The Canadian Medical Association (CMA) and its Quebec office are pleased to provide this submission to the Committee on Transportation and the Environment on Bill 44: An Act mainly to ensure effective governance of the fight against climate change and to promote electrification. The CMA maintains that governance of the fight against climate change will not be effective unless it integrates the health impacts on the Quebec population. Physicians in Quebec, across Canada, and around the world have a unique role to play in helping advance government and public understanding of the health consequences of climate change and in supporting the development of effective public health responses. The CMA’s submission provides recommendations to better prepare and mitigate the impacts of a changing climate on people’s health and the health care system in Quebec.
How Climate Change Affects Health
The World Health Organization has identified climate change as the biggest threat to global health.
1 In Canada, the immediate health effects of climate change are a growing concern. In this century, Canada will experience higher rates of warming in comparison to other countries around the world. Northern Canada, including northern Quebec (Nunavik), will continue to warm at more than triple the global rate. These warming conditions will lead to an increase in extreme weather events, longer growing seasons, melting of the permafrost, and rising sea levels.2
Physicians are at the front lines of a health care system that is seeing growing numbers of patients experiencing health problems related to climate change, including heat-related conditions, respiratory illnesses, infectious disease outbreaks and impacts on mental health. For example, the heat wave in southern Quebec in 2018 was linked to over 90 deaths.3
Examples of the extent of this issue include:
The number of extremely hot days is expected to double or triple in some parts of Canada in the next 30 years and will lead to an increase in heat-related impacts (e.g., heat stroke, myocardial infarction, kidney failure, dehydration, stroke).4
Air pollution contributes to approximately 2,000 early deaths each year in Quebec by way of heart disease, stroke, lung cancer, and respiratory disease (such as aggravated asthma).5
An increase in vector-borne diseases such as Lyme disease has increased significantly in Quebec, with the number of cases increasing from 125 in 2014 to 338 in 2018.6
Extreme weather events are increasing in frequency, intensity and duration across Quebec and can negatively impact mental health (e.g., anxiety, depression and post-traumatic stress disorder),7 as well as place additional strain on the health care system.
Increasing temperatures are affecting the ice roads used in winter, and other roads built on permafrost in northern Quebec, threatening food security.8
There are sub-populations that are more susceptible to the health-related impacts of climate change. For example, in northern Quebec, climate change is already increasing health risks from food insecurity due to decreased access to traditional foods, decreased safety of ice-based travel, and damage to critical infrastructure due to melting permafrost. For the rest of Canada, the health impacts vary by geographic region, but include a list of issues such as increased risk of heat stroke and death, increases in allergy and asthma symptoms due to a longer pollen season, mental health implications from severe weather events, and increases in infectious diseases, UV radiation, waterborne diseases and respiratory impacts from air pollution. 9
Seniors, infants and children, socially disadvantaged individuals, and people with existing medical conditions such as cardiovascular disease, are at greater risk of being affected by climate change. The susceptibility of a population to the effects of climate change is dependent on their existing vulnerabilities and their adaptive capacity. 10,11
Figure 1. Examples of Health Impact of Climate Change in Canada5
Climate Change: A Health Emergency
Recent polls have demonstrated that Canadians are very concerned about climate change and its impact on health. A 2017 poll commissioned by Health Canada revealed that 79% of Canadians were convinced that climate change is happening, and of those people 53% accepted that it is a current health risk and 40% believe it will be a health risk in the future.12 As well, a 2019 poll commissioned by Abacus Data reports that Quebecers are the most anxious about climate change and think about the climate more often than people living in the rest of Canada. The same poll reports that 59% of people in Quebec believe that climate change is currently an emergency and 12% reported that it will likely become an emergency in a few years.13 These numbers are not surprising considering the intensity and frequency of extreme weather events in Quebec in recent years. The CMA believes climate change is a public health crisis. Over the past few years in Canada, there have been numerous extreme climate events, such as wildfires in British Columbia,
extreme heat waves in Quebec, and storm surges on the east coast. In southern Quebec, a changing climate has also increased the range of several zoonoses, including blacklegged ticks, which are vectors of Lyme disease.14 Physicians across Quebec are seeing patient outcomes affected by the changing climate and are advocating for change. The health impacts of climate change were raised at last year’s COP25 meeting in Madrid, Spain, among an international group of leading environment and health stakeholders, including the CMA. The group collectively called on governments to broaden the scope of their climate change initiatives and investments to include health care.
A lack of progress in reducing greenhouse gas emissions and building adaptive capacity threatens both human lives and the viability of health systems, with the potential to disrupt core public health infrastructure and overwhelm health services, not to mention the economic and social costs. In Quebec, the research consortium Ouranos estimated in 2015 that extreme heat, Lyme disease, West Nile virus and pollen alone will cost the Quebec state an additional $609 million to $1,075 million,15 and could result in up to 20,000 additional lives lost within the next 50 years.
Canada is currently not on track to meet the international targets set out by the Paris Agreement.16 The 2019 report from Lancet Countdown, the largest international health and climate research consortium, states that continued inaction on meeting the targets set out by the Paris Agreement will result in the health of a child born today being impacted negatively by climate change at every stage of its life.
The CMA recommends that adaptation and mitigation measures be prioritized to limit the effects of climate change on public health.
Hearing Health Care Professionals on Climate Change Last June, the CMA was pleased with the announcement made by the Minister of the Environment and the Fight Against Climate Change, Benoit Charette, to create a task force to ensure effective governance of the fight against climate change, including meeting Quebec’s international climate targets.17 Climate change crosses multiple sectors and requires experts from diverse backgrounds to create solutions to adapt and mitigate the impacts of climate change. Considering the overwhelming evidence of the impacts of climate change on human health, it is paramount that a health representative sits on the committee that will be advising the Minister. Physicians and health professionals have a critical role to play in advancing public understanding of the potential impacts of climate change on health and promoting appropriate actions aimed at protecting the health of Canadians. Physicians believe that what’s good for the environment is also good for human health. Protecting human health must be at the core of all environmental and climate change strategies within Quebec.
Recommendation 2: The CMA recommends that a health representative sit on the committee that will be advising the minister.
Dedicated Funding for a Greener Health Care System
The 2019 Lancet Countdown on Health and Climate Change reports that Canada has the third-highest per capita greenhouse gas emissions coming from its health care sector in the world. Health care related emissions account for approximately 4.5% of the country’s total emissions. Hospitals produce a significant proportion of health sector emissions as they are always on, are resource intensive, and have strict ventilation standards. Hospital services also produce large amounts of waste through the use of single-use items (e.g., hospital gowns and surgical supplies).
To remedy this problem, the CMA recommends that experts from research, education, clinical practice, and policy work together to reduce greenhouse gas emissions and that funding be dedicated to measuring the carbon footprint of different institutions and addressing these issues. Health care providers are uniquely positioned to advocate for innovative solutions that will help reduce greenhouse gas emissions by the health sector and improve public health.18 By reducing greenhouse gas emissions from the health system, the Quebec government will better position itself to be consistent with the timelines and goals of the Paris Agreement for zero-emissions for healthcare by 2050.19
The CMA recommends that a portion of the Green Fund’s budget be dedicated to the greening of health systems.
The CMA’s submission highlights the need to better prepare and mitigate the health impacts of a changing climate, as well as the need for a health representative to advise the minister, and the allocation of funding for the greening of health systems in Quebec. Physicians are in a unique position to help the government develop strategies to mitigate the impacts of climate change and ultimately improve population health.
Summary of recommendations
The CMA recommends that adaptation and mitigation measures be prioritized to limit the effects of climate change on public health.
The CMA recommends that a health representative sit on the committee that will be advising the minister.
The CMA recommends that a portion of the Green Fund’s budget be dedicated to the greening of health systems.
1 Costello A, Abbas M, Allen A, Ball S, et al. The Lancet and University College London Institute for Global Health Commission, The Lancet, 2009;373( 9676):1693-1733. Available: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60935-1/fulltext (accessed 2020 Jan 25).
2 Government of Canada. Canada’s Changing Climate Report. Ottawa: Government of Canada; 2019. Available: https://www.nrcan.gc.ca/sites/www.nrcan.gc.ca/files/energy/Climate-change/pdf/CCCR_FULLREPORT-EN-FINAL.pdf (accessed 2020 Jan 25).
3 Institut national de santé publique du Québec. Surveillance des impacts des vagues de chaleur extrême sur la santé au Québec à l’été 2018 [French only]. Québec : Institut national de santé publique du Québec; 2018. Available: https://www.inspq.qc.ca/bise/surveillance-des-impacts-des-vagues-de-chaleur-extreme-sur-la-sante-au-quebec-l-ete-2018 (accessed 2020 Jan 25).
4 Guilbault S, Kovacs P, Berry P, Richardson G, et al. Cities adapt to extreme heat: celebrating local leadership. Ottawa: Health Canada Institute for Catastrophic Loss Reduction; 2016. Available: https://www.iclr.org/wp-content/uploads/PDFS/cities-adapt-to-extreme-heat.pdf (accessed 2020 Jan 25).
5 Health Canada. Health Impacts of Air Pollution in Canada--an Estimate of Premature Mortalities. Ottawa: Health Canada; 2017. Available: https://www.canada.ca/en/health-canada/services/air-quality/health-effects-indoor-air-pollution.html (accessed 2020 Jan 25).
6 Santé et services sociaux Québec. Maladie de Lyme. Tableau des cas humains – Archives 2014 à 2018. [French only]. Available: https://www.msss.gouv.qc.ca/professionnels/zoonoses/maladie-lyme/tableau-des-cas-humains-lyme-archives/ (accessed 2020 Jan 25).
7 Cunsolo A, Ellis N. Ecological grief as a mental health response to climate change-related loss. Nature Climate Change 2018;8:275-81.
8 Rosol R, Powell-Hellyer S, Chan HM. Impacts of decline harvest of country food on nutrient intake among Inuit in Arctic Canada: impact of climate change and possible adaptation plan. Int J Circumpolar Health 2016;75(1):31127. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4937722/pdf/IJCH-75-31127.pdf (accessed 2020 Jan 25).
9 Howard C, Buse C, Rose C, MacNeill A, Parkes, M. The Lancet Countdown on Health and Climate Change: Policy Brief for Canada. London: Lancet Countdown, Canadian Medical Association, and Canadian Public Health Association, 2019. Available: https://storage.googleapis.com/lancet-countdown/2019/11/Lancet-Countdown_Policy-brief-for-Canada_FINAL.pdf. (accessed 2020 Jan 25).
10 Canadian Medical Association (CMA). CMA Policy. Climate Change and Human Health. Ottawa: CMA; 2010. Available: https://policybase.cma.ca/en/permalink/policy9809 (accessed 2020 Jan 25).
11 Health Canada. Climate Change and Health. Ottawa: Health Canada; 2020. Available: https://www.canada.ca/en/health-canada/services/climate-change-health.html (accessed 2020 Jan 26).
12 Environics Health Research. Public Perceptions of Climate Change and Health Final Report. Ottawa: Health Canada; 2017.
13 Abacus Data. Is Climate Change “An Emergency” and do Canadians Support a Made-in-Canada Green New Deal? Ottawa: Abacus Data; 2019. Available: https://abacusdata.ca/is-climate-change-an-emergency-and-do-canadians-support-a-made-in-canada-green-new-deal/ (accessed 2020 Jan 26).
