbpp-pcpe. phac-aspc.gc.ca/public-health-topics/seniors/ (accessed 2017 Oct 23). 23 Government of Canada. Action for Seniors report. 2014. Ottawa: Government of Canada; 2014. Available: https://www.canada.ca/en/ employment-social-development/programs/seniors-action-report.html (accessed 2017 Oct 23). 24 World Health Organization (WHO). Age-friendly environments. Geneva: WHO; 2017. Available: http://www.who.int/ageing/projects/age­ friendly-environments/en/ (accessed 2017 Oct 23).
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Aligning health and economic policy in the interest of Canadians : CMA’s 2004 Pre-Budget Submission to the Standing Committee on Finance

https://policybase.cma.ca/en/permalink/policy1949
Last Reviewed
2012-03-03
Date
2004-11-18
Topics
Health systems, system funding and performance
  2 documents  
Policy Type
Parliamentary submission
Last Reviewed
2012-03-03
Date
2004-11-18
Topics
Health systems, system funding and performance
Text
For the past several years, the Canadian Medical Association (CMA) has been delivering two overall messages to the Standing Committee on Finance. First, we believe that Canadians’ health and their health care system must be recognized as ongoing priorities. Second, we have been making the case that economic policy, including tax policy, must be better aligned with national health policy. This year’s brief provides specific examples of how the federal government can take action to address both of these issues. We begin with an assessment or a “check up” of the health of our health system. We then provide constructive suggestions on how to successfully implement the health agreement reached at the September 13-15, 2004 meeting of First Ministers. Finally, we draw attention to the need for continued investments in public health and healthy public policy. Canadians remain increasingly concerned about the future state of their health care system, particularly in terms of accessing essential care. While their health status has improved over the past decades, international comparisons suggest there is considerable room for improvement. The significant announcements made over the past year related to reinvestments in health care and public health are a welcomed start to support health stakeholders in facing these challenges. The next steps must build on this progress. INVESTING IN HEALTH CARE Build on The First Ministers Meeting Agreement In terms of health care, we must begin by noting that the First Ministers Meeting Agreement (FMM Agreement) was a significant achievement. It represents a positive policy framework to run with, but it must now receive the necessary fiscal, political and legislative follow-through. Legislation should be enacted that specifies the accountability framework for the Agreement. The Wait Times Reduction Fund should be subject to contribution agreements that specify how provinces and territories will use their share of this fund to reduce wait times. Critical to future success is the need for health care stakeholders to be actively involved with all facets of the Agreement, particularly in developing clinically derived wait time benchmarks. Make Health Human Resources a Priority At the same time, the federal government can do more to address accessibility to health care services by making a stronger commitment to increasing Canada’s health human resources capacity. Several strategies are outlined in this brief, beginning with the need to ensure that the Wait Times Reduction Fund in the FMM Agreement is used immediately to address the crisis in health human resources rather than in the last four years of the ten-year Agreement as currently projected. One specific health human resources strategy that the federal government should pursue is providing greater support for the training of students in health care professions as part of an overall health human resources strategy. High student debt is a key health human resource issue. It is estimated that, by the time medical students enter their pre-practice postgraduate training period, many are doing so with a debt of at least $120,000 or more. This high debt load is affecting both the kind of specialty that physicians-in-training choose, and ultimately where they decide to practice. As a result, the CMA calls upon the federal government to implement a national strategy to extend the Canada Student Loans interest payment benefit to eligible health professional students pursuing postgraduate training. Such action would provide a fairer approach and would alleviate some of the problems associated with our current training system of health professionals. ALIGNING TAX POLICY WITH HEALTH POLICY The CMA has highlighted the need to better align tax policy with national health policy goals for some time and we believe this challenge remains a priority. One example of where tax policy and health policy can be better aligned is how the GST is currently applied to the health care sector and to physicians—something the Finance Committee has acknowledged in previous reports. Hospitals in Canada must still pay a portion of the GST on their purchase of goods and services siphoning away millions of dollars that would otherwise be used for patient care. The federal government recognized in the 2004 budget the need to provide a full GST rebate to municipalities, one of the four sectors covered by the so-called “MUSH” formula (Municipalities, Universities, Schools and Hospitals). We call on the government to apply the same logic and provide a full GST rebate to the health care sector. Another problem exists with how the GST is applied to independent health professionals, such as physicians, providing care to Canada’s publicly funded system. By virtue of being “tax exempt” under The Excise Act, physicians cannot claim any input tax credits to offset the GST costs they pay on their purchases of equipment, rent and utilities. Unlike other self-employed people, physicians cannot pass on any of these additional costs. This is a fundamental issue of tax fairness. It can be resolved by zero rating the GST on publicly funded health services provided by independent health providers thereby making them eligible to receive input tax credits. INVESTING IN HEALTH This past year saw many positive developments made to Canada’s public health system. The CMA was pleased to see the creation of the position of Minister of State, Public Health. We commend the Government of Canada for its establishment of the Public Health Agency of Canada and for its selection of Dr. David Butler-Jones as the new Chief Public Health Officer of Canada. However, the government must continue to reinvest in public health to ensure that the country has a system that earns the trust of Canadians. Investing in public health also makes good economic policy. We have seen in recent years the incredible economic impact that public health outbreaks can have on a country’s economy. Close the Naylor Gap in Public Health The National Advisory Committee on SARS and Public Health (the Naylor Report) estimated that approximately $1 billion in annual funding is required to implement and sustain the public health programming that Canada requires. While representing an important reinvestment in this country’s public health system, the funding announced in the 2004 Budget falls well short of this basic requirement. Accordingly, the CMA calls on the federal government to address the $450 million “Naylor Gap” as soon as possible. Establish National Health Goals Guiding this country’s efforts to improve the health of Canadians should be the establishment and monitoring of national health goals. Thus, the CMA fully supports the First Ministers’ call to establish a Pan-Canadian Public Health Strategy that includes the setting of health goals that are independently monitored. These goals should also cover environmental health goals given their direct implication on Canadians’ health status. Invest in Health Not Tobacco Another key area for the CMA where current economic policy is not aligned with national health policy is the Canada Pension Plan’s investment in tobacco stocks. Despite the fact that tobacco continues to kill approximately 45,000 Canadians a year and costs Canadian society approximately $11 billion per year in net cost, the Canada Pension Plan continues to invest millions ($94 million) in the tobacco industry. We strongly believe that the CPP Investment Board should be prohibited from investing in the tobacco industry and that it divest its current tobacco holdings. Other major pension and investment plans have successfully executed this policy including the MD Funds held for Canada’s physicians at MD Management Ltd. a wholly-owned subsidiary of CMA. Accordingly, we call on the Standing Committee on Finance along with the Standing Committee on Health to jointly review the CPP investment policy as it relates to investments in tobacco. The FMM Agreement and last year’s funding announcements for public health must be seen as for what they are—first steps to sustaining Canada’s health care system and its public health infrastructure. Canada’s physicians and the CMA are committed to working with governments and other health care stakeholders to ensure that these financial investments lead to positive and enduring change, and ultimately improved health for all Canadians. RECOMMENDATIONS Recommendation 1 The federal government move quickly to enact legislation to implement the funding and accountability provisions of the First Ministers’ Agreement. The legislation should specify that the $4.5 billion Wait Times Reduction Fund be subject to contribution agreements with the provinces and territories. Recommendation 2 The federal government work with relevant stakeholders to extend interest free status on Canada Student Loans for all eligible health professional students pursuing postgraduate training. Recommendation 3 As part of an effort to ensure that its tax policy is consistent with the goals of its health policy and the sustainability of Canada’s health care system, the federal government should: - increase the GST rebate for publicly funded health care institutions and clinics to 100% ($90 million annually for hospitals) - zero rate GST on publicly funded health services provided by independent health care providers ($75 million annually for medical services). Recommendation 4 The Standing Committees on Finance and Health hold a joint review of the CPP policy as it relates to investments in tobacco (both current and potential) by the CPP Investment Board. II. CMA’S ANNUAL CHECKUP Much has happened over the past year in regards to Canada’s health and health care systems. First, we witnessed the creation of the Health Council of Canada, an institution that can play a significant role in improving the accountability of Canada’s health system. Second, we saw several announcements aimed at rebuilding Canada’s public health system including the establishment of the Public Health Agency of Canada and the subsequent appointment of Canada’s first Chief Public Health Officer. And in September, federal, provincial and territorial First Ministers reached a historic agreement on a 10-year plan to strengthen health care. Canadians no doubt welcome these developments. They have made it known to governments and health care providers alike that access to health care has become their top public policy issue. Not surprisingly, health was the top issue during the recent federal election campaign. For four years, the CMA has been tracking Canadians’ assessment of our health care system through our National Report Card on the Sustainability of Health Care. We are sad to report that the number of Canadians giving the nation's health care system a grade of C or F this year increased by a dramatic 9% over last year. While Canadians still give the system an overall B grade, the percentage of C and F grades was the highest since Ipsos-Reid began conducting the survey on behalf of the CMA in 2001. Moreover, our survey results found that 97% agreed that any discussion to make the system more sustainable needs to guarantee timely access for essential health services. As our fact sheet on Canadians’ health and their health care system illustrates (see Appendix A), improving access remains a major challenge for our health care system. Canada has one of the poorest physician-to-population ratios among all OECD countries. It is therefore not surprising that in 2003, 14% of Canadians reported not having a regular family physician (25% in Quebec). A recent Statistics Canada survey on wait times found that the proportion of patients who considered their wait time unacceptable was 17% for non-emergency surgery, 21% for diagnostic tests and 29% for specialist visits. 1 Over the past year, CMA has been very active in bringing attention to the issue of access and wait times. The CMA co-sponsored a colloquium on managing wait times last April that culminated in the recently released report, The Taming of the Queue: Toward a Cure for Health Care Wait Times. 2 But what about the state of Canadians’ health itself? Certainly our health status has improved greatly over the past decades. However, while Canadians are among the healthiest people in the world, citizens in several industrialized countries are enjoying better health status. For example, disability-free life expectancy, that is quality of life years lived, for Canadian males is 18th among the 30 OECD countries and 16th for Canadian females. Canada’s rate of infant mortality—deaths during the first year of life—is among the highest in the OECD. But we need not compare ourselves to other countries to find differences in levels of health status. Significant discrepancies in health status also exist among Canadians, be it between provinces, between regions, between communities or between neighbourhoods. For example, there remain significant inequities in health status between Aboriginal Canadians and non-Aboriginal Canadians—the incidence of hepatitis and tuberculosis among Aboriginal Canadians are five and ten times higher respectively than for other Canadians. It has now been over a year since the Report of the National Advisory Committee on SARS and Public Health or the “Naylor Report” was released. The report has lead to some positive developments in rebuilding Canada’s public health system. It will be needed as some serious public health issues continue to face the country including: * the spread of infectious diseases (e.g., C. difficile bacterium); * the rise in the number of Canadians with unhealthy body weights including rising levels of obesity; * high levels of physical inactivity; * smoking, particularly among youth; * relatively low rates of immunization; and * threats to environmental health including those that threaten our clean air, and safe food and drinking water. In summary, notwithstanding all that has transpired this year, Canadians’ health and their health care system remain high public priorities. While their health status has improved over the past decades, there is considerable room for improvement, some of which can be addressed through public health measures and better access to care. The significant announcements made over the past year related to health system and public health financing are a welcomed start to support health stakeholders in facing these challenges. III. THE FIRST MINISTERS’ MEETING AGREEMENT The CMA closely followed the September 13-15, 2004 First Ministers Meeting on the Future of Health Care. In fact, we worked with our health care colleagues leading up to the meeting to identify possible strategies for improving the system. 