Use the Health Insurance Card to pay for food (adapted from TFPC, 1997)
Building on a concept first developed by Brewster Kneen, the Toronto Food Policy Council proposed that our publicly-funded health insurance program should pay for food as part of a health promotion strategy. Although some provinces (cf., Manitoba, New Brunswick), provide benefits for low-income pregnant women, this proposal directly links population health risks to food acquisition. With estimates provided by epidemiologists from Toronto Public Health, it became clear that a program for pregnant and lactating women would pay for itself in saved expenses associated with Low Birthweight Births (LBW). Given the number of diseases and conditions that have food as a significant risk factor, it may be that a population-wide scenario would produce even greater savings, but that modelling has yet to be done. Equally possible is that the redesign of our food system would be improving population health to such a significant degree that this intervention could remain strategically targeted to vulnerable populations and specific diseases/conditions. The LBW case is quickly summarized here.
The LBW prevention scenario
Basic vegetables and fruits, some dairy products, or meat alternatives would be purchased from all food distribution outlets with the health card. The costs are paid from the health care budget. Each individual has a total/month that can be debited to the system.
What would the criteria for eligible basic commodities be?
- servings from each of the main food groupings as defined by the Canada Food Guide
- food selection weighted towards those items that the mothers typically under consume (e.g., whole grains, fruits, vegetables)
- food selection weighted against those things that people typically overconsume (e.g., fat, sugar, salt, animal product)
- focus mostly on products that are produced in province (recognizing that they are not necessarily available all year round), except if it particularly compromises access to culturally appropriate foods
- focus on nutrient-dense foods to ensure maximum nutritional return for dollars invested
- respecting cultural diversity
- respecting some degrees of choice by providing options within categories
The program should provide 25% of daily serving requirements from each of the main food groupings (as defined by the Canada Food Guide). Monthly volume/weight and cost allocations would be based on: 25%/day x days per month x monthly average prices.
Examples of foods that could be part of the program:
- Complex carbohydrates: rice, potatoes, sweet potatoes, ground provisions, whole grain cereals, breads, and pastas
- Vegetables: carrots, squash, beets, brassicas, red/orange peppers, bok choy, okra, callaloo, bitter melon
- Fruits: apples, pears, peaches, cherries, melons, local berries
- Protein: beans, tofu, seeds, nuts
- Dairy: yoghurt, milk, cheese including ripe cheeses, kefir, cottage cheese
The provincial health insurance card would be encoded to act like a debit card. Health professionals would verify pregnancy and lactation and the time period would be encoded on the card. As people purchase, costs of eligible foods are subtracted from the amount allocated. Stores keep totals and submit them to the province for reimbursement, under the authority of the health care practitioner that authorized the dietary intervention. The program would be designed to minimize negative effects on cash flow and smaller and independent operations. Arrangements would also be made for non-supermarket distribution systems (e.g., buying clubs, box schemes, community-supported agriculture projects, farmers' markets).
If successful, this approach could be extended to other conditions and diseases with a very clear diet-related influence.
Provinces will need to create new regulations under their health insurance legislation and regulations to make this viable. For example, in Ontario, under the Health Insurance Act, and associated regulations, providing food in this way would have to be identified as an insured service. The practitioner would be identifying the eligible food retail locations as payees under the regulations and the foods covered and reimbursement ranges would be specified. The regulations might need to create a schedule of eligible food retailers as well.
Interestingly, a large Missouri food bank has run a pilot with similar parameters for 100 women, providing food boxes and meal kits of healthy foods. They found reductions in LBW from 16.3 / 100 births to 11.0 and savings of US$190,000 across the pilot. Applied to the Medicaid population of St. Louis, health care savings were projected to amount to US$5.3 million. Their hope, if a full randomized controlled study starting next year confirms these types of results, is that private and public health insurers will pay for food for food insecure pregnant women to avoid having to pay LBW health care costs later (Food Bank News, 2020).