14 Howard C, Rose C, Hancock T. Lancet Countdown 2017 Report: Briefing for Canadian Policymakers. Lancet Countdown and Canadian Public Health Association. Available: https://storage.googleapis.com/lancet-countdown/2019/10/2018-lancet-countdown-policy-brief-canada.pdf. (accessed 2020 Jan 25).
15 Ouranos. Vers l’adaptation. Synthèse des connaissances sur les changements climatiques au Québec [French only]. Montreal: Ouranos; 2015. Available: https://www.ouranos.ca/publication-scientifique/SyntheseRapportfinal.pdf (accessed 2020 Jan 25).
16 Government of Canada. Greenhouse Gas Emissions. Ottawa: Government of Canada; 2018. Available: https://www.canada.ca/en/environment-climate-change/services/environmental-indicators/greenhouse-gas-emissions.html (accessed 2020 Jan 26).
17 Gouvernment du Québec. Press Release: Minister Benoit Charette announces an unprecedented process to develop the forthcoming Electrification and Climate Change Plan. Québec: Gouvernment du Québec;
2019. Available: http://www.environnement.gouv.qc.ca/infuseur/communique_en.asp?no=4182 (accessed 2020 Jan 26).
18 Eckelman MJ, Sherman JD, MacNeill AJ. Life cycle environmental emissions and health damages from the Canadian healthcare system: An economic-environmental-epidemiological analysis. PLoS Med 2018;15(7):e1002623. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6067712/pdf/pmed.1002623.pdf (accessed 2020 Jan 25). (accessed 2020 Jan 26).
19 Intergovernmental Panel on Climate Change (IPCC). Global Warming of 1.5C--Summary for Policymakers, France: IPCC; 2018. Available: https://www.ipcc.ch/sr15/ (accessed 2020 Jan 25).
Primary care is the backbone of our health care system in Canada and a national priority for this government.
The echoing words of the Speech from the Throne certify that the Government will strengthen health care and “Work with provinces, territories, health professionals and experts in industry and academia to make sure that all Canadians can access a primary care family doctor.” The Health Minister’s mandate letter further confirms that the Government will work “with the support of the Deputy Prime Minister and Minister of Intergovernmental Affairs, the Minister of Finance and the Minister of Seniors, to strengthen Medicare and renew our health agreements with the provinces and territories” to “ensure that every Canadian has access to a family doctor or primary health care team”.
We recognize that strengthening primary care through a team-based, inter-professional approach is integral to improving the health of all people living in Canada. This belief is consistent across our alliance of four major groups: the Canadian Medical Association, the Canadian Nurses Association, the Canadian Association of Social Workers and the College of Family Physicians of Canada. There is nothing more suiting or fortunate than for a team-based approach to be wholeheartedly supported by an even larger team of teams.
We commend the Government’s commitment
to increasing Canadians’ access to primary care.
We have a model to make it happen.
The Primary Health Care Transition Fund 2, a one-time fund over four years, would provide the necessary funding to help establish models of primary care based on the Patient’s Medical Home, a team-based approach that connects the various care delivery points in the community for each patient. This model is rooted in the networking of family physicians, nurse practitioners, nurses, social workers and other health professionals as a team. This is the only way to provide comprehensive primary care to patients. It will enable a more exhaustive approach to patient care, ultimately leading to increased prevention and better health outcomes for Canadians. Consider it the main artery
in meeting the needs of patients and communities.
A commitment to the Primary Health Care Transition Fund 2 gives substance to the promise of building a network of care that addresses immediate health needs while connecting to ongoing social and community health services. This Fund model bolsters Canadians. It is backed by doctors, nurses, and social workers. A phalanx of Canadian care providers stand behind it. An entire country will benefit from it.
In support of the federal government’s commitment to improve Canadians’ access to primary care,
we recommend a one-time fund in the amount of $1.2 billion over four years to expand the establishment of primary care teams in each province and territory.
The CMA has always taken an interest in and a stand on various health issues affecting the medical profession and patients. Access to health care is one such issue.
The CMA recently commissioned Ipsos to conduct an extensive survey on the population’s concerns regarding access to health care. The data indicates that Quebecers are the most pessimistic in the country—and this sentiment is even more pronounced when respondents think about the future. Forty percent of survey respondents are concerned about access to health care, and more than half (55%) have a negative perception of the future of the health care system, compared with 26% and 47%, respectively, for the rest of Canada.1 It also appears that Quebecers are significantly affected by the shortage of health professionals and the increase in system costs due to the aging population and the growing number of seniors with health care needs.
The public’s worries are also shared by our members and physicians in Quebec, who are concerned by the fact that their patients are not receiving the care and services they need in a timely manner.
The government of Quebec is making a significant investment in the health care network, a budget item that accounts for almost 50% of total program expenditures.2 The CMA applauds this effort.
The CMA submission proposes certain measures that have a two-fold objective: improving the health of Quebecers and ensuring the sustainability of the health care system for future generations.
The CMA submission is divided into three parts: improving support to elderly patients and caregivers; tobacco and vaping control; and reducing unnecessary examinations and treatments to optimize use of the health care system’s financial and human resources.
Seniors and caregivers
It is no secret that Quebec’s population is aging rapidly. According to data from the Institut de la statistique du Québec cited in the Plan stratégique du ministère de la Santé et des Services sociaux, seniors are expected to make up 25% of the population in 2031 and 28% in 2066, compared with 18% in 2016.3
Although aging is not necessarily synonymous with poor health or disability, the likelihood of both of these conditions increases with age. Close to seven out of ten Quebecers aged 65 and over report two or more long-term health conditions, and 93% of these individuals take medication.4 The most common health issues among people aged 65 and over are arthritis and hypertension.5 Moreover, the incidence of cancer rises significantly with age.6
The aging population thus exerts additional pressure on a health care system that is already stretched thin. The CMA has long been lobbying the federal government to increase the Canada Health Transfer to take into account the needs of the aging population when calculating the Transfer. Consequently, the CMA supports the Quebec government’s negotiations with the federal government to secure an increase in federal health transfer payments.
To ensure a sustainable health care system, it is important to invest in measures that will allow the public to maintain their health as they age, and that foster seniors’ independence—such as a healthy lifestyle, adequate nutrition and treatment adherence, where applicable. The Quebec government has already taken steps to foster the well-being of elderly persons, such as implementing the senior assistance tax credit and increasing support for home support services. The Minister Responsible for Seniors and Informal Caregivers has announced the development of a provincial policy for caregivers in 2020–2021, as indicated in the recently submitted strategic plan.3
These initiatives aimed at improving the lives of seniors and caregivers are to be commended. The CMA believes that the scope of these initiatives should be widened.
Support for seniors
In its economic update presented on December 3, 2018, the Quebec government announced a new tax credit for seniors over age 70. More specifically, this tax credit provides annual assistance of up to $200 per senior and $400 per couple.
The CMA welcomes this initiative, but it should be noted that seniors aged 65 and overspend more than $2,200 on health care fees each year7 (health care items, medication, dental care, insurance premiums, etc.). Given that this level of spending is significant and that 60% of seniors have an annual income under $30,000,8 this tax credit appears to be insufficient for those who have to bear these additional daily health expenses. We must collectively
ensure that certain seniors will not have to forego treatment because they cannot afford it.
Quebecers’ health care expenses have been increasing in recent years,9 and the CMA believes it is essential that this growing problem be dealt with right now. The CMA recommends that the Quebec government create an allowance for seniors aged 65 and over. This new allowance, which would be modelled after the family allowance, would provide financial assistance to low- and medium-income seniors to help them manage additional health-related expenses.
The CMA also believes that the senior assistance tax credit should be extended to people ages 65 to 69.
Like seniors’ advocacy groups, the CMA recommends greater recognition of family caregivers’ contribution to the Quebec health care system. This could take the form of a greater tax credit for caregivers offered in Quebec.
Family caregivers are an integral part of the health care system, as they play an active role in enabling seniors to stay at home—which is what most seniors prefer.10
The Ministère de la Santé et des Services sociaux plans to increase home support services as part of its 2019–2023 strategic plan.10 The CMA believes that this initiative should be combined with increased assistance for family caregivers.
In 2016, the demographic portrait of caregivers in Quebec indicated that 35% of Quebecers, or 2.2 million people, provided care to a senior. Of these, around 15% acted as caregivers for more than 10 hours a week. With the aging of the population set to accelerate in the coming years and decades, caregivers’ unpaid working hours will increase significantly. In Canada, according to a 2011 study, close to 80% of all assistance to recipients of long-term care was provided by family caregivers. This represents a contribution of over five billion dollars’ worth of unpaid services for the public health network.11
According to the CMA, the tax credit for caregivers is an indispensable and necessary financial contribution for these people and the seniors receiving care, but this measure in no way reflects the costs assumed by caregivers. More support should be provided to people who give their time every day, sustain financial losses and compensate for the lack of resources in the health care system.
Given the indispensable role family caregivers play, the CMA recommends that the government increase the tax credit for caregivers so that it better reflects their contribution to society—and this should apply to all four types of family caregivers defined by Revenu Québec:12
Caregivers who take care of a senior spouse who is unable to live alone
Caregivers who house an eligible relative
Caregivers who cohabit with an eligible relative who is unable to live alone
Caregivers who support an eligible relative whom they regularly and continuously assist in carrying out basic activities of daily living
The CMA recommends:
1. Expanding the senior assistance tax credit to support people who are between the ages of 65 and 69
2. Creating a seniors’ allowance to provide financial assistance to low- and medium-income seniors to help them manage additional health-related expenses
3. Increasing the tax credit for caregivers, for all types of family caregivers recognized by Revenu Québec
Smoking and vaping prevention
Although the government of Quebec must pay specific attention to seniors’ care to lighten the burden on the health care system, prevention is still just as important. Prevention has proven to be useful in reducing health care costs by eliminating the need for certain treatments and hospitalizations.13 Measures to control smoking and vaping fall under this category.
For decades, the CMA has been promoting the benefits of a smoke-free society with the support of our physician members, who are witnesses to tobacco’s harmful effects on health. The CMA issued its first public health warning on the risks associated with tobacco use in 1954, and since then has made a significant contribution to the development of public policies related to the industry. One needs only to think of the role that the CMA played in the federal government’s decision to require that tobacco products be sold in plain packaging and standard sizes.
Every government in the country has been actively committed to the fight against tobacco for years, and there has been a significant drop in tobacco use over time. However, regular tobacco use in Quebec has settled at around 15% of the population aged 12 or older.14 Unfortunately, this proportion is still too high.
There is another growing phenomenon among young people that we believe merits the attention of the Minister of Finance: e-cigarettes, also referred to as vaping devices. According to the Enquête québécoise sur la santé des jeunes du secondaire 2016-2017 [Quebec health survey of high school students 2016-2017], one third of youths have used e-cigarettes.15 Although these types of products do not contain tobacco, they do contain nicotine and aromatic substances that could be harmful to people’s health. The CMA recommends increasing research on the potential health consequences these devices can have on people, and the validity of claims that they are an effective means to quit smoking. We also support prohibiting e-cigarette sales to minors, enforcing strict regulation of the sale of these products and prohibiting vaping in locations where smoking is currently forbidden. We also recommend that the marketing restrictions on tobacco products be applied to vaping products and devices as well.