3 For instance, we recommended the development and adoption of pan-Canadian benchmarks for wait times based on clinical evidence and the creation of a special Canada Health Access Fund to support Canadians’ access to medically necessary care in other regions. While not all of our proposals were accepted, the September First Ministers’ Meeting Agreement (herein referred to as the FMM Agreement) features many aspects that the CMA has been championing for some time and is certainly a positive achievement. In particular, we are happy to see a desire “to make timely access to quality care a reality for all Canadians.” We applaud the leadership shown by the government in this regard. We also believe that the Agreement provides an opportunity for a new era of cooperative medicare by engaging physicians and other providers meaningfully. Contrary to belief, health care providers have not been offered many opportunities to participate at federal, provincial and territorial planning tables. We therefore welcome the opportunity to work collaboratively on identifying clinically derived wait time benchmarks. Canada’s physicians can and desire to play a significant role in this regard. We therefore believe the FMM Agreement is a necessary first step or “a framework to go with” towards strengthening our health care system. But as we said in September following the release of the Agreement, “the real heavy lifting begins now.” Accordingly, we believe that a number of requirements are necessary to ensure this Agreement fulfills its objectives. We see these requirements as putting words to actions for realizing the full potential of the FMM Agreement. Enact Legislation to Confirm Financial Support and Accountability Provisions The CMA supports enacting federal legislation to confirm the budgetary allocations in the Agreement ($18 billion over 6 years and $41 billion over 10 years). This includes a 6% escalator to the Canada Health Transfer (CHT) that will provide predictable funding for provincial and territorial health care systems. This is a provision that we have been recommending for many years. While $41 billion is a lot of money, we must remind ourselves that this amounts to little more than a 3% increase over 10 years of provincial government health expenditures based on projections of current government spending. Moreover, we estimate that the Agreement will add only .2% to Canada’s spending levels per GDP during this period. In other words, the FMM Agreement, while necessary and appreciated, will not propel Canada into the top echelon of health care spenders among the leading industrialized countries. As health care has become a dominant public policy issue, we expect to see future high level discussions in coming years on both future funding levels and on the direction of health care reform efforts. We are also pleased to see a new Equalization agreement that will complement the FMM Agreement. The Equalization program plays a key role in ensuring that all provinces have adequate and comparable levels of health care and other social services. The issue of Equalization payments to the provinces was identified in discussions leading up to the September First Ministers Meeting over concern that increased federal transfers to health care could be offset by decreases in Equalization payments. The subsequent agreement on Equalization will therefore serve to support the FMM Agreement given that increases in health care transfers to provinces will not be offset by decreases in equalization payments while providing predictable multi-year funding. A strong accountability framework also needs to be included in the legislation. The FMM Agreement specifies several process accountabilities such as a commitment by governments to report on access indicators and establish wait time benchmarks by December 31, 2005. The CMA believes that the Wait Times Reduction Fund should be subject to contribution agreements that specify how provinces and territories will use their share of this fund to reduce wait times. For the Agreement to mean something commitments have to backed up—financial and/or political consequences must follow if commitments are not met. It will be important to have an independent, third party organization assess progress in an open and transparent manner. The Health Council of Canada, identified in the FMM Agreement, could be the body to undertake an annual independent assessment, providing it receives the necessary resources to do so. The Canadian Institute for health Information also has an important role to play in ensuring comparable indicators are used to measure progress. It is essential to involve practicing physicians throughout the implementation of the FMM Agreement, particularly in the development of clinically derived wait time benchmarks. The determination of clinically derived wait time benchmarks means just that—they must be clinically derived and must not be based on political or financial considerations. To this end, the CMA will play a leadership role in developing consensus with physicians and other expert organizations on acceptable wait-time standards and protocols based on the best available clinical evidence. RECOMMENDATION 1 The federal government move quickly to enact legislation to implement the funding and accountability provisions of the First Ministers’ Agreement. The legislation should specify that the $4.5 billion Wait Times Reduction Fund be subject to contribution agreements with the provinces and territories. Improve Access by Addressing Health Human Resources The CMA is pleased to see the First Ministers acknowledge for the first time the current and worsening shortage of health human resources (HHR) in this country. However, the FMM Agreement does not adequately provide a strategy for addressing this crisis beyond the development of health human resources action plans and support for an Aboriginal Health Human Resources Initiative. The CMA believes that the lack of immediate action on HHR is one area where the Agreement falls short. As noted in our fact sheet, Canada is currently experiencing a shortage in health human resources. Canada’s ratio of 2.1 physicians per 1,000 population remains one of the lowest among OECD countries and below the OECD average of 2.9. Initial results from the 2004 National Physician Survey—the largest census survey of physicians ever conducted in Canada—find that up to 3,800 physicians will retire in the next two years, more than double the existing rate. Furthermore, 26% of physicians intend to reduce the number of hours they work. 4 One must remember that timely access to health care services is first and foremost about the people who provide quality care and the tools and infrastructure they need to meet the growing demand for medical services in Canada. In order for the FMM Agreement to be successful in improving access to care, governments must make health human resources a major priority beginning by ensuring that the Wait Times Reduction Fund is used immediately to address the crisis in health human resources rather than in the last four years of the ten-year Agreement as currently projected. 5 Given the current shortages in health human resources, action on HHR must begin now—not in 2010. In addition, the CMA calls upon the federal government to play a key role in improving the availability of health human resources by developing a pan-Canadian HHR strategy that includes the involvement of health care providers. Specifically, we need a three pronged pan-Canadian HHR strategy that would address: (1) HHR planning; (2) increasing the supply of health professionals; and, (3) retention issues. Planning Despite the large sum of funding that governments invest in health care, they do so without having the benefit of a national long-term health human resources strategy. Canada has 14 provincial/territorial and federal health care systems in operation. Yet, our immigration policies are largely conducted on a national basis and there is a high degree of labour mobility between provinces. Presently, there is no overall national coordinating committee to assist provinces and territories in the planning of health human resources, particularly one that includes all pertinent stakeholders including physicians and other health care professionals. We believe a National Coordinating Committee for Health Human Resources involving representation from health care professions should be established for such purposes—something both the Romanow and Senator Kirby reports recommended. Research is required to support long-term planning in HHR. The CMA has previously proposed the creation of an arm’s length Health Institute for Human Resources (HIHuR) that would promote collaboration and the sharing of HHR research among the well-known university-based centres of excellence as well as research communities within professional associations and governments. Supply Canada’s HHR policy goal should be to ensure Canada is self-sufficient in the supply of physicians and other health care professionals. Several strategies are required to fulfill this goal. They include: * Dedicating a specific fund to increase enrollment in undergraduate and postgraduate medical education (especially re-entry positions). Medical school enrollment should be increased to a minimum of 2,500 positions by 2007. * Expanding the post-MD system to accommodate the increase in graduates for training including the several hundred international medical graduates (IMGs) in Canada who have been deemed eligible for post-MD training here. The goal should be to increase the number of first-year residency training positions to a level of 120% of the graduates produced annually by Canadian medical schools. See Appendix B for how this can be implemented. The estimated cost of adding 500 positions is $75 million over five years. In fact, this government’s election platform included a commitment to provide funding to top-up training for 1,000 foreign trained medical professionals. * Expediting the integration of international medical graduates by funding a fast-track on-line assessment program administered by the Medical Council of Canada. It would determine the suitability and eligibility of IMGs for completion of post-MD training (estimated cost $20 million over 5 years). * Implementing a national strategy to extend the Canada Student Loans interest payment benefit to postgraduate trainees in medicine. High student debt impacts both the kind of specialty that physicians-in-training choose, and ultimately where they decide to practice—making it a key health human resource issue (see box below). The Canadian Medical Association commends the federal government for its commitment to reduce the financial burden on students in health care professions, as announced in the FMM Agreement. Did you know? Becoming a full-fledged, practicing physician is an arduous and expensive endeavor. It requires a minimum of 9 years (6) of post-secondary education and training that is often financed through sizeable government and private loan debt, such as lines of credit. It is estimated that, by the time medical students enter their pre-practice postgraduate training period, many are doing so with a debt of at least $120,000 (7) or more. RECOMMENDATION 2 The federal government work with relevant stakeholders to extend interest free status on Canada Student Loans for all eligible health professional students pursuing postgraduate training. Retention Retention remains a major concern for the health care workforce including physicians. We speak not only in terms of losing physicians to other countries but to other professional pursuits as well (i.e., opportunities away from the front line delivery of care). There is little point in recruiting new physicians at the front end if we lose sight of how to keep them once they are highly skilled and are in their most productive years. Retention issues are crosscutting. Indeed, a major frustration for physicians today are the difficulties faced trying to access other types of care for their patients such as diagnostic testing, specialty care or community services. Thus, improving access to a comprehensive range of health care providers and services and reducing wait times—as previously addressed—can help. We also believe that investments in information technologies (IT) can help improve the coordination of health care and allow physicians to spend more time with their patients to provide quality care. There is currently limited connectivity among community-based physicians, community based services, specialists, hospitals and diagnostic facilities. IT investments can improve the integration of care, improve patient safety and improve the management of wait times. They can link regional and provincial wait time management systems while supporting more comprehensive scheduling systems. Prescriptions can be sent electronically to the local pharmacist while public health warnings can be sent electronically to physicians’ offices. We recognize that investments in IT are already occurring and systems will be put in place over the next decade. However, we believe that by accelerating IT investments today, system efficiencies and savings can be achieved sooner along with improvements to health care delivery and coordination. The application of tax policy to the health care sector is another retention issue that greatly frustrates physicians. This issue is discussed in the next section. Align Tax Policy With Health Policy The CMA continues to advocate for a review of the relationship between federal tax policy and health care policy in Canada. Taxation is a powerful instrument of public policy. Good tax policy should reinforce and support good health care policy. Yet, it has been 40 years since the federal government last undertook an overarching review of Canada’s tax system (the 1962-1966 Royal Commission on Taxation -the Carter Commission). Standard public finance theory suggests that two objectives of effective tax policy are distributive equity and correcting inefficiencies in the private sector. 8 For some time, the CMA has expressed concern over inequities in tax policy and inconsistencies between national health policy goals and tax policy. We are aware that the committee is looking for ideas on tax changes that can lead to a more productive economy. At the same time, we recognize that the government is committed to improving Canadians’ access to health care. Ensuring this country’s tax policy is supporting our health care system is a good way to achieve both objectives. Specifically, the CMA calls on the federal government to remove the application of the Goods and Services Tax (GST) to the health care sector. Currently, not-for-profit hospital services receive an 83% rebate on the GST they pay on goods and services, while not-for-profit health organizations receive a rebate of 50%. Health care professionals working in free-standing clinics do not qualify for any GST relief (discussed below). The estimated portion of funding paid by hospitals alone back to the federal government in the form of GST revenue is estimated to be $90 million per year. That is the equivalent of the purchase cost of almost 40 MRI machines! The CMA believes that all publicly funded health care services should be spared from having to use scarce health care resources to remit GST and should receive the full GST rebate. Would this be setting a precedent? The answer is “no”. Prescription drugs, a significant proportion of total health care costs, have been zero-rated since 1996. Furthermore, the 2004 federal budget confirmed that municipalities would be able to recover 100% of the GST and the federal component of the harmonized sales tax (HST) immediately. As part of the “MUSH” sector (municipalities, universities, schools and hospitals), we believe the time has come to extend the full rebate to the health care sector. The federal government must stop taxing publicly funded health care. The uneven application of the GST rebate to different health services is also impeding efforts to renew and reorient the delivery of health services. Currently, community-based services such as clinics and nursing homes receive a GST rebate of only 50% while hospitals receive a rebate of 83%. Does it make sense that a nursing home or a home care service should pay more for GST than a hospital, particularly when trying to move to a more accessible community-based system? The variability of GST rebates makes no sense for organizations such as regional health authorities that oversee a range of health services but which pay differing rates. The government acknowledged in its 2003 Budget that there was a need to review how the GST is applied to care settings outside of hospitals. We await this review. Such inconsistencies distort the efficiency of the health care sector yet are relatively simple to address. 9 Physician services, on the other hand, are deemed “tax exempt” under The Excise Act. This means that physicians cannot claim any input tax credits despite the fact they must pay GST on their purchases of equipment, rent and utilities. And unlike other self-employed individuals or small businesses, physicians cannot pass on any of these additional costs as approximately 98% of physician compensation is from government health insurance plans. To date, provincial governments have been unwilling to provide funding to reflect the additional costs associated with the GST (insisting that it is a federal matter). Physicians are not asking for special treatment. They are looking for fairness within the tax system. If physicians, as self-employed individuals, are considered small businesses for tax purposes, then it only seems reasonable that they should have the same tax rules extended to them that apply to other small businesses (i.e., eligibility to receive input tax credits). This is a fundamental issue of tax fairness. In fact, this committee has twice before acknowledged the need to reassess the application of the GST on physician services. 10 The unfair manner in which the GST is applied to the health care sector has been an on-going source of major frustration to the physician community and remains unresolved. We believe that addressing this matter would be helpful in the country’s efforts to retain its physicians. Other self-employed health care providers that provide publicly funded services face a similar problem. RECOMMENDATION 3 As part of an effort to ensure that its tax policy is consistent with the goals of its health policy and the sustainability of Canada’s health care system, the federal government should: - increase the GST rebate for publicly funded health care institutions and clinics to 100% ($90 million annually for hospitals) - zero rate GST on publicly funded health services provided by independent health care providers ($75 million annually for medical services). IV PUBLIC HEALTH: HEALTHY PUBLIC As previously noted, much has happened over the past year with respect to Canada’s public health system. The CMA was pleased to see the creation of the position of Minister of State, Public Health. We commend the Government of Canada for its establishment of the Public Health Agency of Canada and for its selection of Dr. David Butler-Jones as the new Chief Public Health Officer of Canada. The 2004 Budget’s commitment to approximately $665 million for investments for public health over the next 3 years was also a welcomed announcement. The CMA will provide its full support to work with Dr. Butler-Jones and the Public Health Agency of Canada, Ministers Bennett and Dosanjh to develop a coordinated and integrated plan to manage and improve public health in Canada. These developments certainly represent a good step towards rebuilding the country’s public health system. Address the “Naylor Gap” In spite of these initiatives, it remains essential to remind this government and Canadians that further attention to public health is necessary. As a member of the Canadian Coalition for Public Health in the 21st Century (CCPH21), the CMA calls on the federal government to enhance its financial commitment to the renewal of Canada’s public health system The public health system is a vital component of a sustainable health system by reducing pressures on the health care system and providing a net benefit to society. 