Open letter requesting federal Minister of Health to revisit the Canada Health Act for mental health

VIA EMAIL: [email protected]

The Hon. Mark Holland, M.P., P.C.
Minister of Health
70 Colombine Driveway, Tunney’s Pasture, Floor 16
Ottawa, Ontario  K1A 0K9

Subject: Request to meet to address the exclusion of mental health and substance use health care services in Canada’s public universal health care system

Dear Minister Holland,

I write on behalf of the Canadian Mental Health Association (CMHA) and our listed partners to request a meeting to acknowledge the government’s efforts to date to enhance access to mental health and substance use health services and to discuss the exclusion of mental health and substance use health care services from Canada’s public universal health care system and remedies to address it.

BACKGROUND
The Government of Canada plays a critical role in setting national standards for accessibility, oversight, quality and equity in health care as demonstrated through the federal government’s creation of the national three-digit suicide prevention line (9-8-8), support for a National mental health and substance use health Standard Collaborative led by the Standards Council of Canada, the creation of the Mental Health Commission of Canada and Canadian Centre on Substance Use and Addiction, among other initiatives.

We acknowledge the steps the Government of Canada has taken, with the recent bilateral agreements, to boost the capacity of provinces and territories to provide and expand mental health and substance use health services. While welcome, these investments are not permanent, nor are they accompanied by legislation that transparently establishes accountability mechanisms for both funding and service quality or adequately addresses the adverse treatment that mental health and substance use health services receive under the current legislation. As a consequence, the time-limited bilateral agreements therefore continue to position this care outside the legislative framework of Medicare. The decision to fund mental health and substance use health care should not be “optional” or rest on the fiscal capacity of the provinces and territories.

THE ISSUE
Under the Canada Health Act, mental health and substance use health services are covered only if they are delivered by physicians or in hospitals and are considered “medically necessary” or “medically required”. Notwithstanding the stated objective of the Canada Health Act to provide universal and comprehensive health care to promote the physical and mental well-being of Canadians, the scope of the Act – particularly in its definitions of “insured services” and “comprehensiveness” – predominantly addresses physical health care needs and fails to effectively address mental health care and substance use health care needs. The result is that public coverage of mental health and substance use health services is relegated to discretionary, non-core status and is left either unaddressed or inadequately addressed on an optional basis by the provinces and territories or taken up by private entities, some of which require strengthened oversight and regulation.

In the absence of a requirement from the federal government to cover mental health and substance use health services, some jurisdictions offer certain insured services, while others do not. Services not covered can include counselling, psychotherapy, substance use and addictions treatments, eating disorder treatments, and treatment for PTSD, among others. The result is a systemic pattern of unequal access to mental health and substance use health care services for persons with mental health and/or substance use health needs.

We believe the federal government, under the Canadian Charter of Rights and Freedoms has an unmet obligation to ensure comprehensive and equitable access to effective mental health and substance use health services, subject to appropriate oversight, delivered outside of hospital settings and by providers beyond physicians, through the Canada Health Act. We contend that failure to do so represents violations of sections 7 and 15 of the Canadian Charter of Rights and Freedoms.

As stated in the Canada Health Act, mental health is, in principle, an important part of the standards we have set for “universal health care.” The Act states that the role of this legislative framework is “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.” Despite this commitment, a great deal of mental health and substance use health care in Canada is provided in non-physician community healthcare settings, which are not explicitly covered by the Act. This has created a patchwork approach to care and the existence of private for-profit programming.

THE CONSEQUENCES
Provincially or territorially funded mental health and substance use health programs almost all have limited spaces and long waitlists. Categorizing these areas of care as non-medically necessary means they are underfunded, with Canadians receiving inadequate care, delayed care, or no care at all, unless they can pay for it out of pocket or through limited private/employer-based insurance plans. When people cannot afford to pay, they are less likely to receive the care they need, which negatively affects their life and security of the person. Canadians least likely to be able to afford to pay out of pocket, or have access to benefits, experience the highest prevalence of mental health concerns.