The CMA also believes that governments would be well advised to draw inspiration from strategies that have been successful in curbing tobacco use and reducing the appeal of e-cigarettes, particularly among young people. According to the World Health Organization (WHO), a 10% increase in the price of tobacco results in a 4% to 8% drop in consumption. Taxes on vaping products could therefore have the same deterrent effect, especially among young people, who are more sensitive to price variations.16 This is why it is imperative that we do not wait for the outcome of the work carried out by the special vaping intervention group led by the Ministère de la Santé et des Services sociaux (MSSS) before taking action.
Effective January 1, 2020, the government of British Columbia raised the sales tax on vaping products from 7% to 20%17 to prevent and reduce the use of these products by young people. The CMA recommends that the government of Quebec emulate this policy by increasing taxes on vaping and tobacco products.
The right care at the right time
According to data from the Canadian Institute for Health Information (CIHI), up to 30% of tests, treatments and procedures in Canada are potentially unnecessary. Unnecessary tests, treatments, and procedures not only add zero value to care, but they may also expose patients to additional risks and waste health resources.18
In 2012, as certain treatments were being overused or not adding value for patients, the CMA was a leading partner in the Choosing Wisely Canada campaign, which was launched in Quebec in 2014. This program helps health care professionals and patients engage in a dialogue about unnecessary tests and treatments and helps them make smart and effective choices to ensure quality health care. Guides and recommendations for patients and health
care professionals have been developed through this campaign to make them aware of overuse and overdiagnosis.
The ultimate goal of Choosing Wisely is to improve the performance of the health care system.
A survey indicates that almost half of physicians (48%) agree that they need more support and tools to help them determine which services are not suitable for their patients.19 The tools provided by the Choosing Wisely campaign have proven effective. The CMA believes that their use by Quebec physicians and patients is beneficial.
Publicizing campaigns and developing and updating tools and recommendations require significant financial resources. Elsewhere in the country, several provinces are providing financial support to Choosing Wisely. However, Quebec ended its financial commitment in the past year.
Given the Quebec government’s commitment regarding the appropriateness of care, the CMA recommends supporting the Choosing Wisely Quebec campaign with a long-term financial commitment.
Summary of CMA recommendations
Senior and caregiver support
The CMA is proposing three main recommendations to support seniors and their caregivers. The recommended measures are aimed at ensuring healthy aging and recognizing family caregivers’ economic and social contribution in Quebec.
1. Expand the senior assistance tax credit to support people who are between the ages of 65 and 69.
2. Create an allowance for seniors to help them manage private health care costs.
3. Increase the tax credit for caregivers, for all types of caregivers recognized by Revenu Québec.
Implementation of a tax on tobacco and vaping products
The government of British Columbia announced its intent to increase the sales tax on vaping products from 7% to 20%, effective January 1, 2020,20 to prevent and reduce the use of these products by young people. The CMA recommends that the government of Quebec emulate this policy by heavily taxing vaping and tobacco products.
Contribution to the Choosing Wisely Canada program
Given the Quebec government’s commitment regarding the appropriateness of care, the CMA recommends supporting the Choosing Wisely Quebec campaign with a long-term financial commitment.
1 Ipsos, Canadian Medical Association (CMA). Canadians are Nervous About the Future of the Health System. Ottawa: CMA; 2019. Available: https://www.cma.ca/sites/default/files/pdf/news-media/Canadians-are-Nervous-About-the-Future-of-the-Health-System-E.pdf (accessed 2020 Jan 13).
2 Gouvernement du Québec. Update on Québec’s Economic and Financial Situation. Quebec: Gouvernement du Québec; Fall 2019. Available : http://www.finances.gouv.qc.ca/documents/Autres/en/AUTEN_updateNov2019.pdf (accessed 2020 Jan 13).
3 Ministère de la Santé et des Services sociaux. Plan stratégique 2019-2023(French only). Quebec : Ministère de la Santé et des Services sociaux; December 2019. Available : https://cdn-contenu.quebec.ca/cdn-contenu/adm/min/sante-services-sociaux/publications-adm/plan-strategique/PL_19-717-02W_MSSS.pdf (accessed 2020 Jan 13).
4 Institut de la statistique du Québec. Enquête québécoise sur les limitations d’activités, les maladies chroniques et le vieillissement 2010-2011(French only). Quebec : Institut de la statistique du Québec; October 2013. Available: http://www.stat.gouv.qc.ca/statistiques/sante/services/incapacites/limitation-maladies-chroniques-utilisation.pdf (accessed 2020 Jan 13). 5 Statistics Canada. Table 13-10-0096-01 Health characteristics, annual estimates. Ottawa: Statistics Canada; 2019. Available: https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1310009601&%3BpickMembers%5B0%5D=1.6&%3BpickMembers%5B1%5D=2.6&%3BpickMembers%5B2%5D=3.1&request_locale=en. (accessed 2020 Jan 13).
6 Canadian Cancer Statistics Advisory Committee. Canadian Cancer Statistics, September 2019. Toronto: Canadian Cancer Society; September 2019. Available: https://www.cancer.ca/~/media/cancer.ca/CW/cancer%20information/cancer%20101/Canadian%20cancer%20statistics/Canadian-Cancer-Statistics-2019-EN.pdf?la=en-CA (accessed 2020 Jan 13). 7 Institut de la statistique du Québec. Dépenses moyennes des ménages déclarants, selon le groupe d'âge de la personne de référence, Québec, 2006 (French only). Quebec: Institut de la statistique du Québec; 2006. Available: http://www.stat.gouv.qc.ca/statistiques/conditions-vie-societe/depenses-avoirs-dettes/depenses/depdeclar_age.htm (accessed 2020 Jan 13). 8 Santé et des Services sociaux. Les aînés du Québec - Quelques données récentes (2e édition)(French only). Quebec: Santé et des Services sociaux; June 2018. Available: https://publications.msss.gouv.qc.ca/msss/fichiers/ainee/aines-quebec-chiffres.pdf (accessed 2020 Jan 13).
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10 Ministère de la Santé et des Services sociaux, Plan stratégique 2019-2023 [2019–2023 Strategic plan] (French only). Quebec: Santé et des Services sociaux; December 2019. Avalable: https://cdn-contenu.quebec.ca/cdn-contenu/adm/min/sante-services-sociaux/publications-adm/plan-strategique/PL_19-717-02W_MSSS.pdf (accessed 2020 Jan 13).
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12 Revenu Québec. Tax Credit for Caregivers. Quebec: Revenu Québec; 2019. Available: https://www.revenuquebec.ca/en/citizens/tax-credits/tax-credit-for-caregivers/ (accessed 2020 Jan 13).
13 Public Health Agency of Canada. Investing in Prevention: The Economic Perspective. Ottawa: Public Health Agency of Canada; May 2009. Available: http://www.phac-aspc.gc.ca/ph-sp/pdf/preveco-eng.pdf (accessed 2020 Jan 13).
14 Statistics Canada. Table 13-10-0096-10 Smokers, by age group. Ottawa: Statistics Canada; 2018. Available:
https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1310009610 (accessed 2020 Jan 13).
15 Institut de la statistique du Québec. Enquête québécoise sur la santé des jeunes du secondaire 2016-2017. Résultats de la deuxième édition. La santé physique et les habitudes de vie des jeunes, Tome 3 (French only). Quebec: Institut de la statistique du Québec; December 2018. Available: https://www.stat.gouv.qc.ca/statistiques/sante/enfants-ados/alimentation/sante-jeunes-secondaire-2016-2017-t3.html(accessed 2020 Jan 13).
16 World Health Organization (WHO). Tobacco Free Initiative: https://www.who.int/tobacco/economics/taxation/en/
17 Legislative Assembly of British Columbia, Bill 45 – 2019: Taxation Statutes Amendment Act. Geneva: WHO; 2019. Available: https://www.leg.bc.ca/parliamentary-business/legislation-debates-proceedings/41st-parliament/4th-session/bills/first-reading/gov45-1 (accessed 2020 Jan 13).
18 Choosing Wisely Canada. Implementing Choosing Wisely Canada Recommendations. Toronto: Choosing Wisely Canada; 2020. Available: https://choosingwiselycanada.org/implementation/ (accessed 2020 Jan 13).
19 Canadian Medical Association, e-Panel Survey Summary: Choosing Wisely Canada (distributed to 3,864 e-Panel members and completed in November 2016): https://www.cma.ca/e-panel-survey-summary-choosing-wisely-canada.
20 Legislative Assembly of British Columbia. Bill 45 – 2019: Taxation Statutes Amendment Act. Vancouver: Legislative Assembly of British Columbia; 2019. Available: https://www.leg.bc.ca/parliamentary-business/legislation-debates-proceedings/41st-parliament/4th-session/bills/first-reading/gov45-1 (accessed 2020 Jan 13).
Subject: Improving Long-term Care for People in Canada
Dear Minister Hajdu and Minister Schulte,
We are writing to you with recommendations for responding to the staggering effects COVID-19 has had on our health-care system, particularly in long-term care (LTC) homes across Canada. These recommendations were recently unveiled by the Canadian Nurses Association (CNA) on May 27 through a report entitled 2020 Vision: Improving Long-term Care for People in Canada (attached to this letter). We invite you to read it and consider the proposals we are bringing forward.
As you know, Canada has had unacceptable rates of COVID-19-related deaths in LTC; by late April, 79% of the country’s deaths due to COVID-19 were linked to outbreaks in these homes. These tragic numbers are in part a result of decades of neglect of the LTC sector and a growing mismatch between the level of care required by people living in those settings, and the level of care available. Furthermore, the recent reports from the military deployed to Ontario and Quebec’s long-term care homes have emphasized the shocking and horrific conditions that exist in some nursing homes in Canada.
We applaud the Prime Minster’s recent commitment to work closely and support the province’s efforts to improve standards of care for older people in long-term care
homes across the country. Moreover, further decisive action needs to be undertaken. To address the flaws COVID-19 has revealed in the support and care systems available to Canada’s older people, we recommend that your Government take immediate action on three important fronts:
The Government of Canada should immediately appoint a commission of inquiry on aging;
Federal public health leaders must work with provincial, territorial and Indigenous governments and public health leaders to review the country’s COVID-19 response and organize preparations for the next pandemic;
Federal, provincial and territorial governments must increase investments in community, home and residential care to meet the needs of our aging population.
As the Prime Minister indicated last week, providing support in the short term and having broader discussions in the long term is critical. We believe many solutions can be put in place now in some long-term care homes if they had better funding, for example. In the long term, a deeper look to identify the best models for delivering better health and social services will support safe and dignified aging for every person in Canada.
We recognize the challenges involved to address the issues in the support and care systems for older people in Canada. The benefits of redesigning how we provide care for older people (Canada’s largest growing demographic) and others with complex continuing care needs will go beyond improving their lives and health. A good long-term care system, in tandem with effective, well-organized community and home care, will ease pressure on the acute-care system and eliminate many of the gaps in the continuum of care that too often result in previously independent older people landing in the hospital or long-term care.
Acting on these three recommendations will help to provide a solid foundation on which to build a safe and dignified future for Canada’s older people. Canada is known
for its humanitarian work around the world. It’s time we brought those values home, to care for the people to whom this country and each one of us owes so much.