11 Two thirds of total deaths in Canada are due to chronic diseases such as cardiovascular disease, cancer, lung disease and diabetes (Type II melitus)—many of which are preventable. Investing in public health also makes good economic policy. We have seen in recent years the incredible economic impact that public health outbreaks can have on a country’s economy. For instance, it has been estimated that the SARS outbreak cost the Canadian economy over $1.5 billion in 2003 alone with its impact still being felt. 12 As stated in the Report of the National Advisory Committee on SARS and Public Health (the Naylor Report), “we are constantly a short flight away from serious epidemics.” 13 Accordingly, we were pleased to hear the government’s Speech from the Throne state that the government will proceed with the development of the Pan-Canadian Public Health Network. But we have to overcome several years of inattention to public health issues and the public health infrastructure—something that cannot be rectified in a year. Spending levels on public health in Canada are meager. International comparisons are difficult to find and to compare, but it appears that this is one instance where Canada could learn from its neighbour to the south with its higher level of spending on public health (see Box comparing public health spending between Canada and the United States). 14 While the role of public health was referred to in the FMM Agreement, no additional funding for public health was included. Comparing Levels of Public Health Spending: Canada vs. the United States Using data from CIHI and the US Centers for Medicare and Medicaid Services, the CMA has developed the following comparative estimates of spending on public health in Canada versus the United States in 2002. [TABLE CONTENT DOES NOT DISPLAY POPERLY. SEE PDF FOR PROPER DISPLAY] Canada United States 1. Per capita spending on public health services ($CDN, PPP adjusted) $138 $207 2. Share of spending on public health as a % of public health care spending 5.5% 7.2% 3. Share of spending on public health as a % of total health care spending 3.9% 3.3% [TABLE END] The United States spends approximately 50% more on public health than Canada when comparing per capita payments. The United States also spends more on public health when considering public health spending as a percentage of all publicly funded services (due in part to a proportionately smaller publicly funded sector). Conversely, Canada spends more on public health if looking at the percentage of spending on public health as a percentage of total health care spending. This is due in part to a proportionately larger privately funded sector in the United States. Since public health is predominately a public good paid by governments, we believe it is most appropriate to compare the results from the first two indicators. The Naylor Report estimated that public health in Canada accounted for 2.6% to 3.5% of total publicly funded health expenditures in Canada and 1.8% to 2.5% of total health expenditures. While these estimates are lower than those provided above, they still support our observation that public health spending in Canada is lower than in the United States. The Naylor report provided a blue print for action and reinvestment in the public health system for the 21st century. It estimated that approximately $1 billion in annual funding would be required to implement and sustain the public health programs that Canada requires. In its submission to the National Advisory Committee on SARS and Public Health, the CMA also identified an essential range of comprehensive public health programming and initiatives totaling an estimated $1.5 billion over 5 years. 15 The federal government has thus far committed approximately $665 million in new programming (one-time funding, over 2 years, and over 3 years), well short of Dr. Naylor’s $1 billion per year. This “Naylor Gap” of approximately $450 million per year is identified below in Table A. [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Table A: Estimating “The Naylor Gap” Naylor Funding Recommendations (by 2006-07) Budget 2004 Naylor Gap Public Health Agency of Canada Related Funding - $300 million per year core budget of PPHB and other related federal services to be transferred to new agency - core functions to be expanded by $200 million per year within 3-5 years - $404 million transferred from Health Canada to Agency - $165 million over 2 years to assist in setting up new agency, increase emergency response capacity, enhance surveillance, establish regional centres of excellence, expand laboratory capacity, strengthen international coordination and collaboration $117.5 million per year ($200 million by Naylor minus $82.5 million per year committed by the federal government averaged out). Moreover, nothing earmarked beyond 2005-06. System Funding 3 programs of transfers at a cost of $500 million per year: - $300 million for Public Health Partnerships Program to build capacity at local level - $100 million for communicable disease surveillance - $100 million to bolster national immunization strategy - $100 million (one-time) to Canada Health Infoway to pay for real-time public health surveillance system - $400 million over three years for: - $300 million for national immunization strategy - $100 million for provinces to address immediate gaps in capacity Approximately $333 million per year ($500 million per year request by Naylor less Budget 2004 commitments of $500 million over 3 years or $167 million per year averaged out.) Total: $1 billion per year $404 million annually plus $665 million in new programming (one-time funding, over 2 years, or over 3 years) Total “Naylor Gap”: $450.5 million per year [TABLE END} We acknowledge that the Public Health Agency of Canada is just being created. We also recognize that Budget 2004 noted that: “The Government of Canada expects to make further investments once the new Canada Public Health Agency is operational, the Chief Public Health Officer has developed a comprehensive public health plan, and the Government has had the opportunity to evaluate the need for additional resources.” 16 Nevertheless, it is critical that reinvestment in Canada’s public health system continue as soon as possible to protect and promote the health of Canadians. These additional investments are needed to fully implement Dr. Naylor’s recommendations. This includes operating costs for a real time communication system for front line public health providers during health emergencies. It would ensure a two-way flow of information between front-line health care providers and public health professionals at the local public health unit, the provincial public health department and the Public Health Agency of Canada. The CMA has recently submitted a proposal to Canada Health Infoway to develop a system (the Health Emergency Communication and Co-ordination Initiative) that would link Canada’s physicians with governmental authorities. The additional investments should also be used to help address the recruitment and retention of public health practitioners. 17 In contrast with other areas of health expenditures, we know very little about how public health dollars are allocated and with what results. Presently, public health expenditures are lumped together with some health system administration costs. We believe there is a need for a better tracking and public reporting of public health expenditures. Set and Meet National Health Goals The CMA was pleased to see support by First Ministers in the FMM Agreement to establish a Pan-Canadian Public Health Strategy and health goals that are independently monitored. We believe health goals are a key component in addressing the serious public health challenges that lie ahead. Goals stimulate action and improve system accountability. Unlike Canada, many other countries—including the United States, the UK and Australia—have set health goals for their populations at the national level. At the CMA’s August 2004 General Council meeting, physicians agreed on health goals for physical activity, healthy body weights and obesity (see box below). These goals are already having an effect. Recently, the BC Minister of Health, Colin Hansen, accepted the challenge from the President of the British Columbia Medical Association, Dr. Jack Burak, to increase fitness levels by 10 per cent by 2010. We also need to be more preoccupied with setting, meeting and monitoring environmental health goals. Let us look at drinking water for example. As hard as it may be for Canadians to believe, a safe supply of water is a key health concern for Canadians today just as it was at the turn of the 20th century. The polluting of our water supply—including the presence of antibiotic-resistant bacteria through the use of antibiotics in human and animal health—and a lack of adequate water treatment infrastructure systems have contributed to the problem. Above all, we as Canadians need to recognize that a large natural supply of water and other natural resources do not eliminate the need for strong environmental governance. Public health officials play an important role in this respect. But it is pointless to set goals without any intention of meeting them. Resources will be necessary to meet the selected health goals such as the training and hiring of public health workers, as well as funding to support public advertising and marketing campaigns. Physical Activity and Healthy Body Weight Goals for Canada (Endorsed at CMA General Council, August 2004, Toronto) The Canadian Medical Association urges all levels of government to commit to a comprehensive, integrated and collaborative national strategy for increasing the physical activity levels of all Canadians, with a target of a 10% increase in each province and territory by the year 2010. The Canadian Medical Association calls on all stakeholders to develop, as an urgent priority, an action plan to address the obesity epidemic in Canada, with a goal of increasing by 15% within ten years the proportion of Canadians who are at a healthy weight. Invest in Health Not in Tobacco Improving health status is more than promoting healthy lifestyle behaviour. A healthy society also requires public policy that supports health (e.g. adequate income and education, proper housing, adequate nutrition, a clean and safe environment.) Tobacco use is a good example of a health risk that has been significantly reduced with the help of public policy measures, such as higher tobacco taxes, continued restrictions on tobacco advertising and promotion, and restrictions on smoking in public places. But there remains inconsistency in Canada's public policies—in this case between the investment policies of the CPP Investment Board and Canada's health policy goals. Canadians are very proud of their public pension plan, the Canada Pension Plan (CPP). It is a well-supported social program that has been viewed as a best practice model by several countries. Yet, despite the fact that tobacco continues to kill approximately 45,000 Canadians a year and costs Canadian society approximately $11 billion per year in net cost, (18) the Canada Pension Plan holds $94 million worth of tobacco investments. Canada’s physicians see the toll that tobacco consumption creates. We see the physical and mental suffering that tobacco-caused diseases bring to patients and their families. Accordingly, the CMA has consistently recommended a wide range of measures to control tobacco use such as higher tobacco taxes, continued restrictions on tobacco advertising and promotion, restrictions on smoking in public places, enforcement of bans on sales to minors, reduction of the level of toxic ingredients in tobacco and the provision of smoking cessation programs. We are pleased with the efforts to date but we are by no means finished in our battle. As our fact sheet shows, there are still segments of the population, particularly among our youth, that have high rates of smoking. The federal government in recent years has spent hundreds of millions of dollars on a tobacco reduction strategy that, when combined with efforts being taken by the provinces and municipalities, is making a difference for Canadians. However, the CPP Investment Board is investing and voting as shareholders in a pattern that is inconsistent with both public health policy, and the tobacco reduction measures being implemented across Canada. It is inconsistent and illogical for one arm of government to expend many millions of dollars of public money in an effort to reduce tobacco use, while another arm invests many millions of dollars of money in tobacco companies and supports these companies in their drive to be profitable. Resolution of the Canadian Medical Association General Council, August 2004: …the government amend the Canada Pension Plan Investment Board Act so that CPP investments in the tobacco industry are prohibited and the CPP Investment Board divests itself of existing tobacco holdings. The CMA is prepared to back up what it is prescribing—MD Management Ltd’s “MD Funds” which are managed for Canada’s physicians has followed this policy for almost ten years. Other major pension and investment plans have successfully followed this policy as well including several US State retirement and pension funds and the American Medical Association Pension Fund. While the CMA clearly believes that the CPP Investment Board should not invest in the tobacco industry and that existing tobacco holdings should be divested, we recognize that this committee might want to look at the matter in greater context to assess its full impact. We suggest that this be done in conjunction with the Standing Committee on Health. RECOMMENDATION 4 The Standing Committees on Finance and Health hold a joint review of the CPP policy as it relates to investments in tobacco (both current and potential) by the CPP Investment Board. IV. CONCLUSION The Finance Committee’s last report on the pre-budget hearings noted that the CMA’s submission identified relatively small, one-time investments that can support the health care system. 19 This year’s submission once again puts forward strategic investments that we believe support Canada’s health policy goals and which serve to effectively implement the FMM Agreement. Our recommendations are also directed at improving the alignment of Canada’s economic policy with its health policy. It is natural to think of an agreement as an end point. But in reality, the FMM Agreement and last year’s funding announcements for public health must be seen as for what they are—first steps to sustaining Canada’s health care system and its public health system. Canada’s physicians and the CMA are committed to working with governments and other health care stakeholders to ensure the financial investments announced over the past year lead to positive and enduring change, and ultimately improved health for all Canadians. END NOTES 1 Claudia Sanmartin et al. Access to Health Care Services in Canada, 2003. Statistics Canada, 2004. 2 Canadian Medical Association. The Taming of the Queue: Toward a Cure for Health Care Wait Times. Discussion Paper. July 2004. Ottawa. 3 CMA, Better Access for Better Health, September 2004; Canadian Healthcare Association, Canadian Medical Association, Canadian Nurses Association, Canadian Pharmacists Association. “Common Vision for the Canadian Health System,” September, 2004. 4 National Physician Survey, “Initial Data Release of the 2004 Physician Survey”, October 2004. 5 A note listed under the funding schedule indicates that moneys flowing to the Wait Times Reduction Fund for health human resources ($250 million for four years) will come only during the final four years of the Agreement. 6 Average duration. Only 2/16 medical schools have a 3 (versus 4) year program. 7 This estimate is based on federal government actual and estimated costs as well as current actual national average tuition fees in undergraduate programs in medicine. Data sources: (1) Statistics Canada, The Daily, April 26, 2004, National Graduates Survey: Student Debt, p. 3. (2) Government of Canada, Canlearn. Saving for your child's education, The projected cost of your child's education. University Tuition. Typical 1996 university cost living away from home: $13,000 - $3,500 tuition = $9,500 x 24% (8 years x 3% inflation cited in reference above) = $11 780. see: http://www.canlearn.ca/financing/saving/guaranteefuture/clcos.cfm?langcanlearn=en (3) Association of Canadian Medical Colleges for tuition 8 For a further discussion of the role of taxation in public policy, refer to Musgrave, Richard A. and Peggy B. Musgrave’s Public Finance in Theory and Practices. 1973. New York: McGraw-Hill. 9 Canadian Medical Association, Tax and Health—Taking Another Look. Discussion Paper, May 2002. 10See Keeping the Balance, 1997 Report of the Standing Committee on Finance; Facing the Future: Challenges and Choices for a New Era, 1998 Report of the Standing Committee on Finance. 11 See for example, Laurie J. Goldsmith, Brian Hutchinson and Jeremiah Hurley, Economic Evaluation Across the Four Faces of Prevention: A Canadian Perspective. (Hamilton: Centre for Health Econoimcs and Policy Analysis, McMaster University), May 2004. 12 The Conference Board of Canada, “The Economic Impact of SARS”, Ottawa, May 2003. 13 Report of the National Advisory Committee on SARS and Public Health, Learning From SARS: Renewal of Public Health in Canada, October 2003. 14 Based on data from the Center for Medicare and Medicaid Services (http://www.cms.hhs.gov/statistics/nhe/). 15 Canadian Medical Association, Answering the Wake Up Call: CMA’s Public Health Action Plan. Submission to the National Advisory Committee on SARS and Public Health, June 2003. 16Government of Canada, Department of Finance Canada, The Budget Plan 2004, p. 101. 2004. 17 See Answering the Wake-up Call: CMA’s Public Health Action Plan for other initiatives that should be funded to rebuild Canada’s public health system. 18 Adapted from estimates provided by Murray J. Kaiserman, “The Cost of Smoking in Canada, 1991”, Chronic Diseases in Canada, Vol. 18, No. 1, 1997. Available at http://www.phac-aspc.gc.ca/publicat/cdic-mcc/18-1/c_e.html. 19 Report of the Standing Committee on Finance, Canada: People, Places and Priorities, November 2002.