Without access to appropriate, high-quality, voluntary care that is available on-demand at the onset of symptoms, people at risk end up in crisis, often making hospitals and other emergency responses their only recourse. This places extreme pressure on the acute care system. Hospitals may be unable to provide effective referrals for out-of-hospital recovery or offer follow-up supports. It results in long waits times, poor health outcomes, morbidity and mortality, as well as reduced access to care for disadvantaged populations. It has also resulted in the overrepresentation of people with mental illnesses and substance use health problems within the criminal justice system, in shelters or relegated to the street.

The absence of federal legislation enshrining mental health and substance use health services in Medicare has created a structural barrier that discourages and systemically prevents the delivery of comprehensive, consistent, and equal coverage of mental health and substance use health services across provincial and territorial health insurance plans. It is also a major contributor to the current mental health, toxic drug, and homelessness crises in Canada. Moreover, a mentally healthy population is more productive and requires less health care spending.

PROPOSED SOLUTIONS
The federal government has the responsibility and capacity to transform the mental health system. When it comes to mental health and substance use health, it would simply be inaccurate to call our health system universal, or comprehensive. It’s true there is mental health and substance use health care available, but not on “uniform terms and conditions” as provided for under the CHA. Only some Canadians will have access to it. Canada has failed to put in place a federal legal framework providing mental health and substance use health care equal to physical health care.

To address this anachronism we are requesting that your government either amend the Canada Health Act to explicitly include community-based mental health and substance use health care services subject to adequate oversight, accompanied by adequate earmarked increase to the Canada Health Transfer, or, create parallel mental health and substance use health care legislation that includes robust funding and accountability measures and, at a minimum, adherence to the principles of public administration, comprehensiveness, universality, portability, and accessibility.

Acting on either option would foster mental health and substance use health equity across our country.  

We would appreciate the opportunity to meet to discuss the points raised in this letter and are open to a joint meeting with relevant ministers and representatives from the partner organizations signatory to this letter.

Sincerely,

Margaret Eaton
National CEO, Canadian Mental Health Association
[email protected]

On behalf of the following signatories:

• Anthony Esposti, CEO, CAPSA
• Dr. C. Tess Sheldon, MSc, JD, LLM, PhD, Assistant Professor, University of Windsor │ Faculty of Law
• Professor (Dr) Kwame McKenzie, CEO Wellesley Institute, Professor of Psychiatry University of Toronto, Director of Health Equity CAMH
• Pam Hrick, Executive Director & General Counsel, Women’s Legal Education and Action Fund (LEAF)
• Dr. Lisa Votta-Bleeker, Chief Executive Officer, Canadian Psychological Association
• Sean Krausert, Executive Director, Canadian Association for Suicide Prevention 
• Michelle D’Amico, Executive Director, National Initiative for Eating Disorders.
• Allison Dunning, Executive Director, Peer Support Canada
• Ian Culbert, Executive Director, Canadian Public Health Association
• Frédérique Chabot, Executive Director, Action Canada for Sexual Health and Rights
• Patricia Tomasi, Executive Director, Canadian Perinatal Mental Health Collaborative
• Abrar Mechmechia, CEO & Founder of ABRAR Trauma and Mental Health Services 
• Shauna Cronin, Founder, Frayme
• Hélène Sabourin, CEO, Canadian Association of Occupational Therapists
• Paul-Emile Cloutier, President and CEO, HealthCareCAN
• Canadian Council of Muslim Women (CCMW)
• Dr. Hygiea Casiano, President, Canadian Psychiatric Association
• Nicola Otter, Executive Director, Canadian Consortium for Early Intervention in Psychosis
• Dr. AnnMarie Churchill, President and Lead Executive Officer, Stepped Care Solutions

c.c. The Hon. Ya’ara Saks, Minister of Mental Health and Addictions
[email protected]

c.c. The Hon. Arif Virani, Minister of Justice and Attorney General of Canada
[email protected]

c.c. Eric Costen, Acting Deputy Minister, Health Canada
[email protected]