We look forward to discussing these proposals with you and your staff as soon as possible. Sincerely,
RN, MN, PhD, CCHN(C) President Canadian Nurses Association
RN, BSN, MN, PhD(c) President,
Canadian Association for Rural and Remote Nursing
Canadian Association of Social Workers
RN, BN, ASMH, Med President Canadian Family Practice Nurses Association
RPN, MN, PhD(c)President,
Lori Schindel Martin,
RN, PHD President
Canadian Gerontological Nursing Association
BN, RN, CPMHN(C) Past President
Canadian Federation of Mental Health Nurses
RN, BScN, President
Canadian Indigenous Nurses Association
MD CCFP (PC) FCFP President Canadian Medical Association
Canadian Public Health Association
Miranda R Ferrier
MD CM, CCFP, FCFP, CAE, ICD. D
Executive Director & Chief Executive Officer College of Family Physicians of Canada
Ontario Personal Support Workers Association
Canadian Support Workers Association
RPN-GPNC(C), BAHSc (Hons), MHSc(c)
Professional Advocacy Director
Gerontological Nursing Association
MN, NP, President NPAC-AIIPC
Nurse Practitioner Association of Canada
Re: Recommendations for Canada’s long-term recovery plan
Dear Prime Minister Trudeau,
We would like first to thank and commend you for your leadership throughout this pandemic. Your government’s
efforts have helped many people in Canada during this unprecedented time and have prevented Canada from facing
outcomes similar to those seen in other countries experiencing significant pandemic-related hardship and suffering.
We are writing to you with recommendations as you develop a plan for Canada’s long-term recovery and the
upcoming Speech from the Throne on September 23rd.
The COVID-19 pandemic has further exposed and amplified many healthcare shortfalls in Canada such as care for
older adults and mental health-care. Added to that, the economic fallout is impacting employment, housing, and
access to education. These social determinants of health contribute to and perpetuate inequality, which we see the
pandemic has already exacerbated for vulnerable groups. Action is needed now to address these challenges and
improve the health-care system to ensure Canada can chart a path toward an equitable economic recovery.
To establish a foundation for a stronger middle class, Canada must invest in a healthier and fairer society by
addressing health-care system gaps that were unmasked by COVID-19. We firmly believe that the measures we are
recommending below are critical and should be part of your government’s long-term recovery plan:
1. Ensure pandemic emergency preparedness
2. Invest in virtual care to support vulnerable groups
3. Improve supports for Canada’s aging population
4. Strengthen Canada’s National Anti-Racism Strategy
5. Improve access to primary care
6. Implement a universal single-payer pharmacare program
7. Increase mental health funding for health-care professionals
We know the months ahead will be challenging and that COVID-19 is far from over. As a nation, we have an
opportunity now, with the lessons from COVID-19 still unfolding, to bring about essential transformations to our
health-care system and create a safer and more equitable society.
1. Ensure pandemic emergency preparedness
We commend you for your work with the provinces and territories to deliver the $19 billion Safe Restart Agreement
as it will help, in the next six to eight months, to increase measures to protect frontline health-care workers and
increase testing and contact tracing to protect Canadians against future outbreaks. Moving forward, as you develop a
plan for Canada’s long-term recovery, we strongly recommend the focus remains in fighting the pandemic. Beyond
the six to eight months rollout of the Safe Restart Agreement, it is critical that a long-term recovery plan includes provisions to ensure a consistent and reliable availability of personal protective equipment (PPE) and large-scale
capacity to conduct viral testing and contact tracing.
2.Invest in virtual care to support vulnerable groups
The sudden acceleration in virtual care from home is a silver lining of the pandemic as it has enabled increased
access to care, especially for many vulnerable groups. While barriers still exist, the role of virtual care should
continue to be dramatically scaled up after COVID-19 and Canada must be cautious not to move backwards. Even
before the pandemic, Canadians supported virtual care tools. In 2018, a study found that two out of three people
would use virtual care options if available.i During the pandemic, 91% of Canadians who used virtual care reported
We welcome your government’s $240 million investment in virtual health-care and we encourage that a focus be
given to deploying technology and ensuring health human resources receive appropriate training in culturally
competent virtual care. We also strongly recommend accelerating the current 2030 target to ensure every person in
Canada has access to reliable, high-speed internet access, especially for those living in rural, remote, northern and
3.Improve supports for Canada’s aging population
Develop pan-Canadian standards for the long-term care sector
The pandemic has exposed our lack of preparation for managing infectious diseases anywhere, especially in the longterm
care sector. The result is while just 20% of COVID-19 cases in Canada are in long-term care settings, they
account for 80% of deaths — the worst outcome globally. Moreover, with no national standards for long-term care,
there are many variations across Canada in the availability and quality of service.iii We recommend that you lead the
development of pan-Canadian standards for equal access, consistent quality, and necessary staffing, training and
protocols for the long-term care sector, so it can be delivered safely in home, community, and institutional settings,
with proper accountability measures.
Meet the health-care needs of our aging population
Population aging will drive 20% of increases in health-care spending over the next years, which amounts to an
additional $93 billion in spending.iv More funding will be needed to cover the federal share of health-care costs to
meet the needs of older adults. This is supported by 88% of Canadians who believe new federal funding measures
are necessary.v That is why we are calling on the federal government to address the rising costs of population aging
by introducing a demographic top-up to the Canada Health Transfer. This would enhance the ability of provinces and
territories to meet the needs of Canada’s older adults and invest in long-term care, palliative care, and community
and home care.
4.Strengthen Canada’s National Anti-Racism Strategy
Anti-Black racism exists in social structures across Canada. Longstanding, negative impacts of these structural
determinants of health have created and continue to reinforce serious health and social inequities for racialized
communities in Canada. The absence of race and ethnicity health-related data in Canada prevents identification of
further gaps in care and health outcomes. But where these statistics are collected, the COVID-19 pandemic has
exploited age-old disparities and led to a stark over-representation of Black people among its victims. We are calling
for enhanced collection and analysis of race and ethnicity data as well as providing more funding under Canada’s
National Anti-Racism Strategy to address identified health disparities and combat racism via community-led
5. Improve access to primary care
Primary care is the backbone of our health-care system. However, according to a 2019 Statistics Canada surveyvi,
almost five million Canadians do not have a regular health care provider. Strengthening primary care through a teambased,
interprofessional approach is integral to improving the health of all people living in Canada and the
effectiveness of health service delivery. We recommend creating a one-time fund of $1.2 billion over four years to
Page 3 of 4
expand the establishment of primary care teams in each province and territory, with a special focus in remote and
underserved communities, based on the Patient’s Medical Home visionvii.
6. Implement a universal single-payer pharmacare program
People across Canada, especially those who are vulnerable, require affordable access to prescription medications that
are vital for preventing, treating and curing diseases, reducing hospitalization and improving quality of life.
Unfortunately, more than 1 in 5 Canadians reported not taking medication because of cost concerns, which can lead
to exacerbation of illness and additional health-care costs. We recommend a comprehensive, universal, public system
offering affordable medication coverage that ensures access based on need, not the ability to pay.
7.Increase mental health funding for health-care professionals
During the first wave of COVID-19, 47% of health-care workers reported the need for psychological support. They
described feeling anxious, unsafe, overwhelmed, helpless, sleep-deprived and discouraged.viii Even before COVID-
19, nurses, for instance, were suffering from high rates of fatigue and mental health issues, including PTSD.ix
Furthermore, health-care workers are at high risk for significant work-related stress that will persist long after the
pandemic due to the backlog of delayed care. Immediate long-term investment in multifaceted mental health supports
for health-care professionals is needed.
We look forward to continuing to work with you and your caucus colleagues on transforming the health of people in
Canada and the health system.
Tim Guest, M.B.A., B.Sc.N., RN
Canadian Nurses Association (CNA)
Tracy Thiele, RPN, BScPN, MN,
Canadian Federation of Mental Health
Lori Schindel Martin, RN, PhD,
Canadian Gerontological Nursing
E. Ann Collins, BSc, MD
Canadian Medical Association (CMA)
Canadian Support Workers Association
Dr. Cheryl L. Cusack RN, PhD
Community Health Nurses of Canada
Lenora Brace, MN, NP
Nurse Practitioner Association of
~ r. Cheryl
Hon. Chrystia Freeland, Minister of Finance
Hon. Patty Hajdu, Minister of Health
Hon. Deb Schulte, Minister of Seniors
Hon. Navdeep Bains, Minister of Innovation, Science and Industry
Ian Shugart, Clerk of the Privy Council and Secretary to Cabinet
Dr. Stephen Lucas, Deputy Minister of Health
Dr. Theresa Tam, Chief Public Health Officer of Canada
The Canadian Medical Association (CMA) is pleased to provide the House of Commons Standing Committee on Finance this pre-budget submission. It provides recommendations to address major pan-Canadian challenges to the health of Canadians: improve how we provide care to our growing elderly population; improve access to primary care across the country; increase digital health literacy to take advantage of the benefits of new health information technologies; and better prepare for and mitigate the health impacts of a changing climate on Canadians.
Health systems across the country are currently struggling to meet the needs of our aging population. People aged 85 years and over—many of whom are frail—make up the fastest growing age group in Canadai.
Provincial and territorial health care systems (as well as care systems for populations falling under federal jurisdiction) are facing many challenges to meet the needs of an aging population. Canadians support a strong role for the federal government in leading a national seniors strategy and working with the provinces to ensure that all Canadians have the same level of access and quality of services, no matter where they live.
The 2017 federal/provincial/territorial funding agreement involving $6 billion over 10 years to improve access to home care services is a welcomed building block. But without greater investment in seniors care, health systems will not keep up. To be truly relevant and effectively respond to Canadians’ present and future needs, our health care system must provide integrated, continuing care able to meet the chronic and complex care needs of our growing and aging population. This includes recognizing the increased role for patients and their caregivers in the care process.
The federal government must ensure transfers are able to keep up with the real cost of health care. Current funding levels clearly fail to do so. Health transfers are estimated to rise by 3.6% while health care costs are expected to rise by 5.1% annually over the next decade.ii
The federal government ensure provincial and territorial health care systems meet the care needs of their aging populations by means of a demographic top-up to the Canada Health Transfer.iii
Providing care often comes with a financial cost such as lost income due to the caregiver’s withdrawal from the workforce to provide care. There are also increasing out-of-pocket costs for both caregivers and care receivers for health care-related expenses—privately covered expenditures on home and long-term care for seniors are projected to grow by an average of 5.8 per cent annually—nearly 1.5 times the pace of household disposable income growth. While the federal government offers tax credits that can be claimed by care receivers/caregivers, they are significantly under-utilized. While representing a significant proportion of caregivers, those with low or no income receive little to no federal government support through these programs. Middle-income earners also receive less than those earning high incomes.
The federal government create a Seniors Care Benefit that would be an easier, fairer and more effective way to support caregivers and care receivers alike.iv
Access to Care
Since the mid-1990s, the federal and provincial/territorial governments (FPT) have provided sustained leadership in promoting and supporting the transformation of primary care in Canada. In 2000, the First Ministers concluded the first of three Health Accords in which they agreed to promote the establishment of primary health care teamsv supported by a $800 million Primary Health Care Transition Fund (PHCTF) funded by the federal government, but jointly governed. The PHCTF resulted in large-scale sustained change in primary care delivery models in Ontario, Quebec and Alberta with interest in other jurisdictions as well.