Documents
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Annual report on the status of Canada's health care system and its funding

https://policybase.cma.ca/en/permalink/policy1517
Last Reviewed
2017-03-04
Date
2004-08-18
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Resolution
GC04-84
The Canadian Medical Association will ensure the development of an annual report on the status of Canada's health care system, including a component on the financial sustainability of the publicly funded medicare program.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
2004-08-18
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Resolution
GC04-84
The Canadian Medical Association will ensure the development of an annual report on the status of Canada's health care system, including a component on the financial sustainability of the publicly funded medicare program.
Text
The Canadian Medical Association will ensure the development of an annual report on the status of Canada's health care system, including a component on the financial sustainability of the publicly funded medicare program.
Less detail

Canada Health Access Fund

https://policybase.cma.ca/en/permalink/policy1490
Last Reviewed
2017-03-04
Date
2004-08-18
Topics
Health human resources
Health systems, system funding and performance
Resolution
GC04-10
The Canadian Medical Association calls on the federal and provincial/territorial governments to establish a Canada Health Access Fund to assure that individual Canadians can obtain portable and timely access to care at the time and to the extent of their needs.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
2004-08-18
Topics
Health human resources
Health systems, system funding and performance
Resolution
GC04-10
The Canadian Medical Association calls on the federal and provincial/territorial governments to establish a Canada Health Access Fund to assure that individual Canadians can obtain portable and timely access to care at the time and to the extent of their needs.
Text
The Canadian Medical Association calls on the federal and provincial/territorial governments to establish a Canada Health Access Fund to assure that individual Canadians can obtain portable and timely access to care at the time and to the extent of their needs.
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Care to new immigrants and refugees

https://policybase.cma.ca/en/permalink/policy13699
Date
2017-08-23
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
Resolution
GC17-04
The Canadian Medical Association supports development of clinical best practice guidelines for the provision of care to new immigrants and refugees.
Policy Type
Policy resolution
Date
2017-08-23
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
Resolution
GC17-04
The Canadian Medical Association supports development of clinical best practice guidelines for the provision of care to new immigrants and refugees.
Text
The Canadian Medical Association supports development of clinical best practice guidelines for the provision of care to new immigrants and refugees.
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Chaoulli: CMA/COA submission regarding timeliness of access to health care

https://policybase.cma.ca/en/permalink/policy1956
Last Reviewed
2011-03-05
Date
2004-03-19
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Court submission
Last Reviewed
2011-03-05
Date
2004-03-19
Topics
Health systems, system funding and performance
Text
S.C.C. File No.: 29272 IN THE SUPREME COURT OF CANADA (ON APPEAL FROM THE COURT OF APPEAL OF QUEBEC) B E T W E E N: JACQUES CHAOULLI AND GEORGE ZELIOTIS Appellants (Appellants) - and - ATTORNEY GENERAL OF QUÉBEC Respondent (Respondent) - and - ATTORNEY GENERAL OF CANADA Respondent (Mis en cause) - and - ATTORNEY GENERAL OF BRITISH COLUMBIA, ATTORNEY GENERAL OF ONTARIO, ATTORNEY GENERAL OF MANITOBA, ATTORNEY GENERAL OF NEW BRUNSWICK, ATTORNEY GENERAL OF SASKATCHEWAN, AUGUSTIN ROY, SENATOR MICHAEL KIRBY, SENATOR MARJORY LEBRETON, SENATOR CATHERINE CALLBECK, SENATOR JOAN COOK, SENATOR JANE CORDY, SENATOR JOYCE FAIRBAIRN, SENATOR WILBERT KEON, SENATOR LUCIE PÉPIN, SENATOR BRENDA ROBERTSON AND SENATOR DOUGLAS ROCHE, THE CANADIAN MEDICAL ASSOCIATION AND THE CANADIAN ORTHOPAEDIC ASSOCIATION, CANADIAN LABOUR CONGRESS, CHARTER COMMITTEE ON POVERTY ISSUES AND THE CANADIAN HEALTH COALITION, CAMBIE SURGERIES CORPORATION, FALSE CREEK SURGICAL CENTRE INC., DELBROOK SURGICAL CENTRE INC., OKANAGAN PLASTIC SURGERY CENTRE INC., SPECIALTY MRI CLINICS INC., FRASER VALLEY MRI LTD., IMAGE ONE MRI CLINIC INC., MCCALLUM SURGICAL CENTRE LIMITED, 4111044 CANADA INC., SOUTH FRASER SURGICAL CENTRE INC., VICTORIA SURGERY LTD., KAMLOOPS SURGERY CENTRE LTD., VALLEY COSMETIC SURGERY ASSOCIATES INC., SURGICAL CENTRES INC., THE BRITISH COLUMBIA ORTHOPAEDIC ASSOCIATION AND THE BRITISH COLUMBIA ANESTHESIOLOGISTS SOCIETY Interveners FACTUM OF THE INTERVENERS CANADIAN MEDICAL ASSOCIATION AND THE CANADIAN ORTHOPAEDIC ASSOCIATION BORDEN LADNER GERVAIS LLP World Exchange Plaza 1100 – 100 Queen St. Ottawa, Ontario K1P 1J9 Guy Pratte/Freya Kristjanson Tel: (613) 237-5160/(416) 367-6388 Fax: (613) 230-8842/(416) 361-7053 Net: gpratte/fkristjanson@blgcanada.com Solicitors for the Interveners, The Canadian Medical Association and The Canadian Orthopaedic Association AND TO: JACQUES CHAOULLI 21, Jasper Avenue Ville Mont-Royal, Quebec H3P 1J8 Tel.: (514) 738-2377 Fax: (514) 738-4062 Appellant, self-represented AND TO: BERGERON, GAUDREAU, LAPORTE 167, rue Notre Dame de l’Île Gatineau, Quebec J8X 3T3 Richard Gaudreau Tel: (819) 770-7928 Fax: (819) 770-1424 Agent for the Appellant, Jacques Chaoulli AND TO: TRUDEL & JOHNSTON 85, de la Commune Est, 3e étage Montreal, Quebec H2Y 1J1 Philippe H. Trudel Bruce W. Johnston Tel.: (514) 871-8385 Fax: (514) 871-8800 Counsel for the Appellant, George Zéliotis AND TO: MCCARTHY TÉTRAULT LLP 1400 - 40 Elgin Street Ottawa, Ontario K1R 5K6 Colin S. Baxter Tel.: (613) 238-2000 Fax: (613) 238-9836 Agent for the Appellant, George Zéliotis AND TO: BERNARD, ROY ET ASSOCIÉS 8.01 - 1, rue Notre-Dame Est Montreal, Québec H2Y 1B6 Robert Monette Tel.: (514) 393-2336 Fax: (514) 873-7074 Counsel for the Respondent, Attorney General of Québec AND TO: NOËL & ASSOCIÉS 111, rue Champlain Hull, Quebec J8X 3R1 Sylvie Roussel Tel.: (819) 771-7393 Fax: (819) 771-5397 Agent for the Respondent, Attorney General of Quebec AND TO: CÔTE, MARCOUX & JOYAL Complexe Guy Favreau, Tour Est 200, boul. Rene-Levesque O. 5 etage Montréal, Québec H2Z 1X4 André L’Espérance Tel: (514) 283-3525 Fax: (514) 283-3856 Counsel for the Respondent, Attorney General of Canada AND TO: D’AURAY, AUBRY, LEBLANC & ASSOCIÉS 275, rue Sparks Ottawa, Ontario K1A 0H8 Jean-Marc Aubry, Q.C. Tel.: (613) 957-4663 Fax: (613) 952-6006 Agent for the Respondent, Attorney General of Canada AND TO: MINISTRY OF ATTORNEY GENERAL Legal Services Branch 6th Floor, Sussex Building P.O. Box 9280 Stn Prov Govt 1001 Douglas Street Victoria, B.C. V8W 9J7 George H. Copley, Q.C. Tel: (250) 356-8875 Fax: (250) 356-9154 Counsel for the Intervener, Attorney General of British Columbia AND TO: BURKE-ROBERTSON Barristers and Solicitors 70 Gloucester Street Ottawa, Ontario K2P 0A2 Robert E. Houston, Q.C. Tel: (613) 236-9665 Fax: (613) 235-4430 Agent for the Intervener, Attorney General of British Columbia AND TO: ATTORNEY GENERAL OF ONTARIO 720 Bay Street, 4th Floor Toronto, Ontario M5G 2K1 Janet E. Minor Shaun Nalatsuru Tel: (416) 326-4137 Fax: (416) 326-4015 Counsel for the Intervener, Attorney General of Ontario AND TO: BURKE-ROBERTSON Barristers and Solicitors 70 Gloucester Street Ottawa, Ontario K2P 0A2 Robert E. Houston, Q.C. Tel: (613) 236-9665 Fax: (613) 235-4430 Agent for the Intervener, Attorney General of Ontario AND TO: ATTORNEY GENERAL OF MANITOBA Department of Justice 1205-405 Broadway Winnipeg, Manitoba R3C 3L6 Tel: (204) 945-0679 Fax: (204) 945-0053 AND TO: GOWLING LAFLEUR HENDERSON LLP 2600-160 Elgin Street P.O. Box 466, Stn. “D” Ottawa, Ontario K1P 1C3 Henry S. Brown, Q.C. Tel: (613) 233-1781 Fax: (613) 563-9869 Agent for the Intervener, Attorney General of Manitoba AND TO: ATTORNEY GENERAL OF NEW BRUNSWICK P.O. Box 6000, Room 444 670 King St., Centennial Building Fredericton, N.B. E3B 5H1 Gabriel Bourgeois, Q.C. Tel: (506) 453-3606 Fax: (506) 453-3275 Counsel for the Intervener, Attorney General of New Brunswick AND TO: GOWLING LAFLEUR HENDERSON LLP 2600-160 Elgin Street P.O. Box 466, Stn. “D” Ottawa, Ontario K1P 1C3 Henry S. Brown, Q.C. Tel: (613) 233-1781 Fax: (613) 563-9869 Agent for the Intervener, Attorney General of New Brunswick AND TO: ATTORNEY GENERAL OF SASKATCHEWAN Constitutional Law Branch 8th Floor – Scarth Street Regina, Saskatchewan S4P 3V7 Tel: (306) 787-8385 Fax: (306) 787-9111 AND TO: GOWLING LAFLEUR HENDERSON LLP 2600-160 Elgin Street P.O. Box 466, Stn. “D” Ottawa, Ontario K1P 1C3 Henry S. Brown, Q.C. Tel: (613) 233-1781 Fax: (613) 563-9869 Agent for the Intervener, Attorney General of Saskatchewan AND TO: AUGUSTIN ROY AND TO: BERGERON, GAUDREAU, LAPORTE 167, rue Notre Dame de l’Île Gatineau, Quebec J8X 3T3 Richard Gaudreau Tel: (819) 770-7928 Fax: (819) 770-1424 Agent for the Intervener, Augustin Roy AND TO: LERNERS LLP 2400 - 130 Adelaide Street West Toronto , Ontario M5H 3P5 Earl A. Cherniak, Q.C. Tel: (416) 867-3076 Fax: (416) 867-9192 Counsel for the Interveners, Senator Michael Kirby, Senator Marjory Lebreton, Senator Catherine Callbeck, Senator Joan Cook, Senator Jane Cordy, Senator Joyce Fairbairn, Senator Wilbert Keon, Senator Lucie Pépin, Senator Brenda Robertson and Senator Douglas Roche AND TO: GOWLING LAFLEUR HENDERSON LLP 2600-160 Elgin Street P.O. Box 466, Stn. “D” Ottawa, Ontario K1P 1C3 Brian A. Crane, Q.C. Tel: (613) 233-1781 Fax: (613) 563-9869 Agents for the Interveners, Senator Michael Kirby, Senator Marjory Lebreton, Senator Catherine Callbeck, Senator Joan Cook, Senator Jane Cordy, Senator Joyce Fairbairn, Senator Wilbert Keon, Senator Lucie Pépin, Senator Brenda Robertson and Senator Douglas Roche AND TO: SACK GOLDBLATT MITCHELL 20 Dundas Street West Suite 1130, P.O. Box 180 Toronto, Ontario M5G 2G8 Steven Shrybman Tel: (416) 977-6070 Fax: (416) 591-7333 Counsel for the Intervener, Canadian Labour Congress AND TO: BURKE-ROBERTSON Barristers and Solicitors 70 Gloucester Street Ottawa, Ontario K2P 0A2 Robert E. Houston, Q.C. Tel: (613) 236-9665 Fax: (613) 235-4430 Agent for the Intervener, Canadian Labour Congress AND TO: UNIVERSITY OF VICTORIA P.O. Box 2400, Station CSC Victoria , British Columbia V8W 3H7 Martha Jackman Tel: (250) 721-8181 Fax: (250) 721-8146 Counsel for the Interveners, Charter Committee on Poverty Issues and the Canadian Health Coalition AND TO: LANG MICHENER 300-50 O’Connor Street Ottawa , Ontario K1P 6L2 Marie-France Major Tel: (613) 232-7171 Fax: (613) 231-3196 Agent for the Interveners, Charter Committee on Poverty Issues and the Canadian Health Coalition AND TO: BLAKE, CASSELS & GRAYDON LLP Suite 2600, Three Bentall Centre 595 Burrard Street, P. O Box 49314 Vancouver, B. C. V7X 1L3 Marvin R.V. Storrow, Q.C. Tel: (604) 631-3300 Fax: (604) 631-3309 Counsel for the Interveners, Cambie Surgeries Corporation, False Creek Surgical Centre Inc., Delbrook Surgical Centre Inc., Okanagan Plastic Surgery Centre Inc., Specialty MRI Clinics Inc., Fraser Valley MRI Ltd., Image One MRI Clinic Inc., McCallum Surgical Centre Limited and 4111044 Canada Inc., South Fraser Surgical Centre Inc., Victoria Surgery Ltd., Kamloops Surgery Centre Ltd., Valley Cosmetic Surgery Associates Inc., Surgical Centres Inc., the British Columbia Orthopaedic Association and the British Columbia Anesthesiologists Society AND TO: BLAKE, CASSELS & GRAYDON LLP World Exchange Plaza 20th Floor, 45 O’Connor Ottawa, Ontario K1P1A4 Gordon K. Cameron Tel: (613) 788-2222 Fax: (613) 7882247 Agent for the Interveners, Cambie Surgeries Corporation, False Creek Surgical Centre Inc., Delbrook Surgical Centre Inc., Okanagan Plastic Surgery Centre Inc., Specialty MRI Clinics Inc., Fraser Valley MRI Ltd., Image One MRI Clinic Inc., McCallum Surgical Centre Limited and 4111044 Canada Inc., South Fraser Surgical Centre Inc., Victoria Surgery Ltd., Kamloops Surgery Centre Ltd., Valley Cosmetic Surgery Associates Inc., Surgical Centres Inc., the British Columbia Orthopaedic Association and the British Columbia Anesthesiologists Society TABLE OF CONTENTS PART I: FACTS 1 1. Overview 1 2. CMA/COA’s Interest in the Appeal 2 3. CMA/COA’s Position on the Facts 3 PART II: QUESTIONS IN ISSUE 8 PART III: ARGUMENT 8 1. Breach of Section 7 of the Charter 8 (a) Right to Life and Security of the Person 9 (i) Infringement of Life and Security of the Person 9 (ii) Real Apprehension of Charter Section 7 Violation 10 (b) Principles of Fundamental Justice 11 (c) Not an Economic Right 15 2. Not Saved Under Charter Section 1 17 PART IV: SUBMISSIONS CONCERNING COSTS 18 PART V: ORDER SOUGHT 19 PART VI: TABLE OF AUTHORITIES 20 PART VII: STATUTES AND REGULATIONS 22 PART I: FACTS 1. Overview 1. The Canadian Medical Association (“CMA”) and the Canadian Orthopaedic Association (“COA”) support the existing single payer (publicly funded) model of health care delivery, but are concerned that delays in access to medically necessary health care may put the life and health of patients in Canada at risk. The CMA/COA submit that governments must address the issue of timeliness of access to health care if they wish to maintain the viability and constitutionality of the social contract that is Medicare. 2. The CMA/COA put forward a position that they believe best protects the public health care system, while at the same time recognizing that failures in that system which threaten the life, liberty and security of the person of patients in Canada may constitute a Charter section 7 breach. The CMA/COA submit that so long as access to medically necessary care is provided in a timely manner, there is no Charter section 7 breach. In the absence of a clear commitment to timely access and where as a matter of fact the public system fails to provide timely access to medically necessary health care, legislative prohibitions that impede access or the means for access to medical treatment necessary to the life, liberty and security of the person do breach Charter section 7. 