Change the Canada Health Act to the Canada Health Promotion Act (adapted from TFPC, 1997)
A brief history
Historically, since the constitution names hospital as provincial jurisdiction, health care was viewed as primarily provincial responsibility and it took some time for the federal government to participate more fully. In 1944, the CCF government of Saskatchewan implemented public insurance coverage for hospital care. Partly in response, the Federal government began contributing in 1948 to the building of hospitals through the National Health Grant Program. They built on this, from 1957, through the Hospital Insurance and Diagnostic Services Act which paid the provinces half the costs of medical treatments performed within hospitals. This had the unfortunate effect in many communities of making the hospital the centre of health care delivery because alternative services or those performed outside of the hospital were not covered by public insurance. Equally unfortunate, even as the Saskatchewan government and regional health authorities were attempting to implement phase II of the Douglas vision (health promotion, group practice, service coordination, participatory governance), the federal government was reluctant to support that phase. The end result essentially was a publicly funded sick care system that has only slowly evolved toward the Douglas vision.
In the 1960s and 70s, the Federal government was increasingly concerned about its 50/50 funding agreement with the provinces. In 1974, it released the Lalonde Report - A New Perspective on the Health of Canadians: A Working Document - designed to redefine the "medical orientation" of the system and move back toward the need for phase II. Unfortunately, rather than tackling reform of health care delivery and health promotion, the government focused primarily on the financial aspects and in 1977 introduced Established Program Financing (EPF), designed to contribute financially to the previously established programs of Healthcare, Higher Education, and Social Services; and to act as a replacement for program funding for Hospitalization (1958), Medical Care (1966), and Post Secondary Education (1967). The provinces were paid lump sums that were no longer tied to the "actual costs" of the system and these monies were distributed as provinces deemed necessary.
The Canada Health Act of 1984 (CHA) outlined a new and controversial role for the Federal government. It provided transfer grants on the condition that provinces meet national standards.
- cover all medically necessary services
- provide uniform access to at least 95% of the population
- be administered by a non-profit agency answerable to the provincial Ministry of Health
- provide services to out-of-province Canadians
- provide reasonable access to health services regardless of financial circumstances
The Act was designed on the Federal government's vision of a universal, nationally based program financed by both levels of government. But the Federal government has slowly reduced the proportion of its payments and transfers to the provinces. In turn, the provinces have taken dollars from education and social services to finance rising health care costs.
Many of the problems with the dominant model foreseen by the Lalonde Report have become glaringly evident. The report, although having numerous weaknesses regarding social determinants, predicted that Medicare growth rates would exceed economic growth; a mal-distribution of services in rural and urban areas; a lack of regional healthcare initiatives. Although the recommendations regarding policy development and implementation have essentially been ignored, the World Health Organization (WHO) adopted the spirit of the Lalonde Report in 1977 when it redefined health as "a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity". Subsequently, this vision of health found its way into many provincial and federal reports and commissions.
A Canada Health Promotion Act
Although health care policy is designed to "protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers." (Article 3, CHA), the purposes of the current CHA are more narrow: "to establish criteria and conditions in respect of insured health services and extended health care services provided under provincial law that must be met before a full cash contribution may be made" (Article 4, CHA).
To reflect the wider purpose of Canadian health care policy, many articles need to be modified to include health promotion activities and practitioners in the funding mechanisms. See Instruments, Legislation, Federal for details.
Create a Canada Food Act
Given some of the jurisdictional parallels between health and food in Canada, a comparable Act could be adopted that sets out the criteria for participation of all food system actors in the change process and the rules for federal allocation of funding. At this stage in the transition, the federal government will be transferring resources to the provinces at significant levels, and assuring compliance with national requirements will be important.
Equally significant, at this stage, food will be viewed as a strategic resource, somewhat comparable to the way the airwaves are currently perceived. The Canada Food Act will therefore adapt elements from the Broadcasting Act that support its position as a public good with widespread domestic control. The Broadcasting Act provides authority for significant Canadian control of the broadcasting system, Canadian content rules, supervision of the mix of public, private, and community actors in the system, flexibility for regional and demographic requirements, assurance of national coverage, and cost-effective delivery. The Act also creates public institutions to deliver on broadcasting policy.
Thus, elements of both existing Acts are incorporated in the Canada Food Act. Details of the Act are provided in Instruments, Legislation, Federal.