However, the job is far from finished. Across Canada, access to primary care is challenging for many Canadians with a persistent shortage of family physicians. In 2017, 4.7 million Canadians aged 12+ reported they did not have a regular health care provider.vi Even those who have a regular provider experience wait time issues.
There has been widespread interest in primary care models since the development of the College of Family Physicians of Canada’s (CFPC) vision document Family Practice: The Patient’s Medical Home (PMH), initially launched in 2011vii and recently re-launched.viii The model is founded on 10 pillars depicted in Figure 1.
Figure 1. The Patient’s Medical Home, 2019
The updated model places increased emphasis on team-based care and introduces the concept of the patient’s medical neighborhood that sets out connections between the primacy care practice and all delivery points in the surrounding community. While comprehensive baseline data are lacking, it seems
safe to conjecture that most Canadians are not enrolled in a primary care model that would measure up to the model’s 10 pillars.
The federal government, in concert with provinces and territories, establish a targeted fund in the amount of $1.2 billion to support a new time-limited Primary Health Care Transition Fund that would build on the success of the fund launched in 2000 with the goal of widely introducing a sustainable medical home model across jurisdictions. This would include the following key elements:
Age-sex-weighted per capita allocation across the provinces and territories;
Joint governance of the FPT governments with meaningful stakeholder engagement;
Respect for the Canada Health Act principles;
Common objectives (e.g., modeled on the CFPC Patient’s Medical Home framework);
Canada and most industrialized countries will experience a digital health revolution over the next decade with great potential to improve patient and population health. Digital health can be described as the integration of the electronic collection and compilation of health data, decision support tools and analytics with the use of audio, video and other technologies to deliver preventive, diagnostic and treatment services that promote patient and population health.
While most Canadian physicians’ offices and health care facilities are now using some form of electronic record keeping and most households have internet access, there remains a large deficit in using virtual care, both within jurisdictions and across provincial/territorial boundaries. Recently the CMA, the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada established a Virtual Care Task Force to identify opportunities for digital health to improve health care delivery, including what regulatory changes are required for physicians to deliver care to patients within and across provincial/territorial boundaries.
To take full advantage of digital health capabilities it will be essential for the population to have a functional level of digital health literacy: the ability to seek, find, understand and appraise health information from electronic sources and apply the knowledge gained to addressing or solving a health problem.ix This also includes the capability of communicating about one’s health to health care professionals (e.g., e-consults), self-monitoring health (e.g., patient portals) and receiving treatment online (e.g., Web-based cognitive behavioral therapy).x
There are no current data available on health literacy in Canada, let alone digital health literacy. One basic barrier to achieving digital health literacy is access to, and usage of the Internet, which has been termed the “digital divide” (e.g., older Canadians and low income households are less likely to have Internet access).Error! Bookmark not defined.
In 2001 the federal government established the Financial Consumer Agency of Canada (FCAC). Its mandate includes informing consumers about their rights and responsibilities in dealing with financial institutions and providing information and tools to help consumers understand and shop for financial products and services.xi In 2014 the FCAC appointed a Financial Literacy Leader who has focused on financial literacy, including activities such as conducting financial capability surveys and the development of a National Strategy for Financial Literacy.xii
Considering the anticipated growth of digital/virtual care it would be desirable to understand and promote digital health literacy across Canada. What the federal government has done for financial literacy could serve as a template for digital health literacy.
The federal government establish a Digital Health Literacy Secretariat to:
Develop indicators and conducting surveys to measure and track the digital health literacy of Canadians;
Develop tools that can be used both by Canadians and their health care providers to enhance their digital health literacy; and
Assess and make recommendations on the “digital divide” that may exist among some population sub-groups due to a lack of access to information technology and lower digital health literacy.
Climate Change and Health
Climate change is the public health imperative of our time. There is a high level of concern among Canadians about their changing climate. A 2017 poll commissioned by Health Canada demonstrates a high level of concern among Canadians about their changing climate: 79% were convinced that climate change is happening, and of these, 53% accepted that it is a current health risk, with 40% believing it will be a health risk in the future.
The World Health Organization (WHO) has identified air pollution and climate change as one of the biggest threats to global health. Health care professionals see first-hand the devastating health impacts of our changing climate including increased deaths from fine particulate matter air pollution and increased heat-related conditions. Impacts are most common in vulnerable populations such as adults over 65 years, the homeless, urban dwellers and people with a pre-existing disease.
Canada’s health care system is already treating the health effects of climate change. A lack of progress in reducing emissions and building adaptive capacity threatens both human lives and the viability of Canada’s health system, with the potential to disrupt core public health infrastructure and overwhelm health services, not to mention the economic and social costs. The federal government must provide leadership to deal with the impact already being felt in Canada and around the world.
The federal government make strong commitments to minimize the impact of climate change on the health of Canadians by:
Ensuring pan-Canadian and inter-jurisdictional coordination to standardize surveillance and reporting of climate-related health impacts such as heat-related deaths, develop knowledge translation strategies to inform the public, and generate clinical and public health response plans that minimize the health impacts;
Increasing funding for research on the mental health impacts of climate change and psychosocial adaptation opportunities; and
Ensuring funding is provided to the health sector to prepare for climate change impacts through efforts to increase resiliency (i.e., risk assessments, readiness to manage disease outbreaks, sustainable practice).
i Statistics Canada. The Chief Public Health Officer's Report on the State of Public Health in Canada, 2014: Public Health in the Future. Ottawa: Statistics Canada; 2015. Available: http://www.phac-aspc.gc.ca/cphorsphc-respcacsp/2014/chang-eng.php; (accessed 2016 Sep 19).
ii The Conference Board of Canada. Meeting the care needs of Canada’s aging population. Ottawa: The Conference Board; 2018.
iii Canadian Medical Association. Meeting the demographic challenge: Investments in seniors care. Pre-budget submission to the House of Commons Standing Committee on Finance. August 3, 2018. https://policybase.cma.ca/documents/Briefpdf/BR2018-16.pdf
iv The Conference Board of Canada. Measures to Better Support Seniors and Their Caregivers. March 2019. https://www.cma.ca/sites/default/files/pdf/health-advocacy/Measures-to-better-support-seniors-and-their-caregivers-e.pdf
v Canadian Intergovernmental Conference Secretariat. News release – First Ministers’ meeting communiqué on health. September 11, 2000. http://www.scics.ca/en/product-produit/news-release-first-ministers-meeting-communique-on-health/. Accessed 04/22/19.
vi Statistics Canada. Primary health care providers, 2017. https://www150.statcan.gc.ca/n1/en/pub/82-625-x/2019001/article/00001-eng.pdf?st=NGPiUkM5. Accessed 04/21/19.
vii College of Family Physicians of Canada. A vision for Canada. Family Practice: the patient’s medical home. http://www.cfpc.ca/uploadedFiles/Resources/Resource_Items/PMH_A_Vision_for_Canada.pdf. Accessed 04/22/19.
viii College of Family Physicians of Canada. The patient’s medical home 2019. https://patientsmedicalhome.ca/files/uploads/PMH_VISION2019_ENG_WEB_2.pdf. Accessed 04/21/19.
ix Norman C, Skinner H. eHealth literacy: essential skills for consumer health in a networked world. J Med Internet Res 2006;8(2):e9. Doi:10.2196/jmir.8.2.e9.
x Van der Vaart R, Drossaert C. Development of the digital health literacy instrument: measuring a broad spectrum of health 1.0 and health 2.0 skills. J Med Internet Res. 2017;19(1):e27. Doi:10.2196/jmir.6709.
xi Financial Consumer Agency of Canada. About FCAC.
xii Financial Consumer Agency of Canada. National Strategy for Financial Literacy. Phase 1: strengthening seniors’ financial literacy. https://www.canada.ca/content/dam/canada/financial-consumer-agency/migration/eng/financialliteracy/financialliteracycanada/documents/seniorsstrategyen.pdf. Accessed 06/24/19. https://www.canada.ca/en/financial-consumer-agency/corporate/about.html. Accessed 07/01/19.
Recommendation: That the federal government ensure provincial and territorial health care systems meet the care needs of their aging populations by means of a demographic top-up to the Canada Health Transfer.
The Canadian Medical Association unites physicians on national health and medical matters. Formed in Quebec City in 1867, the CMA’s rich history of advocacy led to some of Canada’s most important health policy changes. As we look to the future, the CMA will focus on advocating for a healthy population and a vibrant profession.
The Canadian Medical Association (CMA) is pleased to provide the House of Commons Standing Committee on Finance this pre-budget submission, focused on the major challenges confronting seniors care in Canada. As Canada’s demographic shift advances, the challenge of ensuring quality seniors care will only become more daunting unless governments make critical investments in our health care system today. This is a national issue that will affect all provinces and territories (PTs). However, not all PTs will bear the costs equally. The current federal health transfer system does not take demographics into account. The CMA proposes the federal government fund a share of the health care costs associated with our aging population by means of a new “demographic top-up” to the Canada Health Transfer (CHT).
Recommendation: That the federal government ensure provincial and territorial health care systems meet the care needs of their aging populations by means of a demographic top-up to the Canada Health Transfer.
Seniors Care: Challenges and Opportunities
Canada, like most OECD economies, is grappling with the realities of a rapidly aging population. The population of seniors over the age of 65 in Canada has increased by 20% since 2011 and it has been projected that the proportion of Canada’s total population over 65 will exceed one-third by 2056 with some provinces like Newfoundland and Labrador reaching that point as soon as the mid-2030s.1 Census figures also show that the fastest growing demographic in Canada between 2011 and 2016 was individuals over 90, growing four times the rate of the overall population during this period.2
These demographic changes have a number of major implications for the future of Canadian society. Chief among them is the new pressure they add to our health care system. As the population ages, it is expected that health care costs will grow at a significantly faster rate than in previous years. As demonstrated in Chart 1 below, population aging will be a top contributor to rising health care costs over the decade ahead. By 2026–27, these increases will amount to $19 billion in additional annual health care costs associated with population aging, as shown in Chart 2.
Many seniors experience varying degrees of frailty, which the Canadian Frailty Network (CFN) defines as “a state of increased vulnerability, with reduced physical reserve and loss of function across multiple body systems” that “reduces ability to cope with normal or minor stresses, which can cause rapid and dramatic changes in health.”3 About 75% to 80% of seniors report having one or more chronic conditions.4 It is primarily the care associated with management of these conditions as well as increased residential care needs that drive the higher costs associated with seniors care. The average annual per capita provincial/territorial health spending for individuals age 15 to 64 is $2,700 compared with $12,000 for seniors age 65 and over.5
Our medicare system, which was established over half a century ago, is not designed or resourced to deal with this new challenge. The median age of Canadians at the time of the Medical Care Act’s enactment in 1966 was 25.5 years. It is now 40.6 years and is expected to rise to 42.4 years in the next decade.5 While past governments have placed significant focus on hospital care (acute and sub-acute), transitional care, community supports such as home care and long-term care (LTC) have been largely underfunded. Demographic changes have already begun to place pressure on our health care system, and the situation will only become worse unless funding levels are dramatically raised.
Chart 1: Major contributors to rising health care costs (forecast average annual percentage increase, 2017–26)5
Chart 2: Provincial/terrioritial health care costs attributable to population aging ($ billions, all PTs relative to 2016–17 demographics)5
Individuals in Ontario wait a median of 150 days for placement in a LTC home.6 In many communities across the country acute shortages in residential care infrastructure mean that seniors can spend as long as three years on a wait list for LTC.7 Seniors from northern communities are often forced to accept placements hundreds of kilometres from their families.8 The human and social costs of this are self-evident but insufficient spending on LTC also has important consequences for the efficiency of the system as a whole.