3. The fundamental issue in this case is whether it is constitutionally justifiable for governments to legislatively preclude a patient from seeking access or the means for access to medical treatment necessary to the life, liberty and security of the person, when such treatment is not available in a timely manner in the public system by reason of significant waiting times, under-funding, inadequate human and physical resources, or other impediments. 4. The purpose and effect of the matrix of federal and provincial statutes applicable to Medicare is to establish the public health care system as the sole payer of medically necessary (“insured”) services. In Québec, for example, the government defines what constitute medically necessary services, pays for all insured service provided to residents of Québec, sets out the conditions under which the insured services may be funded outside the province, and otherwise forbids by law the provision of private insurance for such insured services. While the Québec government has legislated to provide medically necessary care, the legislation does not extend to the provision of timely access to medically necessary care. It is this disjunction which has caused the CMA/COA to intervene in this case. Governments are not held accountable for the failure to provide medically necessary services in a timely manner in the public system. 5. This is not a case of economic rights because in the context of health care any clinically excessive delay can have profound consequences on both the physical and psychological aspects of a person’s life and security of the person. The CMA/COA, as physicians, submit that it is the impact of the deterioration of the public health care system to the point that it cannot deliver timely access to Canadians that is the heart of the issue. In this context, “timely access” refers to the delivery of care within a medically appropriate timeframe. Medically necessary health care delayed is health care denied. 2. CMA/COA’s Interest in the Appeal 6. The CMA is the national voice of Canadian physicians, with over 57,000 members in each of the ten provinces and the three territories. Its mission is to serve and unite the physicians of Canada, and to be the national advocate, in partnership with the people of Canada, for the highest standards of health and health care. An affiliate of the CMA, the COA is a voluntary medical speciality society of physicians with specialized training and certification in orthopaedic surgery. The COA’s goals are to achieve excellence in orthopaedic care for Canadians, in part through ensuring that adequate and accessible health care resources are available for Canadians. 7. The CMA/COA are committed to the fundamental principles of the national system of Medicare – comprehensiveness, universality of coverage, portability of benefits, reasonable access and non-profit administration. Furthermore, the CMA Code of Ethics, article 31, states that physicians should “recognize the responsibility of physicians to promote fair access to health care resources”. However, excessive waiting times in the public system threaten the viability of Medicare unless and until governments clearly commit to and factually do provide timely access. The decision of this Court will have a profound and lasting effect on the Canadian health care system, of which physicians are an integral part. It will directly affect the conditions under which patients receive treatment from physicians and other providers. Canadian Medical Association, Code of Ethics of the Canadian Medical Association, (Ottawa: The Association), October 1996, CMA/COA Authorities, Tab 17 3. CMA/COA’s Position on the Facts 8. Madam Justice Piché found at trial that if access to the health system is not possible, it is illusory to think that rights to life and security are respected. She further found that the prohibition on the purchase of private insurance is an infringement of life and security of the person where there are excessive waiting times for essential medical services in the public system. The trial judge found that waiting lists are too long and that, even if the question is not always one of life or death, all individuals are entitled to receive the care they need in a clinically responsive manner. She held, however, that the infringement did not violate fundamental justice given the historical context and the social benefits to all of a publicly funded health care system. Judgment of Piché J., Joint Appellants’ Record, Vol. I, pp. 126-127, 129, 134-135, 143 9. More recently, the serious issue of waiting times for medically necessary health care has been considered by two major national studies – the Canadian Commission on the Future of Health Care in Canada (the “Romanow Commission”) and the Report of the Standing Senate Committee on Social Affairs, Science and Technology (“the Senate Committee”). Each of these significant reports concluded that excessive waiting times exist across the country, that governments have available a number of tools to address such waiting times which are not being used to their fullest extent, and that delays in access to medically necessary services may cause the health of patients to deteriorate, as well as stress and anxiety. Canada, Commission on the Future of Health Care in Canada, Building on Values: The Future of Health Care in Canada – Final Report, (Ottawa, 2002) (Chair: Roy Romanow) at 137-150 [hereinafter Romanow, Building on Values], CMA/COA Authorities, Tab 15 Canada, The Standing Senate Committee on Social Affairs, Science and Technology, The Health of Canadians – The Federal Role: Final Report on the State of the Health Care System in Canada, Vol. 6 (Ottawa: 2002) (Chair: Michael Kirby) at 99-121 [hereinafter Kirby, The Health of Canadians, Vol. 6], CMA/COA Authorities, Tab 16 10. The CMA/COA recognize that wait times for diagnosis and treatment are intrinsic to a health care system. No country has sufficient resources at its disposal to build the excess capacity necessary to meet all health needs on an urgent basis. However, excessive wait times emerged as a major public policy issue starting in the mid- to late-1990s following several years of cuts in the financing of public health care. Moreover, public anxiety has been mounting over lengthening wait times for treatment. Public confidence in the system “being there” at the time and to the extent of need is gradually being lost. Kirby, The Health of Canadians, Vol. 6, supra at 109-111, CMA/COA Authorities, Tab 16 11. The Senate Committee cited with approval a recent Statistics Canada study, entitled Access to Health Care Services in Canada, 2001, that provides an indication of the extent to which Canadians are subject to waiting times and the associated stress and anxiety: * Almost one in five Canadians who access health care for themselves or a family member in 2001 encountered some form of difficulty, ranging from problems getting an appointment to lengthy waiting times. * Of the estimated five million people who visited a specialist, roughly 18 %, or 900,000, reported that waiting for care affected their lives. The majority of these people (59 per cent) reported worry, anxiety or stress. About 37 % said they experienced pain. * Canadians reported that waiting for services was clearly a barrier to care. Long waits were clearly not acceptable to Canadians, particularly when they experienced adverse effects such as worry and anxiety or pain while waiting for care. Statistics Canada, Access to Health Care Services in Canada, 2001 by C. Sanmartin, C. Houle, J.-M. Berthelot and K. White, (Ottawa, Minister of Industry, 2002) [hereinafter Statistics Canada, Access to Health Care], cited in Kirby, The Health of Canadians, Vol. 6, supra at 109, CMA/COA Authorities, Tab 21 12. The Statistics Canada report concluded that: Perhaps the most significant information regarding access to care was about waiting times. … Long waits were clearly not acceptable to Canadians, particularly when they experienced adverse affects such as worry and anxiety or pain while waiting for care. Statistics Canada, Access to Health Care, supra at 21, cited in Kirby, The Health of Canadians, Vol. 6, supra at 109, CMA/COA Authorities, Tab 21 13. Furthermore, the Romanow Report acknowledged the problem that Canadian patients and their physicians are faced with: Waiting for health care is a serious concern for Canadians and it has become a preoccupation for health care professionals, managers, and governments. Studies and public opinion polls have consistently shown that one of the top concerns of rural and urban Canadians is health care access… Long waiting times are the main, and in many cases, the only reason some Canadians say they would be willing to pay for treatment outside of the public health care system… As individual provinces and territories have struggled to deal with waiting times and wait lists within their own systems, progress is being made in some areas but more effort needs to be put into generalizing those efforts across the country… Clearly, the progress is not fast enough for Canadians. More can and must be done across the country to give Canadians what they want and deserve - timely access to health care services they need. Romanow, Building on Values, supra at 138-139, CMA/COA Authorities, Tab 15 14. Following its review of the Canadian health care system, the Senate Committee concluded on the issue of waiting time that: In Canada, patient prioritization is not standardized for any medical service (with the exception of [the Cardiac Care Network] in Ontario). This means that there is currently no provincially or nationally accepted method of measuring or defining waiting times for medical services, nor are there standards and criteria for “acceptable” waits for the vast majority of health services. It is impossible, therefore, to determine whether, from a clinical point of view, patients have waited a reasonable or unreasonable length of time to access care. The absence of standardized criteria and methods to prioritize patients waiting for care means that patients are placed and prioritized on waiting lists based on a range of clinical and non-clinical criteria that vary by individual referring physician across institutions, regional health authorities, and provinces. Kirby, The Health of Canadians, Vol. 6, supra at 112, CMA/COA Authorities, Tab 16 15. The Romanow Commission concluded on the issue of current problems with wait lists: One of the most serious concerns is not only the length of time some people wait but the way in which wait lists are managed. In fact, to say wait lists are “managed” is almost a misnomer. There is no consistent way of dealing with wait lists in particular regions let alone on a provincial or national basis. This affects the health of people who wait and it seriously undermines Canadians’ confidence in their health care system. When individual Canadians are told that they are on a wait list for a particular service, they probably assume that there is a master list that is managed and co-ordinated based on the urgency of their need. In reality, that is not what happens. Romanow, Building on Values, supra at 141-143, CMA/COA Authorities, Tab 15 16. Recent international surveys also indicate that the waiting times and access to care for patients who make heavy use of the health care system are markedly poorer in Canada than in four other Western countries. R.J. Blendon et al., “Common concerns Amid Diverse Systems: Health Care Experiences in Five Countries” (2003), 22 Health Affairs 106, CMA/COA Authorities, Tab 14 17. On the international scene, since at least the early 1990’s, mechanisms to address excessive wait times including access standards and care guarantees have been the subject of study, debate and practice in several jurisdictions including the United Kingdom, Sweden and New Zealand. The Organisation for Economic Co-operation and Development (OECD) commissioned a comprehensive study of the international experience with access standards and care guarantees. OECD, Labour and Social Affairs Committee, Tackling Excessive Waiting Times for Elective Surgery: A Comparison of Policies in Twelve OECD Countries, Doc. No. DELSA/ELSA/WD/HEA(2003)6 (2003), CMA/COA Authorities, Tab 19 OECD, Labour and Social Affairs Committee, Explaining Waiting Times Variations for Elective Surgery Across OECD Countries, Working Paper No. 7, Doc. No. DELSA/ELSA/WD/HEA(2003)7 (2003), CMA/COA Authorities, Tab 18 18. While the federal government has never taken the position that timeliness is a component of accessibility, such a position is certainly open to it. The Canada Health Act has established five criteria pursuant to which the federal government will cost-share provincial Medicare programs: portability, comprehensiveness, universality, public administration, and accessibility. “Accessibility” has been interpreted to require that there be no financial barriers to accessing hospital and physician services. Canada Health Act, R.S.C. 1985, c. C-6, s. 7, 12 19. The CMA proposed to the Senate Committee that guidelines and standards around quality and waiting times be established for a clearly defined basket of core services, and argued that “if the publicly funded health care system fails to meet the specified agreed-upon standards for timely access to core services, then patients must have other options to allow them to obtain this required care through other means.” Kirby, The Health of Canadians, Vol. 6, supra at 119, CMA/COA Authorities, Tab 16 20. There are concrete Canadian examples of how timely access may be measured and provided such as the Cardiac Care Network of Ontario, and the Western Canada Waiting List Project, both of which are reviewed in the Senate Committee Report. These projects have demonstrated that a substantial improvement in the waiting list problem is possible through adopting an approach based on the clinical needs of patients on waiting lists. The Senate Committee suggested: * A process to establish standard definitions for waiting times should be national in scope, and * Standard definitions should focus on four key waiting periods – waiting for primary care consultation; for initial specialist consultation; for diagnostic tests; and for surgery. Kirby, The Health of Canadians, Vol. 6, supra at 103-113, CMA/COA Authorities, Tab 16 Romanow, Building on Values, supra at 143-144, CMA/COA Authorities, Tab 15 PART II: QUESTIONS IN ISSUE 21. The CMA/COA take a position on the following constitutional questions as stated by this Court in its Order of August 15, 2003: (1) Does s. 11 of the Hospital Insurance Act, R.S.Q., c. A-28, infringe the rights guaranteed by s. 7 of the Canadian Charter of Rights and Freedoms? (2) If so, is the infringement a reasonable limit prescribed by law as can be demonstrably justified in a free and democratic society under s. 1 of the Canadian Charter of Rights and Freedoms? (3) Does s. 15 of the Health Insurance Act, R.S.Q., c. A-29, infringe the rights guaranteed by s. 7 of the Canadian Charter of Rights and Freedoms? (4) If so, is the infringement a reasonable limit prescribed by law as can be demonstrably justified in a free and democratic society under s. 1 of the Canadian Charter of Rights and Freedoms? 22. The CMA/COA submit that if there is a clear commitment from governments which provides timely access to medically necessary care, there is no constitutional breach. However, constitutional questions #1 and 3, should be answered affirmatively if a patient is denied timely access to health care in the public system with the result that the patient’s life is threatened or the quality of his/her life substantially compromised, and that patient is legislatively precluded from seeking access or the means for access to medically necessary treatment. In this event, the corresponding questions #2 and 4 should be answered negatively. PART III: ARGUMENT 1. Breach of Section 7 of the Charter 23. The analytical approach to be used under section 7 of the Charter has recently been described by this Honourable Court as a three-step process: 1) the identification of the individual interests said to be infringed and a determination of whether those interests fall within the meaning of the phrase “life, liberty and security of the person;” 2) the identification of the principles of fundamental justice engaged in the circumstances of the case; and, 3) whether the threshold infringement found in the first stage of the analysis is inconsistent with the pertinent principle of fundamental justice. R v. Malmo-Levine; R. v. Caine, 2003 SCC 74 at para. 83 [hereinafter Malmo-Levine], CMA/COA Authorities, Tab 10 (a) Right to Life and Security of the Person 24. The CMA/COA submit that when a patient is denied timely access to health care in the publicly funded system with the result that the patient’s life is threatened or the quality of her life substantially compromised, and that patient is legislatively precluded from seeking access or the means for access to medically necessary treatment, the infringement of the rights to life and/or security of the person is clear. However, where the health care service at issue is not essential to maintaining quality and quantity of life, and the delay in accessing that treatment is not clinically significant, then the values and principles reflected in Charter section 7 are not engaged. 25. “Timely access” to health care refers to the delivery of care within a medically appropriate time frame. As discussed in paragraph 20, there are existing Canadian and international initiatives to develop and refine medically appropriate time frames. (i) Infringement of Life and Security of the Person 26. In the context of health care, any clinically excessive delay can have profound consequences on both the physical and psychological aspects of a patient’s life and security of the person. OECD, Labour and Social Affairs Committee, Tackling Excessive Waiting Times for Elective Surgery: A Comparison of Policies in Twelve OECD Countries Annex 1, Doc. No. DELSA/ELSA/WD/HEA(2003)6/ANN1 (2003), CMA/COA Authorities, Tab 20 27. The CMA/COA submit that delay in the medical context, when caused by government laws and policies, may clearly threaten an individual’s life and security of the person. The significance of government-caused delay in the criminal context was recognized in R. v. Morgentaler. Chief Justice Dickson, as he then was, in R. v. Morgentaler found that the increased risk to a woman’s health resulting from the delay caused by the government procedures in obtaining an abortion deprived her of her security of the person. Justice Beetz recognized the additional danger to a woman’s health caused by the state’s intervention which prevented “access to effective and timely medical treatment.” R. v. Morgentaler, [1988] 1 S.C.R. 30 at 59, 101 [hereinafter Morgentaler], CMA/COA Authorities, Tab 11 28. The infringement of a person’s security is not restricted to the physical aspect. State interference with bodily integrity and serious state-imposed psychological stress also constitute a breach of security of the person. There must be an objective assessment of state interference “on the psychological integrity of a person of reasonable sensibility.” It requires more than ordinary stress and anxiety, but does not need to escalate to the level of nervous shock or psychiatric illness. New Brunswick (Minister of Health and Community Services) v. G.(J.), [1999] 3 S.C.R. 46 at para. 60 [hereinafter New Brunswick], CMA/COA Authorities, Tab 7 Morgentaler, supra at 60, CMA/COA Authorities, Tab 11 29. The failure to obtain timely health care may have a serious and profound effect on an individual well beyond the normal stress and anxiety of life. Where there is an increased risk to both physical and mental health resulting from excessive delay in obtaining medically necessary health care, a deprivation of security of the person and significant diminution in the quality and quantity of life will ensue. (ii) Real Apprehension of Charter Section 7 Violation 30. The evidence before the trial judge supports a finding that there is a real apprehension of a violation of Charter section 7 rights. At trial, Piché J. heard evidence from more than fifteen witnesses, including both expert physicians and professors, as well as patients who have been intimately involved with the public health care system. A large quantity of evidence was presented on the delays in access to health care, and its consequences in such fields as orthopaedics, ophthalmology, oncology, cardiology and emergency care. She concluded: De ces témoignages, le Tribunal retient d’abord la sincérité et l’honnêteté des médecins qui ont témoigné, de leur désir de changer les choses, de leur impuissance malheureuse devant des listes d’attente trop longues. Le Tribunal retient que les listes d’attente sont trop longues, que même si ce n’est pas toujours une question de vie ou de mort, tous les citoyens ont droit à recevoir les soins dont ils ont besoin, et ce, dans les meilleurs délais. Judgment of Piché J., Joint Appellants’ Record, Vol. I, pp. 42, 43 31. The CMA/COA submit that deference must be paid to the findings of fact of the trial judge. In the alternative, the CMA/COA submit that this Court has before it all the necessary evidentiary support in order to make the determination on reasonable hypothetical circumstances. The protection under the Charter embodies a preventative aspect when a violation is apprehended, as observed by the trial judge. As Justice Forget at the Court of Appeal held: Obliger une personne à attendre d’être gravement malade (ou d’avoir subi un grave accident) avant d’entreprendre des procédures pour obtenir des soins adéquats de santé aurait pour effet, dans la majorité des cas, de rendre illusoire le recours, compte tenu de l’imprévisibilité de la maladie et de son évolution. Judgment of Court of Appeal, Forget J., Joint Appellants’ Record, Vol. I, p. 187 New Brunswick, supra at paras. 56-68 and 91, CMA/COA Authorities, Tab 7 32. The CMA/COA submit that this Honourable Court should not be waiting for, in the words of the trial judge, “une question de vie ou de mort” before acting. Cases such as Stein v. Québec (Régie de l’Assurance-maladie) demonstrate that timely access to necessary medical care is a real concern. Failures of timely access pose a significant risk to s. 7 rights. Stein v. Québec (Régie de l’Assurance-maladie), [1999] Q.J. No. 2724 (S.C.), CMA/COA Authorities, Tab 13 (b) Principles of Fundamental Justice 33. The section 7 analysis then turns to the principles of fundamental justice which are found in “the basic tenets of our legal system.” The objective of the Health Insurance Act is to regulate the single payer (publicly funded) Medicare system in Québec. The CMA/COA are committed to a sustainable health care system which provides for timely and fair access to medically necessary care. All aspects of health care are intrinsically linked to time – prevention, diagnosis, treatment, and follow up – yet there is no commitment from governments to timeliness as a core aspect of the provision of health care. As a result, the CMA/COA submit the legislation violates principles of fundamental justice due to arbitrariness and irrationality. Re B.C. Motor Vehicle Act, [1985] 2 S.C.R. 486 at 512, CMA/COA Authorities, Tab 8 34. This Honourable Court has identified the three criteria that must be fulfilled in order to establish a principle of fundamental justice: First, it must be a legal principle. This serves two purposes. First, it "provides meaningful content for the s. 7 guarantee"; second, it avoids the "adjudication of policy matters": Re B.C. Motor Vehicle Act, [1985] 2 S.C.R. 486, at p. 503. Second, there must be sufficient consensus that the alleged principle is "vital or fundamental to our societal notion of justice": Rodriguez v. British Columbia (Attorney General), [1993] 3 S.C.R. 519, at p. 590. The principles of fundamental justice are the shared assumptions upon which our system of justice is grounded. They find their meaning in the cases and traditions that have long detailed the basic norms for how the state deals with its citizens. Society views them as essential to the administration of justice. Third, the alleged principle must be capable of being identified with precision and applied to situations in a manner that yields predictable results. Examples of principles of fundamental justice that meet all three requirements include the need for a guilty mind and for reasonably clear laws. Canadian Foundation for Children, Youth and the Law v. Canada (Attorney General), 2004 SCC 4 at para. 8, CMA/COA Authorities, Tab 3 35. The CMA/COA respectfully submit that the trial judge erred in this case in balancing the harms to individuals with the greater good to society of Medicare, under the rubric of Charter section 7 rather than under Charter section 1. As this Court has recently held: The balancing of individual and societal interests within s. 7 is only relevant when elucidating a particular principle of fundamental justice… Once the principle of fundamental justice has been elucidated, however, it is not within the ambit of s. 7 to bring into account such “societal interests” as health care costs. Malmo-Levine, supra at para. 98, CMA/COA Authorities, Tab 10 36. This Honourable Court recently reiterated that the state has an interest in avoiding harm to those subject to its laws which may justify parliamentary action: In other words, avoidance of harm is a “state interest” within the rule against arbitrary or irrational state conduct mentioned in Rodriguez, at p. 594, previously cited, that Where the deprivation of the right in question does little or nothing to enhance the state’s interest (whatever it may be), it seems to me that a breach of fundamental justice will be made out, as the individuals’ rights will have been deprived for no valid purpose. Malmo-Levine, supra at para. 131, CMA/COA Authorities, Tab 10 37. The state has a particular interest in acting to protect vulnerable persons. All patients, including those waiting to receive medical care, are vulnerable to the exercise of state power which limits access to health care. The CMA/COA submit that in the context of the single payer (publicly funded) model of health care delivery where access to alternate means for such care is prohibited by the state, patients are a vulnerable group. It is an arbitrary and irrational use of state power for the Québec Legislature, in section 15 of the Health Insurance Act, to prohibit alternative meaning of access to health care services without assuming a concomitant state obligation to guarantee timely access to necessary medical care, where the failure to afford timely access may lessen the quality and quantity of life. Health Insurance Act, R.S.Q., c. A-29, s. 15 New Brunswick, supra at para. 70, CMA/COA Authorities, Tab 7 B. (R.) v. Children’s Aid Society of Metropolitan Toronto, [1995] 1 S.C.R. 315 at para. 88, CMA/COA Authorities, Tab 1 Rodriguez v. British Columbia (Attorney General), [1993] 3 S.C.R. 519 at 595, CMA/COA Authorities, Tab 12 38. The CMA/COA submit that it is open to this Court to read the concept of timeliness into the existing legislative provisions so as to render them constitutionally compliant. However, in the context of health care, a commitment to timeliness must be demonstrated in fact. The evidence before the trial judge and the findings of the Romanow Commission and the Senate Committee clearly indicate that access to medically necessary health care is not always provided in a timely manner. 39. In the absence of a commitment which provides timely access to publicly funded care, it is irrational for the state to prohibit access or the means of access to other forms of medically necessary care. The CMA/COA do not argue that governments must fund all medical services, but rather that having chosen to provide insured medical services under a single payer (publicly funded) model and prohibiting private insurance for these services, the government must provide the insured services in a timely manner. Failure to do so would be irrational, as it would constitute state action harming vulnerable persons. Hitzig v. Canada, [2003] O.J. No. 3873 (C.A.) at paras. 