When the health of seniors stabilizes after they are admitted to hospital for acute care, health care professionals are often confronted with the challenge of finding better living options for their patients. These patients are typically assigned Alternate Level of Care (ALC) beds as they wait in hospital for appropriate levels of home care or access to a residential care home/facility.
In April 2016, ALC patients occupied 14% of inpatient beds in Ontario while in New Brunswick, 33% of the beds surveyed in two hospitals were occupied by ALC patients.9 The average length of hospital stay of all ALC patients in Canada is an unacceptable 380 days. Not only does ALC care lead to generally worse health outcomes and patient satisfaction than both LTC and home care, but it is also significantly more expensive. The estimated daily cost of a hospital bed used by a patient is $842, compared with $126 for a LTC bed and $42 per day for care at
home.10 Moreover, high rates of ALC patients can contribute to hospital overcrowding, lengthy emergency wait times and cancelled elective surgeries.11 Committing more funding to LTC infrastructure would lead to system-wide improvements in wait times and quality of care by helping to alleviate the ALC problem.
A recent poll found that only 49% of Canadians are confident that the health care system will be able to meet senior care needs and that 88% of Canadians support new federal funding measures.12 Fortunately, there have been some signs at both the provincial and federal levels that seniors care has become an issue of increasing importance. New Brunswick recently introduced a caregiver’s benefit while the Ontario government has recently committed to building 15,000 LTC beds over the next decade. The federal government highlighted home care as a key investment area in the most recent Health Accord bilateral agreements and has made important changes to both the Canada Pension Plan (CPP) and Old Age Security (OAS) programs.
The Demographic Top-Up: Modernizing the CHT
Despite these recent and important initiatives by governments in Canada, additional policy and fiscal measures will be needed to address the challenges of an aging population. Many provincial governments have shown a clear commitment to the issue, but the reality is that their visions for better seniors care will not come to fruition unless they are backed up by appropriate investments. This will not be possible unless the federal government ensures transfers are able to keep up with the real cost of health care. Current funding levels clearly fail to do so. Projections in a recent report by the Conference Board of Canada, commissioned by the CMA, indicate that health transfers are expected to rise by 3.6% while health care costs are expected to rise by 5.1% annually over the next decade.3
Over the next decade, unless changes are made, provinces/territories will need to assume an increasingly larger share of health care costs. If federal health transfers do not account for population aging, the federal share of health care spending will fall below 20% by 2026.5 Aging will affect some provinces more than others, as demonstrated in Figure 1 below. The overall cost of population aging to all of the provinces and territories is projected to be $93 billion over the next decade.5 The absence of demographic considerations in transfer calculations therefore indirectly contributes to regional health inequality as provinces will not receive the support they need to ensure that seniors can count on quality care across Canada.
Figure 1: Increases in health care costs associated with population aging, 2017 to 2026 ($ billions)5
The CMA recommends that the federal government address the health costs of population aging by introducing a “demographic top-up” to the Canada Health Transfer. One model for this would require the federal government to cover a share of the costs projected to be added by population aging in each province/territory (see above) equal to the federal share of total health costs covered now (22%). The Conference Board of Canada estimates that the overall cost of such a change would be $21.1 billion over the next decade (see Table 1).
This funding would greatly enhance the ability of the provinces and territories to make much-needed investments in seniors care and the health care system as a whole. It could be used to support the provinces’ and territories’ efforts to address shortages in LTC, to expand palliative care and home care supports and to support further innovation in the realm of seniors care.
Table 1: Cost of demographic top-Up by province in $ millions5
The evidence that our health care systems are not prepared or adequately funded to ensure appropriate and timely access to seniors care, across the continuum of care, is overwhelming. Wait times for LTC and home care are unacceptably high and complaints about lack of availability in Northern and rural communities are becoming increasingly common. Health care providers in the LTC sector regularly raise concern about overstretched resources and a lack of integration with the rest of the health care system.
By introducing a new demographic top-up to the Canada Health Transfer, the federal government would demonstrate real leadership by ensuring that all provinces/territories are able to adapt to an aging population without eroding quality of care. Furthermore, improvements in how we care for our seniors will lead to improvements for patients and caregivers of all ages through greater system efficiencies (e.g., shorter wait times for emergency care and elective surgeries) and more coordinated care.
The CMA has been, and will continue to be, a tireless advocate for improving seniors care in Canada. The CMA would welcome opportunities to provide further information on the recommendation outlined in this brief.
1Statistics Canada. Age and sex, and type of dwelling data: key results from the 2016 Census. Ottawa: Statistics Canada; 2017. Available: https://www150.statcan.gc.ca/n1/daily-quotidien/170503/dq170503a-eng.htm
2Ministry of Finance Ontario. 2016 Census highlights, fact sheet 3. Toronto: Office of Economic Policy, Labour Economics Branch; 2017. Available: www.fin.gov.on.ca/en/economy/demographics/census/cenhi16-3.html.
3Canadian Frailty Network. What is frailty? Kingston: The Network; 2018. Available: www.cfn-nce.ca/frailty-in-canada/
4Canadian Institute for Health Information (CIHI). Health care in Canada, 2011: a focus on seniors and aging. Available: https://secure.cihi.ca/free_products/HCIC_2011_seniors_report_en.pdf
5The Conference Board of Canada. Meeting the care needs of Canada’s aging population. Ottawa: The Conference Board; 2018. Available: www.cma.ca/En/Lists/Medias/Conference%20Board%20of%20Canada%20-%20Meeting%20the%20Care%20Needs%20of%20Canada%27s%20Aging%20Population.PDF
6Health Quality Ontario. Wait times for long-term care homes. Available: www.hqontario.ca/System-Performance/Long-Term-Care-Home-Performance/Wait-Times
7Crawford B. Ontario’s long-term care problem: seniors staying at home longer isn’t a cure for waiting lists. Ottawa Citizen 2017 Dec 22. Available: https://ottawacitizen.com/news/local-news/ontarios-long-term-care-problem-seniors-staying-at-home-longer-isnt-a-cure-for-waiting-lists
8Sponagle J. Nunavut struggles to care for elders closer to home. CBC News 2017 Jun 5. Available: www.cbc.ca/news/canada/north/nunavut-seniors-plan-1.4145757
9McCloskey R, Jarrett P, Stewart C, et al. Alternate level of care patients in hospitals: What does dementia have to do with this? Can Geriatr J. 2014;17(3):88–94.
10Home Care Ontario. Facts and figures – publicly funded home care. Hamilton: Home Care Ontario; n.d. Available: www.homecareontario.ca/home-care-services/facts-figures/publiclyfundedhomecare
11Simpson C. Code gridlock: why Canada needs a national seniors strategy. Ottawa: Canadian Medical Association; 2014. Available: www.cma.ca/En/Lists/Medias/Code_Gridlock_final.pdf
12Ipsos Public Affairs. Just half of Canadians confident the healthcare system can meet the needs of seniors. Toronto: Ipsos; 2018. Available: www.ipsos.com/en-ca/news-polls/Canadian-Medical-Association-Seniors-July-17-2018
The Canadian Medical Association is pleased to present its views to the study on poverty reduction strategies by the House of Commons Standing Committee on Human Resources, Skills and Social Development and the Status of Persons with Disabilities.
The focus of the Committee’s study on improving the delivery of federal resources and services for the Canadian Poverty Reduction Strategy is of profound interest to the CMA, given our concerns about the need to address the social determinants of health. It is that perspective from which this paper will approach the Committee’s areas of interest.
Social Determinants of Health
The consequences of poverty on health are well established and include lower life expectancy, higher disease burden, and poorer overall health. Research suggests that 15% of population health is determined by biology and genetics, 10% by physical environments, 25% by the actions of the health care system, with 50% being determined by our social and economic environment.1 Many studies show that people low on the socioeconomic scale are likely to carry a higher burden of just about any disease.2
1 Keon, WJ, Pépin L. (2008) Population Health Policy: Issues and Options. Ottawa: The Senate of Canada; 2008. Available at: https://sencanada.ca/content/sen/Committee/392/soci/rep/rep10apr08-e.pdf
2 Op cit. Dunn JR. The Health Determinants Partnership Making Connections Project
3 Munro D. Healthy People, Healthy Performance, Healthy Profits: The Case for Business Action on the SocioEconomic Determinants of Health. The Conference Board of Canada, Ottawa (ON); 2008.
Reducing inequities and thereby improving population health should be an overall objective for all governments in Canada.
The societal cost of poor health extends beyond the cost to the health care system: healthier people lose fewer days of work and contribute to overall economic productivity.3 Those living in the most disadvantaged neighbourhoods experience almost 20 years less disability-free life.
It is fundamental that the health impact of social and economic decisions be part of the policy development and decision-making process.
1. The CMA recommends that health impact assessments be included as part of the policy development and decision-making process in poverty reduction strategies, including in the development of legislation and regulations.
Neighbourhoods and Housing
Mounting evidence suggests that the built environment can play a significant role in our state of health. The literature indicates that the following connections between the built environment and public health are possible:
o Decreased physical activity;
o Increased prevalence of obesity;
o Increased prevalence of asthma and other respiratory diseases;
o Injuries and unintended fatalities;
o Heat exposure.4
4 Frank , L., Kavage S, & Devlin A. (2012). Health and the Built Environment: A Review. World Medical Association
5 Canadian Society of Exercise Physiology. (2011). Canadian Physical Activity Guidelines. Canadian Society of Exercise Physiology
6 CMA. Active Transportation http://policybase.cma.ca/dbtw-wpd/Policypdf/PD09-04.pdf 2009
7 Statistics Canada. (2006, June 28). Childhood Obesity: A Troubling Situation. Retrieved July 15, 2012, from StatsCan: http://www41.statcan.ca/2006/2966/ceb2966_004-eng.htm
Canada's physical activity guidelines recommend that children ages 5 to 11 should be active for at least 60 minutes a day; those 18 and over should be active for at least 150 minutes per week.5 However, physical activity includes more than exercise and leisure time activity, it also includes active transportation such as walking to school, work or errands as part of daily living. CMA’s policy on Active Transportation recommends that all sectors (physicians and other health professionals, government, business and the public) work together, as a matter of priority, to support and encourage active transportation and physical activity.6 Urban planners must work together with health professionals to understand the impact on health.
Research shows that specific populations, such as children, the elderly, and low-income populations, are more affected.
Children: Obesity is an issue for Canadians nationwide, but particularly so for children. Between 1978 and 2004 there was a 70% increase in overweight and obese children aged 12-17.7 Obesity in children can lead to health issues such as hypertension, glucose intolerance, and orthopaedic complications.8 Furthermore it has a high likelihood of carrying over into adulthood and may result in further health problems such as diabetes and heart disease.9 Environments that promote physical activity are
especially important, including mixed use communities with walkable destinations, parks and recreational facilities.10
10 Dannenberg, A., Frumkin, H., & Jackson, R. J. (2011). Making Healthy Places Designing and Building for Health, Well-Being and Sustainability. Island Press.
11 Vogel, T., Brechat, P., Lepetre, P., Kaltenbach, G., Berthel, M., & Lonsdorfer, J. (2009). Health Benefits of Physical Activity in Older Patients: A Review. The International Journal of Clinical Practice, 63(2), 303-320.
12 Centre for Chronic Disease Prevention and Control. . (2002). Diabetes in Canada, 2nd Edition. Ottawa: Health Canada
13 Statistics Canada. (1996-97, May 29). National Population Health Survey, Cycle 2. Canada: The Daily.
14 Creatore, M., Gozdyra, P., Booth, G., & Glazier, R. (2007). Chapter 1: Setting the Context. In M. Creatore, P. Gozdyra, G. Booth, R. Glazier, & M. Tynan, Neighbourhood Environments and Resources for Healthy Living - A Focus on Diabetes in Toronto: ICES Atlas. Toronto: Institute for Clinical Evaluative Sciences.
15 Op cit Dunn JR. The Health Determinants Partnership Making Connections Project
16 Raphael D. Addressing The Social Determinants of Health In Canada: Bridging The Gap Between Research Findings and Public Policy. Policy Options. March 2003 pp.35-40.
Elderly: The elderly population is generally less physically robust and more prone to chronic illnesses, which make them especially vulnerable to air pollution and heat exposure. Physical activity is an important aspect of daily life for this age group as it has been shown to reduce the negative health impacts of aging.11 Being physically active, however, requires accessible and safe streets, and transportation systems that cater to the needs of individuals with mobility issues. Special consideration is required when constructing the built environment to ensure the needs of this growing population.
Low Income Populations: Low income populations are at higher risk for chronic illnesses such as high blood pressure and diabetes, and have a lower overall survivability for major heart attacks.12,13 They are also more likely to smoke, be overweight or obese, and are less likely to be physically active.14 Many of these factors can be linked to limited access to stable housing, housing location (normally close to highways or industrial zones with high pollution exposure), neighbourhood safety, and lack of access to or affordability of healthy food options.
2. The CMA recommends that the federal government work with all sectors to create a culture within communities that supports and encourages active transportation and physical activity.
Hundreds of research papers have confirmed that people in the lowest socio-economic groups carry the greatest burden of illness.15 Studies also suggest that adverse socio-economic conditions in childhood can be a greater predictor of cardiovascular disease and diabetes in adults than later life circumstances and behavioural choices.16 Finally,
the countries reporting the highest population health status are those with the greatest income equality, not the greatest wealth.17
17 Hofrichter R ed. Tackling Health Inequities Through Public Health Practice: A Handbook for Action. The National Association of County and City Health Officials & The Ingham County Health Department. Lansing (USA); 2006.
18 Bierman AS, Angus J, Ahmad F, et al. Ontario Women’s Health Equity Report : Access to Health Care Services : Chapter 7. Toronto (ON) Project for and Ontario Women’s Health Evidence-Based Report; 2010.
19 Bierman AS, Johns A, Hyndman B, et al. Ontario Women’s Health Equity Report: Social Determinants of Health & Populations at Risk: Chapter 12. Toronto (ON) Project for and Ontario Women’s Health EvidenceBased Report; 2010.; Williamson DL, Stewart MJ, Hayward K. Low-income Canadians’ experiences with health-related services: Implications for health care reform. Health Policy 2006; 76:106-121.
20 Canadian Institute for Health Information. Hospitalization Disparities by Socio-Economic Status for Males and Females. Ottawa(ON); 2010. Available: https://secure.cihi.ca/free_products/disparities_in_hospitalization_by_sex2010_e.pdf (accessed 2017 Jan 5)
21 Canadian Institute for Health Information. Hospitalization Disparities by Socio-Economic Status…;Roos LL, Walld R, Uhanova J, et al. Physician Visits, Hospitalizations, and Socioeconomic Status: Ambulatory Care Sensitive Conditions in a Canadian Setting. HSR 2005; 40(4): 1167-1185.
22 Canadian Medical Association. Policy resolution GC15-70 - Basic income guarantee. Approved August 26, 2015
Income plays a role in access to appropriate health care as well. Individuals living in lower income neighbourhoods, are less likely to have primary care physicians18, and are more likely to report unmet health care needs.19 They are more likely to be hospitalized for conditions which could potentially be avoided with appropriate primary care.20,21
In 2015, the CMA passed a resolution endorsing the concept of a basic income guarantee”22, which is a cash transfer from government to citizens not tied to labour market participation. It ensures sufficient income to meet basic needs and live with dignity, regardless of employment status. A basic income guarantee has the potential to alleviate or even eliminate poverty. It has the potential to reduce the substantial, long-term social consequences of poverty, including higher crime rates and fewer students achieving success in the educational system.
In addition, resources and supports are needed to assist low-income Canadians regarding diet, shelter, skills development and other needs..
3. The CMA urges the Government of Canada to prioritize consideration of a basic income guarantee as a policy option for reducing poverty.
Prenatal and Early Childhood
Research suggests that 90% of a child’s brain capacity is developed by age five.23 High quality early childhood programs including programs to nurture and stimulate children and educate parents are highly correlated with the amelioration of the effects of disadvantage on cognitive, emotional and physical development among children.24,25
23 Arkin E, Braveman P, Egerter S & Williams D. Time to Act: Investing in the Health of Our Children and Communities: Recommendations From the Robert Wood Johnson Foundation Commission to Build a Healthier America. Robert Wood Johnson Foundation. Princeton (NJ); 2014.
24 Braveman P, Egerter D & Williams DR. The Social Determinants of Health: Coming of Age. Annu Rev Publ Health. 32:3.1-3.18. 2011.
25 European Union. Commission Recommendation of 20.2.2013: Investing in children: breaking the cycle of disadvantage. Brussels (Belgium); 2013.
26 Canadian Medical Association, Canadian Paediatric Society, College of Family Physicians of Canada. Child and Youth Health: Our Challenge: Canada’s Child and Youth Health Charter. Ottawa October 9, 2007.
In 2007, the Canadian Medical Association, the Canadian Paediatric Society and the College of Family Physicians of Canada released Canada’s Child and Youth Health Charter.26 To reach their potential, children and youth need to grow up in a place where they can thrive — spiritually, emotionally, mentally, physically and intellectually — and get high-quality health care when they need it. That place must have three fundamental elements: a safe and secure environment; good health and development; and a full range of health resources available to all. Children and youth of distinct populations in Canada, including First Nations, Inuit and Métis, must be offered equal opportunities as other Canadian children and youth through culturally appropriate resources.
Our children and youth must have a safe and secure environment where they can access clean water, air and soil; be protected from injury, exploitation and discrimination; and live in healthy family, homes and communities. Further, to ensure good health and development there must be access to prenatal and maternal care for the best possible health at birth and access to quality nutrition for proper growth, development and long-term health.
As well, early learning opportunities and high-quality care, at home and in the community must be accessible. Opportunities and encouragement for physical activity are crucial as well as access to high-quality primary and secondary education. Finally, affordable and available post-secondary education and a commitment to social well-being and mental health are paramount.
4. The CMA recommends that the federal government and the provinces and territories work to ensure that poverty does not continue to be a barrier to the healthy development of Canadian children, particularly in their first five years.
Socio-economic factors play a larger role in creating (or damaging) health than either biological factors or the health care system. Health equity is increasingly recognized as a necessary means by which we will make gains in the health status of all Canadians. Despite a commitment to equal access to health care for all Canadians there are differences in access and quality of care for many groups. For those that are most vulnerable, this lack of access can serve to further exacerbate their already increased burden of illness and disease. Action is still required by the federal government to tackle the underlying social and economic factors which lead to the disparities in the health of Canadians.
The Canadian Medical Association (CMA) is pleased to submit this brief to the Senate Standing Committee on Social Affairs, Science and Technology in support of Bill S-228, An Act to Amend the Food and Drugs Act (prohibiting food and beverage marketing directed at children). The CMA has over 85,000 physician-members; our mission is empowering and caring for patients and its vision is a vibrant profession and a healthy population.
The CMA is encouraged that the Senate is considering legislation that will protect children by prohibiting marketing of food and beverages directed to those under 13 years of age. We applaud Senator Nancy Greene Raine for sponsoring this important bill.
Obesity rates among children and youth in Canada have nearly tripled in the last 30 years. Obesity is of particular concern to Canada’s physicians because it increases a person’s risk of developing a number of serious health problems: high blood pressure, high blood cholesterol, heart disease and stroke, type 2 diabetes, osteoarthritis, lower back pain and other musculoskeletal disorders, and many types of cancer. Type 2 diabetes, once found only in adults, is now being seen in children.
Health advocates are concerned that because of obesity, today’s generation of children will have a shorter life expectancy than their parents. Children and youth who are obese are at higher risk of developing a range of health problems, and weight issues in childhood are likely to persist into adulthood. Diet-related chronic disease risk stems from long-term dietary patterns which start in childhood. Canadian statistics reveal children, consume too much fat, sodium and sugars (foods that cause chronic disease) and eat too little fiber, fruits and vegetables (foods that prevent chronic disease). The current generation of Canadian children is expected to live shorter less healthy lives as a result of unhealthy eating.1
CMA’s Cautions against Marketing
Children and youth in Canada are exposed to a barrage of marketing and promotion of unhealthy foods and beverages through a variety of channels and techniques – tactics which undermine and contradict government, health care professional and scientific recommendations for healthy eating. Research undertaken for the Heart and Stroke Foundation found that kids see over 25 million food and beverage ads a year on their favourite websites and that over 90% of the food and beverage product ads viewed online are unhealthy.2
Unhealthy food and beverage advertising influences children’s food preferences, purchase requests, and consumption patterns and has been identified as a probable cause of childhood overweight and obesity by the World Health Organization.3
The CMA has long been calling on governments to explore ways to restrict the advertising and promotion of high-calorie, nutrient-poor foods. In 2006 CMA recommended that media advertising of high-calorie, nutrient-poor "junk" food in children's television programs be banned altogether. As the ways and means of advertising have expanded so too has our thinking, and in 2012 CMA adopted a policy on Restricting Marketing of Unhealthy Foods and Beverages to Children and Youth in Canada which called for the restriction of all marketing to children under 13 years of age of unhealthy foods and beverages. In 2014, CMA endorsed the Ottawa Principles and the Stop Marketing to Kids Coalition. The Ottawa Principles went further to help refine the definitions, scope and principles meant to guide marketing to kids (M2K) policy-making in Canada.4 They recommend the restriction of commercial marketing of all food and beverages to children and youth age 16 years and younger. Restrictions would include all forms of marketing with the exception of non-commercial marketing for public education.
At present, Canada relies on voluntary industry codes to govern advertising and marketing practices. However, recent Canadian research into industry self-regulation has shown no reduction in children’s exposure to ads for unhealthy foods.5 The CMA believes that for maximum efficacy, regulatory measures are required to minimize the negative effect of food marketing on health. Only legally enforceable regulations have sufficient authority and power to ensure high-level protection of children from marketing and its persuasive influence over food preference and consumption.
Not only health organizations are in favour of restrictions on the marketing to children. Recent public opinion polling from Heart and Stroke’s 2017 Report on the Health of Canadians highlights that 72% believe the food and beverage industry markets its products directly to children, 78% believe the food and beverages advertised to children are unhealthy and 70% feel that children are exposed to too much advertising by the food and beverage industry.