113-121, CMA/COA Authorities, Tab 6 40. Timeliness as a concept integral to many aspects of fundamental justice has been recognized by the common law and equity, through such concepts as laches, or the timeliness of trial rights. In particular, timeliness in the provision of medically necessary health care is essential to preserving human dignity, security of the person and promotion of human health. Blencoe v. British Columbia (Human Rights Commission), [2000] 2 S.C.R. 307 at paras. 121-133, CMA/COA Authorities, Tab 2 R. v. Askov, [1990] 2 S.C.R. 1199 at 1219-1223, CMA/COA Authorities, Tab 9 41. This is not just a failure of the Québec provincial legislature: it is an issue which involves the constitutional obligations of the federal government as well. As discussed above, one of the five criteria established by the federal government for cost-sharing of provincial Medicare is the principle of “accessibility”. The federal government, however, has not acknowledged timeliness as an aspect of accessibility. 42. Recognizing timeliness as intrinsic to accessibility and the requirements of fundamental justice is consistent with the constitutional commitments made by both the federal and provincial governments in section 36(1) of the Constitution Act, 1982, which provides: 36(1) Without altering the legislative authority of Parliament or of the provincial legislatures, or the rights of any of them with respect to the exercise of their legislative authority, Parliament and the legislatures, together with the government of Canada and the provincial governments, are committed to: (a) promoting equal opportunities for the well-being of Canadians; …; and (c) providing essential public services of reasonable quality to all Canadians. Constitution Act, 1982, s. 36(1), being Schedule B to the Canada Act 1982 (U.K.), 1982, c. 11 [hereinafter Constitution Act, 1982] 43. Section 36(1) of the Constitution Act, 1982 establishes a constitutional commitment to promoting opportunities for well-being, and providing essential public services of reasonable quality. However, where governments fail to provide access to necessary medical care in a timely fashion in the public system, it is irrational to use the legislative power of prohibition to forbid viable alternatives. This irrationality contravenes principles of fundamental justice. Where Medicare contains no method of measuring or achieving timely access, the promise that governments will provide medically necessary treatment becomes illusory. Constitution Act, 1982, s. 36(1), supra 44. In the alternative, if this Honourable Court were to conclude that the prohibition is in accordance with the principles of fundamental justice because it promotes legitimate social interests, the CMA would respectfully submit that this conclusion should not be a “frozen” one. Any decision should not enshrine the status quo of excessive wait times as a perpetually viable constitutional state of affairs. This Court could establish threshold criteria for the life and health of Canadian citizens, below which the larger public good cannot be used to justify violations of individual rights. Recent studies such as the Romanow Commission and the Senate Committee found that the waiting time issue is dynamic, evolving and not static. (c) Not an Economic Right 45. Some of the respondents and interveners argue that the issue is one of economic rights – the purchase of insurance – which is not protected by the Charter. The CMA/COA submit that in the realm of access to health care, insurance can be a tool to secure that which is Charter protected – timely access to medically necessary health care. The economic aspect is incidental to securing the right. 46. The CMA/COA take the position that any economic and contract aspects are merely incidental to the real issue of the s. 7 right to life, liberty and security of the person. The trial judge concluded that economic barriers in the impugned legislation are ancillary to the principle of access to health care: Le Tribunal estime que les barrières économiques établies par les articles 15 LAM et 11 LAH sont intimement liées à la possibilité d’accès à des soins de santé. Sans ces droits, compte tenu des coûts impliqués, l’accès aux soins privés est illusoire. Dans ce sens, ces dispositions sont une entrave à l’accès à des services de santé et sont donc susceptibles de porter atteinte à la vie, à la liberté et à la sécurité de la personne. Judgment of Piché J., Joint Appellants’ Record, Vol. I, pp. 126-127 47. The CMA/COA submit that the trial judge was correct in concluding that excessive delay in the provision of necessary medical care violates the right to life, liberty and security of the person. Any economic rights to contract are incidental. This case is about patients in Canada having the right to quality health care in a timely manner. Judgment of Piché J., Joint Appellants’ Record, Vol. I, pp. 125-127, 133-134 48. To deny Canadians the right to timely access to health care on such conjectural grounds as the secondary aspect of this case, which touches economic or contractual aspects, would denude section 7 of its promise to life, liberty and security of the person. A legislative prohibition on the purchase of insurance when timely access is not provided is not the denial of an economic right, but the denial of a fundamental right to life, liberty and security. Eldridge v. British Columbia (Attorney General), [1997] 3 S.C.R. 624 at paras. 91-93 [hereinafter Eldridge], CMA/COA Authorities, Tab 4 2. Not Saved Under Charter Section 1 49. It is clear that once an infringement of section 7 is established, the onus moves to the Government to justify the infringement under s. 1 pursuant to the Oakes test. The framework under section 1 was first established in R v. Oakes : A limitation to a constitutional guarantee will be sustained once two conditions are met. First. the objective of the legislation must be pressing and substantial. Second, the means chosen to attain this legislative end must be reasonable and demonstrably justifiable in a free and democratic society. In order to satisfy the second requirement, three criteria must be satisfied: (1) the rights violation must be rationally connected to the aim of the legislation; (2) the impugned provision must minimally impair the Charter guarantee; and (3) there must be proportionality between the effect of the measure and its objective so that the attainment of the legislative goal is not outweighed by the abridgement of the right. New Brunswick, supra at para. 95 citing Egan v. Canada, [1995] 2 S.C.R. 513 at para. 182, CMA/COA Authorities, Tab 7 50. It has long been established that the rights protected under section 7 are of significant importance and cannot ordinarily be overridden by competing social interests. In addition, “rarely will a violation of the principles of fundamental justice…be upheld as a reasonable limit demonstrably justified in a free and democratic society”. Godbout v. Longueuil (City), [1997] 3 S.C.R. 844 at para. 91, CMA/COA Authorities, Tab 5 New Brunswick, supra at para. 99 citing Re B.C. Motor Vehicle, supra at 518, CMA/COA Authorities, Tab 7 51. The values in issue here are similar to those considered by this Honourable Court in Eldridge, where La Forest J. for the Court held: Given the central place of good health in the quality of life of all persons in our society, the provisions of substandard medical services to the deaf necessarily diminishes the overall quality of their lives. The government has simply not demonstrated that this unpropitious state of affairs must be tolerated in order to achieve the objective of limiting health care expenditures. Stated differently, the government has not made a “reasonable accommodation” of the appellants’ disability. Eldridge, supra at para. 94, CMA/COA Authorities, Tab 4 52. The Romanow Commission has advocated central management of waiting lists, with common indicators, benchmarks and public accounting. The Senate Committee has recommended care guarantees. These are strong indications that solutions exist in a public health care system that will extend a commitment to timely access to medically necessary health care. Kirby, The Health of Canadians, Vol. 6, supra at 103-113, CMA/COA Authorities, Tab 16 Romanow, Building on Values, supra at 143-144, CMA/COA Authorities, Tab 15 53. The CMA/COA submit that if this Court holds that the legislation contravenes the Charter, governments have open to them a full range of options that could be implemented to address excessive waiting times for care. These include government commitments to assurances of timeliness as an essential element of the provision of medically necessary care where wait times are excessive, adopting timeliness as an element of “accessibility” under the Canada Health Act, and committing to clinically responsive access standards as envisioned by the Senate Committee. Other measures such as streamlining and improving the portability of out-of-province provisions in provincial Medicare statutes may also be considered by governments. In the absence of such assurances, however, a system which precludes alternative means to obtain medically necessary health care is unconstitutional where wait times are excessive. 54. Accordingly, it is submitted that a violation of Charter section 7 could be justified pursuant to section 1 if and only if the government were able to prove, on a balance of probabilities based on reliable and credible evidence rather than conjecture, that no alternative exists that could be implemented to ensure timeliness while at the same time maintaining the viability of the public single-payer. PART IV: SUBMISSIONS CONCERNING COSTS 55. The CMA/COA seeks no costs and asks that none be awarded against it. PART V: ORDER SOUGHT 56. The CMA/COA submit that when a person’s life is threatened or the quality of his or her life is substantially compromised and that person is prohibited from obtaining the medically necessary treatment through other means, even though the publicly funded system is unable to provide the necessary care, then constitutional questions # 1 and 3 should be answered affirmatively and the corresponding questions # 2 and 4 should be answered in the negative. Any declaration of unconstitutionality should, however, be delayed by three years, or such other period of time as this Court shall determine, so that the government may during this period institute the systemic commitment to timely access to medically necessary care and ensure simultaneously that individual patients receive care in as timely a manner as possible. 57. The CMA/COA seek leave of this Court, pursuant to rule 59(2), to present oral argument at the hearing of this appeal. Rules of the Supreme Court of Canada, SOR/2002-156, as amended, Rule 59(2) ALL OF WHICH IS RESPECTFULLY SUBMITTED December 12, 2005 Guy Pratte Freya Kristjanson ::ODMA\PCDOCS\LG-OTT-2\350103\1 PART VI: TABLE OF AUTHORITIES Cases Paragraph Nos. B. (R.) v. Children’s Aid Society of Metropolitan Toronto, [1995] 1 S.C.R. 315………………..37 Blencoe v. British Columbia (Human Rights Commission), [2000] 2 S.C.R. 307……………….40 Canadian Foundation for Children, Youth and the Law v. Canada (Attorney General), 2004 SCC 4……………………………………………………………………………34 Eldridge v. British Columbia (Attorney General), [1997] 3 S.C.R. 624…………………….48, 51 Godbout v. Longueuil (City), [1997] 3 S.C.R. 844………………………………………………50 Hitzig v. Canada, [2003] O.J. No. 3873 (C.A.)………………………………………………….39 New Brunswick (Minister of Health and Community Services) v. G.(J.), [1999] 3 S.C.R. 46……………………………………………………………….28, 31, 37, 49, 50 Re B.C. Motor Vehicle Act, [1985] 2 S.C.R. 486………………………………………………...33 R. v. Askov, [1990] 2 S.C.R. 1199………………………………………………………………..40 R v. Malmo-Levine; R. v. Caine, 2003 SCC 74………………………………………….23, 35, 36 R. v. Morgentaler, [1988] 1 S.C.R. 30……………………………………………………….27, 28 Rodriguez v. British Columbia (Attorney General), [1993] 3 S.C.R. 519……………………….37 Stein v. Québec (Régie de l’Assurance-maladie), [1999] Q.J. No. 2724 (S.C.)…………………32 Secondary Sources Paragraph Nos. R.J. Blendon et al., “Common concerns Amid Diverse Systems: Health Care Experiences in Five Countries” (2003), 22 Health Affairs 106………………………………….16 Canada, Commission on the Future of Health Care in Canada, Building on Values: The Future of Health Care in Canada – Final Report, (Ottawa, 2002) (Chair: Roy Romanow)……………………………………………………9, 13, 15, 20, 52 Canada, The Standing Senate Committee on Social Affairs, Science and Technology, The Health of Canadians – The Federal Role: Final Report on the State of the Health Care System in Canada, Vol. 6 (Ottawa: 2002) (Chair: Michael Kirby)……………………………………………………….9, 10, 14, 19, 20, 52 Canadian Medical Association, Code of Ethics of the Canadian Medical Association, (Ottawa: The Association), October 1996…………………………………………..7 OECD, Labour and Social Affairs Committee, Explaining Waiting Times Variations for Elective Surgery Across OECD Countries, Working Paper No. 7, Doc. No. DELSA/ELSA/WD/HEA(2003)7 (2003)……………………………………………...17 OECD, Labour and Social Affairs Committee, Tackling Excessive Waiting Times for Elective Surgery: A Comparison of Policies in Twelve OECD Countries, Doc. No. DELSA/ELSA/WD/HEA(2003)6 (2003)………………………………….17 OECD, Labour and Social Affairs Committee, Tackling Excessive Waiting Times for Elective Surgery: A Comparison of Policies in Twelve OECD Countries Annex 1, Doc. No. DELSA/ELSA/WD/HEA(2003)6/ANN1 (2003)………………...26 Statistics Canada, Access to Health Care Services in Canada, 2001 by C. Sanmartin, C. Houle, J.-M. Berthelot and K. White, (Ottawa, Minister of Industry, 2002)……………………………………………………………………………….11, 12 PART VII: STATUTES AND REGULATIONS Loi canadienne sur la santé, L.R.C. 1985 c. C-6 Canada Health Act, R.S.C. 1985, c. C-6 7. Le versement à une province, pour un exercice, de la pleine contribution pécuniaire visée à l'article 5 est assujetti à l'obligation pour le régime d'assurance-santé de satisfaire, pendant tout cet exercice, aux conditions d'octroi énumérées aux articles 8 à 12 quant à : a) la gestion publique; b) l'intégralité; c) l'universalité; d) la transférabilité; e) l'accessibilité. 12. (1) La condition d'accessibilité suppose que le régime provincial d'assurance-santé : a) offre les services de santé assurés selon des modalités uniformes et ne fasse pas obstacle, directement ou indirectement, et notamment par facturation aux assurés, à un accès satisfaisant par eux à ces services; b) prévoie la prise en charge des services de santé assurés selon un tarif ou autre mode de paiement autorisé par la loi de la province; c) prévoie une rémunération raisonnable de tous les services de santé assurés fournis par les médecins ou les dentistes; d) prévoie le versement de montants aux hôpitaux, y compris les hôpitaux que possède ou gère le Canada, à l'égard du coût des services de santé assurés. (2) Pour toute province où la surfacturation n'est pas permise, il est réputé être satisfait à l'alinéa (1)c) si la province a choisi de conclure un accord et a effectivement conclu un accord avec ses médecins et dentistes prévoyant : a) la tenue de négociations sur la rémunération des services de santé assurés entre la province et les organisations provinciales représentant les médecins ou dentistes qui exercent dans la province; b) le règlement des différends concernant la rémunération par, au choix des organisations provinciales compétentes visées à l'alinéa a), soit la conciliation soit l'arbitrage obligatoire par un groupe représentant également les organisations provinciales et la province et ayant un président indépendant; c) l'impossibilité de modifier la décision du groupe visé à l'alinéa b), sauf par une loi de la province. 7. In order that a province may qualify for a full cash contribution referred to in section 5 for a fiscal year, the health care insurance plan of the province must, throughout the fiscal year, satisfy the criteria described in sections 8 to 12 respecting the following matters: (a) public administration; (b) comprehensiveness; (c) universality; (d) portability; and (e) accessibility. 12. (1) In order to satisfy the criterion respecting accessibility, the health care insurance plan of a province (a) must provide for insured health services on uniform terms and conditions and on a basis that does not impede or preclude, either directly or indirectly whether by charges made to insured persons or otherwise, reasonable access to those services by insured persons; (b) must provide for payment for insured health services in accordance with a tariff or system of payment authorized by the law of the province; (c) must provide for reasonable compensation for all insured health services rendered by medical practitioners or dentists; and (d) must provide for the payment of amounts to hospitals, including hospitals owned or operated by Canada, in respect of the cost of insured health services. (2) In respect of any province in which extra-billing is not permitted, paragraph (1)(c) shall be deemed to be complied with if the province has chosen to enter into, and has entered into, an agreement with the medical practitioners and dentists of the province that provides (a) for negotiations relating to compensation for insured health services between the province and provincial organizations that represent practising medical practitioners or dentists in the province; (b) for the settlement of disputes relating to compensation through, at the option of the appropriate provincial organizations referred to in paragraph (a), conciliation or binding arbitration by a panel that is equally representative of the provincial organizations and the province and that has an independent chairman; and (c) that a decision of a panel referred to in paragraph (b) may not be altered except by an Act of the legislature of the province. CONTRATS D'ASSURANCE ET SUBROGATION Contrats d'assurance prohibés. 15.  Nul ne doit faire ou renouveler un contrat d'assurance ou effectuer un paiement en vertu d'un contrat d'assurance par lequel un service assuré est fourni ou le coût d'un tel service est payé à une personne qui réside ou qui séjourne au Québec ou à une autre personne pour son compte, en totalité ou en partie. Contrats en vigueur pour d'autres services et biens. Si un tel contrat a aussi pour objet d'autres services et biens, il demeure en vigueur quant à ces autres services et biens et la considération prévue à l'égard de ce contrat doit être ajustée en conséquence, à moins que le bénéficiaire de ces services et de ces biens n'accepte de recevoir en échange des avantages équivalents. Délai de remboursement. Si la considération a été payée à l'avance, le montant du remboursement ou de l'ajustement, selon le cas, doit être remis dans les trois mois à moins que la personne assurée n'accepte au cours de cette période de recevoir des avantages équivalents. Montants inférieurs à 5 $. Si le montant total des remboursements ou des ajustements qui doivent être effectués à l'égard d'une même personne en vertu d'un contrat conclu pour au plus une année est inférieur à 5 $, le montant n'est pas exigible mais il doit être remis au ministre pour être versé au Fonds de la recherche en santé du Québec visé dans l'article 96. Exception. Le premier alinéa ne s'applique pas à un contrat qui a pour objet l'excédent du coût des services assurés rendus hors du Québec ou l'excédent du coût des médicaments dont la Régie assume le paiement. Il ne s'applique pas non plus à un contrat qui a pour objet la contribution que doit payer une personne assurée en vertu de la Loi sur l'assurance médicaments ( chapitre A-29.01). CONTRACT OF INSURANCE AND SUBROGATION Coverage under contract of insurance prohibited. 15.  No person shall make or renew a contract of insurance or make a payment under a contract of insurance under which an insured service is furnished or under which all or part of the cost of such a service is paid to a resident or temporary resident of Québec or to another person on his behalf. Contract in force for other services and property. If such a contract also covers other services and property it shall remain in force as regards such other services and property and the consideration provided with respect to such contract must be adjusted accordingly, unless the beneficiary of such services and of such property agrees to receive equivalent benefits in exchange. Delay for reimbursement. If the consideration was paid in advance, the amount of the reimbursement or adjustment, as the case may be, must be remitted within three months unless the insured person agrees, during such period, to receive equivalent benefits. Amounts less than $5. If the total amount of the reimbursements or adjustments to be made as regards one person under a contract made for not more than one year is less than $5, the amount shall not be exigible but it shall be remitted to the Minister to be paid to the Fonds de la recherche en santé du Québec contemplated in section 96. Excess cost. The first paragraph does not apply to a contract covering the excess cost of insured services rendered outside Québec or the excess cost of any medication of which the Board assumes payment nor does it apply to a contract covering the contribution payable by an insured person under the Act respecting prescription drug insurance ( chapter A-29.01). Loi sur l’assurance-maladie, L.R.Q., c. A-29, article 15 Health Insurance Act, R.S.Q., c. A-29, section 15. Constitution Act, 1982, s. 36, being Schedule B to the Canada Act 1982 (U.K.), 1982, c. 11 36. 1) Without altering the legislative authority of Parliament or of the provincial legislatures, or the rights of any of them with respect to the exercise of their legislative authority, Parliament and the legislatures, together with the government of Canada and the provincial governments, are committed to (a) promoting equal opportunities for the well-being of Canadians; (b) furthering economic development to reduce disparity in opportunities; and (c) providing essential public services of reasonable quality to all Canadians. 36. 1) Sous réserve des compétences législatives du Parlement et des législatures et de leur droit de les exercer, le Parlement et les législatures, ainsi que les gouvernements fédéral et provinciaux, s'engagent à a) promouvoir l'égalité des chances de tous les Canadiens dans la recherche de leur bien-être; b) favoriser le développement économique pour réduire l'inégalité des chances; c) fournir à tous les Canadiens, à un niveau de qualité acceptable, les services publics essentiels. 59 (2) Le juge peut à sa discrétion, une fois les mémoires de demande d'autorisation d'appel, d'appel ou de renvoi déposés et signifiés, autoriser l'intervenant à présenter une plaidoirie orale à l'audition de la demande d'autorisation d'appel, le cas échéant, de l'appel ou du renvoi, et déterminer le temps alloué pour la plaidoirie orale. 59 (2) After all of the memoranda of argument on an application for leave to appeal or the facta on an appeal or reference have been filed and served, a judge may, in his or her discretion, authorize an intervener to present oral argument at the hearing of the application for leave to appeal, if any, the appeal or the reference, and determine the time allotted for oral argument. 36. 1) Without altering the legislative authority of Parliament or of the provincial legislatures, or the rights of any of them with respect to the exercise of their legislative authority, Parliament and the legislatures, together with the government of Canada and the provincial governments, are committed to (a) promoting equal opportunities for the well-being of Canadians; (b) furthering economic development to reduce disparity in opportunities; and (c) providing essential public services of reasonable quality to all Canadians. 36. 1) Sous réserve des compétences législatives du Parlement et des législatures et de leur droit de les exercer, le Parlement et les législatures, ainsi que les gouvernements fédéral et provinciaux, s'engagent à a) promouvoir l'égalité des chances de tous les Canadiens dans la recherche de leur bien-être; b) favoriser le développement économique pour réduire l'inégalité des chances; c) fournir à tous les Canadiens, à un niveau de qualité acceptable, les services publics essentiels. Règles de la Cour suprême du Canada, DORS/2002-156, tel qu’amendées, Règle 59(2) Rules of the Supreme Court of Canada, SOR/2002-156, as amended, Rule 59(2) 36. 1) Without altering the legislative authority of Parliament or of the provincial legislatures, or the rights of any of them with respect to the exercise of their legislative authority, Parliament and the legislatures, together with the government of Canada and the provincial governments, are committed to (a) promoting equal opportunities for the well-being of Canadians; (b) furthering economic development to reduce disparity in opportunities; and (c) providing essential public services of reasonable quality to all Canadians. 36. 1) Sous réserve des compétences législatives du Parlement et des législatures et de leur droit de les exercer, le Parlement et les législatures, ainsi que les gouvernements fédéral et provinciaux, s'engagent à a) promouvoir l'égalité des chances de tous les Canadiens dans la recherche de leur bien-être; b) favoriser le développement économique pour réduire l'inégalité des chances; c) fournir à tous les Canadiens, à un niveau de qualité acceptable, les services publics essentiels.
Documents
Less detail

Compensation ceilings for GP's and access to front-line services

https://policybase.cma.ca/en/permalink/policy1524
Last Reviewed
2017-03-04
Date
2004-08-18
Topics
Ethics and medical professionalism
Health human resources
Health systems, system funding and performance
Physician practice/ compensation/ forms
Resolution
GC04-51
The Canadian Medical Association recommends that compensation ceilings for general practitioners where they exist be removed in order to improve access to front-line services.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
2004-08-18
Topics
Ethics and medical professionalism
Health human resources
Health systems, system funding and performance
Physician practice/ compensation/ forms
Resolution
GC04-51
The Canadian Medical Association recommends that compensation ceilings for general practitioners where they exist be removed in order to improve access to front-line services.
Text
The Canadian Medical Association recommends that compensation ceilings for general practitioners where they exist be removed in order to improve access to front-line services.
Less detail

Delivery of publicly insured medical services by the private sector

https://policybase.cma.ca/en/permalink/policy1521
Last Reviewed
2017-03-04
Date
2004-08-18
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Resolution
GC04-88
The Canadian Medical Association encourages the continued delivery of publicly insured medical services by the private sector provided that these services are funded entirely by the public sector.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
2004-08-18
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Resolution
GC04-88
The Canadian Medical Association encourages the continued delivery of publicly insured medical services by the private sector provided that these services are funded entirely by the public sector.
Text
The Canadian Medical Association encourages the continued delivery of publicly insured medical services by the private sector provided that these services are funded entirely by the public sector.
Less detail

Evidence-based health-impact analysis and policy development

https://policybase.cma.ca/en/permalink/policy582
Last Reviewed
2017-03-04
Date
1997-08-20
Topics
Health systems, system funding and performance
Ethics and medical professionalism
Resolution
GC97-31
That the Canadian Medical Association and its Divisions urge government to establish a framework to ensure that the development and implementation of public policy is guided by evidence-based health-impact analysis.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
1997-08-20
Topics
Health systems, system funding and performance
Ethics and medical professionalism
Resolution
GC97-31
That the Canadian Medical Association and its Divisions urge government to establish a framework to ensure that the development and implementation of public policy is guided by evidence-based health-impact analysis.
Text
That the Canadian Medical Association and its Divisions urge government to establish a framework to ensure that the development and implementation of public policy is guided by evidence-based health-impact analysis.
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