In her introduction of Bill S-228, Senator Raine noted that this is not the first time that that legislation on this issue has come before the Canadian Parliament. The CMA sincerely believes that now is the time for action. We cannot delay any longer. Canadian children and parents need an environment free from the influence of food and beverage marketing in which to make health nutritious food choices.
Childhood obesity and overweight are serious health problems in Canada, and as such are of great concern to the country’s physicians and to the Canadian Medical Association. The causes, CMA believes, are rooted mainly in changes in our environment and their effect on our eating and physical activity habits. The consequences are extremely serious, both for individual Canadians’ health and for the sustainability of Canada’s health care system.
CMA believes that the way forward requires a number of different interventions, on many levels. The prohibition of the marketing of foods and beverages directed to children is one element of a wider healthy eating strategy that supports Canadians.
Once again, CMA commends the Senate of Canada on conducting this study. We urge support of the Child Health Protection Act and believe that it can assist in creating a social environment that supports healthy eating and healthy weight.
1 Canadian Medical Association, Restricting Marketing Of Unhealthy Foods And Beverages To Children And Youth In Canada, A Canadian Health Care And Scientific Organization Consensus Policy Statement, December 2012
2 Heart & Stroke (2017). The kids are not alright. How the food and beverage industry is marketing our children and youth to death. 2017 Report on the Health of Canadians.
3 World Health Organization. Set of recommendations on the marketing of foods and non-alcoholic beverages to children. Geneva: World Health Organization, 2010.
4 The Ottawa Principles, Stop Marketing to Kids Coalition, accessed at https://foodsecurecanada.org/sites/foodsecurecanada.org/files/ottawaprinciples.pdf, June 7, 2017.
5 Heart & Stroke (2017). The kids are not alright. How the food and beverage industry is marketing our children and youth to death. 2017 Report on the Health of Canadians.
Canadians are living longer, healthier lives than ever before. This is due in large part to Canada’s health care system, the people working in it, research and medical school excellence, public and private investments and the many advances that have been made over the decades in medicine. However, the Canadian Medical Association (CMA) is deeply concerned that Canada’s health care system isn’t keeping up with the health care needs of older Canadians.
When publicly funded health care was created about 50 years ago, Canada’s population was just over 20 million and the average life expectancy was 71. Today, our population is over 30 million and the average life expectancy is 10 years longer. The aging of our population is both an immense success story and the most pressing policy imperative of our time.
Our submission and recommendations focus on seniors care. We believe the ability of our country to meet the health care needs of this segment of our population is indeed of such high priority that we have come to these consultations with this single issue in mind.
While daunting, the task ahead is by no means impossible and will ultimately result in numerous health and financial benefits. By providing the means to expand long-term care and home care capacity, the Government of Canada will improve health care for seniors and others, create new jobs and add billions of dollars annually to the Gross Domestic Product. Furtherbed demand will vary over this period, peaking in 2032 and beginning to decline thereafter. The five-year projection for beds is as follows:
Table 1: Projected shortage in long-term
care beds, 2017–2021
Number of additional
Year beds required
*Note: the figure for additional beds required in 2017 includes 8,420 beds’ worth of demand that is currently unmet, in the form of patients in alternate level of care beds in hospitals.
The Conference Board estimated the cost to construct 10,500 beds (the average number of new beds required per year from 2017 to 2035) at $3.4 billion per year and $63.7 billion in total, on the basis of a cost estimate of $320,000 per bed (all figures in 2017 dollars). These figures include both public and private spending. This forecast does not include the significant investments required to renovate and retrofit the existing stock of residential facilities.
The average number of new long-term care beds needed in Canada every year up to 2035 is 10,500. The Conference Board of Canada estimates the cost of this to be $3.4 billion per year, for a total public and private expenditure of $63.7 billion. This forecast does not include the investments needed to renovate and retrofit existing long-term care homes.
Construction of new residential care models and renovation/retrofitting of existing facilities will provide significant economic opportunities for many communities across Canada. The construction and maintenance of 10,500 new residential care beds will yield direct economic benefits that include a $1.4 billion annual average contribution to GDP supporting 14,600 jobs yearly during the capital investment phase and a $5.3 billion annual average contribution to GDP supporting an average of 58,300 jobs annually during the facility operation phase. By comparison, nursing homes and residential care facilities employed about 412,000 people in 2016. These investments would also close the significant gap between the projected residential care bed shortages and currently planned investment. When indirect economic contributions are included, the average estimated annual contribution to Canada’s GDP from the construction and operation of the new beds reaches $12.4 billion, supporting an average of 130,000 jobs annually between 2017 and 2035 (in construction, care provision and other sectors).
This bed projection provides a sense of the immense challenge Canada faces in addressing the needs of a vulnerable segment of its population of older seniors. A recent report by the Canadian Institute for Health Information indicated that residential care capacity will need to double over the next 20 years (assuming no change in how care is currently provided), necessitating a transformation in how seniors care is provided in Canada across the continuum of care.13
Efforts to de-hospitalize the system and deal with Canada’s aging population should be part of an overall national seniors strategy. Such a strategy was called for previously by the CMA, other organizations (e.g., the National Association of Federal Retirees), the Standing Senate Committee on National Finance14 and over 50,000 Canadians.15
Fixing seniors care will contribute to the renewal of the entire health system and will improve the productivity of health care delivery across the country. The differing fiscal capacities of the provinces in the current economic climate will mean that improvements in seniors care will advance at an uneven pace. The federal government can provide significant pan-Canadian assistance by investing in residential care infrastructure models.
# of jobs contributions
Capitalinvestment phase Operation phase 14,600 58,300 $1.4 billion $5.3 billion
With indirect contributions 130,000 $12.4 billion
The CMA recommends that the federal government provide targeted funding to support the development of a pan-Canadian seniors strategy to address the needs of the aging population.
The CMA recommends that the federal government include capital investment in residential care infrastructure, including retrofit and renovation, as part of its commitment to invest in social infrastructure.
Caregivers are the backbone of any care system. A 2012 Statistics Canada study found that 5.4 million Canadians provided care to a senior family member or friend. While this care was most often received by a senior in their own residence, 62% of caregivers said the care recipients lived in a home separate from the caregiver’s home.16 Age-related needs are the most common reason for care requirements.17 Caregivers are of all ages; for instance, 27% of caregivers were between the ages of 15 and 29 years.18 One study has forecast that the number of Canadians requiring care will double over the next 30 years.19
Work $5.5 in lost absence: productivity
Personal upwards of or more out-of-a yearpocket: $2,000
A Statistics Canada study found that 56% of caregivers living with the care recipient provided at least 10 hours of care a week. Approximately 22% of caregivers helping a resident in a care facility also provided at least 10 hours of care a week. The chief condition for which care was provided was dementia or Alzheimer’s disease (25%).16
The cost to employers in lost productivity because of caregiving-related absenteeism is estimated at $5.5 billion annually.20 Caregivers also report high out-of-pocket expenses. This is especially true for those living with the care recipient: over 25% spend at least $2,000 annually on out-of-pocket expenses.16
Caregivers require a range of supports including education/training, peer support, respite care and financial assistance. Canadians want governments to do more to help seniors and their family caregivers.21 The federal government’s new combined Canada Caregiver Credit (CCC) is a nonrefundable credit to individuals caring for dependent relatives with infirmities (including persons with disabilities). The CCC will be more accessible and will extend tax relief to more caregivers by including dependent relatives who do not live with their caregivers and by increasing the income threshold.
Notwithstanding these changes and the greater flexibility for caregivers to use Employment Insurance benefits, caregivers will require more support. The CMA recommends making the new CCC a refundable tax credit for caregivers whose tax owing is less than the total credit, resulting in a refund payment to provide further financial support for low-income families.
The CMA recommends that the federal government improve awareness of the new Canada Caregiver Credit and amend it to make it a refundable tax credit for caregivers.
The federal government’s commitment to provide $6 billion over 10 years to the provinces and territories for home care, including support for caregivers, is a welcomed step toward improving opportunities for seniors to remain in their homes. As with previous bilateral funding agreements, it will be important to establish clear operating principles between the parties to oversee the funding implementation including support for caregivers.
The CMA recommends that the federal government develop explicit operating principles for the home care funding that has been negotiated with the provinces and territories to recognize funding for caregivers and respite care as eligible areas of investment.
The federal government’s recent funding investment in home care and mental health is a recognition that Canada has under-invested in home and community-based care to date. Other countries have more supportive systems and programs in place — systems and programs that Canada should consider.
The CMA recommends the federal government convene an all-party parliamentary international study that includes stakeholders to examine the approaches taken to mitigate the inappropriate use of acute care for elderly persons and provide support for caregivers.
he CMA recognizes the federal government’s commitment to help Canadians be as productive as possible in their workplaces and in their communities. Implementing these recommendations as an integrated package is essential to stitching together the elements of community-based and residential care for seniors. In addition to making a meaningful contribution to meeting the future care needs of Canada’s aging population, these recommendations will mitigate the impacts of economic pressures on individuals as well as jurisdictions. The CMA would welcome the opportunity to provide further information and its rationale for each recommendation.
Simpson C. Code Gridlock: Why Canada needs a national seniors strategy. Address to the Canadian Club of Ottawa by Dr. Christopher Simpson, President, Canadian Medical Association; 2014 Nov. 18; Ottawa, Ontario. Available: https://www.cma.ca/En/Lists/Medias/Code_Gridlock_ final.pdf (accessed 2016 Sep 22).
Canadian Institute for Health Information. Seniors and alternate level of care: building on our knowledge. Ottawa: The Institute; 2012 Nov. Available: https://secure.cihi.ca/ free_products/ALC_AIB_EN.pdf (accessed 2016 Sep 22).
3 Access to Care, Cancer Care Ontario. Alternate level of care (ALC) [Prepared for the Ontario Hospital Association]. Toronto: Ontario Hospital Association (OHA); 2016 May.
4 McCloskey R, Jarrett P, Stewart C, et al. Alternate level of care patients in hospitals: What does dementia have to do with this? Can Geriatr J. 2014 Sep 5;17(3):88–94.
5 North East Local Health Integration Network. HOME First shifts care of seniors to HOME. LHINfo Minute, Northeastern Ontario Health Care Update. Sudbury: The Network; 2011. Cited by Home Care Ontario. Facts & figures - publicly funded home care. Hamilton: Home Care Ontario; 2017 Jun. Available: http://www. homecareontario.ca/home-care-services/facts-figures/ publiclyfundedhomecare (accessed 2016 Sep 22).
6 Sponagle J. Nunavut struggles to care for elders closer to home. CBC News. 2017 Jun 5. Available: http://www.cbc. ca/news/canada/north/nunavut-seniors-plan-1.4145757 (accessed 2017 Jun 30).
7 Health Quality Ontario. Wait times for long-term care homes. Toronto: Health Quality Ontario; 2017. Available: http://www.hqontario.ca/System-Performance/Long
Term-Care-Home-Performance/Wait-Times (accessed 2017 Jun 22).
8 Alzheimer Society Canada. The Canadian Alzheimer’s Disease and Dementia Partnership: a collective vision for a national dementia strategy for Canada. Toronto: Alzheimer Society Canada; undated. Available: http:// www.alzheimer.ca/~/media/Files/national/Advocacy/ CADDP_Strategic_Objectives_e.pdf (accessed 2016 Sep 22).
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