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Huge corporations, contracted by government, manage health systems, sell drugs and medical supplies, run IT systems and collect valuable, strategic data for marketing. As an example, a large American company provides multiple services in Nova Scotia. Its global annual revenues are $122 billion. That dwarfs the total expenditure of all Nova Scotia government departments, which is just over $8 billion.

DoctorsNovaScotia, where are you? Stop endlessly negotiating physician contracts. Step up and lead.

People respect their doctors, or at least they used to. It’s time to dump the dinosaurs, admit you need to work with other professions and act like you believe in patient-centred care.

For more information on the SDOH, please see http://www.thecanadianfacts.org/ with references by Juha Mikkonen and Dennis Raphael and also resources at http://www.thinkupstream.net/ directed by Ryan Meili.

The government's proposal will be tabled in "coming weeks," she said, adding "there are many elements that need to be considered as we work to achieve the best possible solution for Canada on this highly sensitive and complex issue." The Supreme Court of Canada struck down the Criminal Code ban on doctor-assisted death in February, 2015, and suspended the ruling's effect for one year.

Both ideas were promoted by a recent parliamentary committee into the matter, which will influence the government's coming legislation. "Our government is committed to developing an approach that strikes the best balance among a range of interests, including personal autonomy, access to health-care services, and the protection of vulnerable persons," said Joanne Ghiz, a spokeswoman for Justice Minister Jody Wilson-Raybould.

The poll of 1,000 adult Canadians found an overall disagreement with the idea of giving access to doctor-assisted dying to people suffering from mental illness or psychiatric conditions. The proposal was opposed by 51.8 per cent of respondents, while 42.4 per cent of respondents agreed with it. The opposition was even greater to granting access to assisted dying to 16- and 17-year-olds. The proposal was opposed by 58.8 per cent of respondents, while it was supported by 36.2 per cent of respondents.

The Trudeau government asked for an extension after last year's election, and must now bring in a law by June 6. In February, a committee of MPs and senators recommended to provide assisted dying to Canadians suffering from both terminal and non-terminal medical conditions that cause enduring and intolerable suffering. More controversially, the committee opened the door to assisted dying for youth under 18, calling on the government to address the issue of "mature minors" within three years of the initial law. The committee added that patients with mental illnesses or psychiatric conditions should not be excluded from eligibility as long as they are competent and meet the other criteria set out in law.

The Conservative MPs on the committee argued the proposals went too far at the time, and now feel vindicated by the poll's findings. Conservative MP Gerard Deltell said his group followed the example of Quebec where the government, after six years of consultations and studies, opted to restrict the right to doctorassisted dying to consenting adults. "The issues of minors and people with mental illnesses raise major problems," Mr. Deltell said in an interview. "At what point does someone suffering from a mental illness offer his or her full and complete consent? It's impossible. ... Same thing for minors."

Still, committee chair and Liberal MP Robert Oliphant said the proposals included "huge safeguards" to prevent any abuse against vulnerable persons who do not want to die. He added that on minors and people with psychological issues, the committee wanted to avoid setting arbitrary criteria and decided to leave clear powers in the hands of doctors. "Will two physicians confirm competency, that the person has capacity, and that the illness is irremediable and grievous, and that the suffering is intolerable to the individual?" Mr. Oliphant said in an interview. "We felt that was the appropriate way to go." The poll also found that 75 per cent of Canadians agreed that doctors "should be able to opt out of offering assisted dying," compared with 21 per cent who disagreed.

The Nanos Research random survey, conducted by telephone and online between March 31 and April 4, offers a margin of error of plus or minus 3.1 percentage points, 19 times out of 20.

But John Frank, a Canadian physician who is now chairman of public health research and policy at the University of Edinburgh, argues in his report that more private health care "would be expected to adversely affect Canadian society as a whole."

"Anything like a user fee is a barrier to people being able to receive medically necessary care and

Philpott said one of the misconceptions about the future of health care is that demographics - a silver tsunami related to an aging population - is going to bankrupt government coffers. While she acknowledged that seven per cent of $1,000-a-day hospital beds are taken up by seniors and 14 per cent of beds are occupied by patients who should be in alternate levels of care, Philpott threw cold water on the "doom and gloom" forecasts that an aging population means "massive infusions of cash" are needed to sustain public health care. Sticking to the federal government's commitment to inject another $3 million over four years into home care, she noted it's not only cost effective but preferred by patients and their families.

Federal health minister Jane Philpott said Tuesday a national pharmacare program is likely years away because of more pressing priorities like primary care, improved health for indigenous people, better care for those with mental illness, and more home care for seniors. "I do not want to promise anything I don't know I can deliver on," she told about 600 delegates and observers at the annual Canadian Medical Association meeting in Vancouver.

The reality is I don't know how this is going to end up. A lot of this will come down to basic principles of fairness." While Canada spends more per capita than many other countries, Philpott said she's concerned about international rating systems that show Canada gets poorer outcomes compared to countries such as Australia, the United Kingdom, France and Germany. During a press scrum, a journalist noted that all those other countries have parallel public/private systems. But Philpott insisted the federal government is only interested in how those other countries deliver care within the publicly funded realm. "Our government is firmly committed to upholding the Canada Health Act. That act has principles around accessibility and universality and it means Canadians have access to care based on need, not on ability to pay," she said. "You cannot have a growing, thriving middle class unless you have a publicly funded universal health care system."

Philpott attempted to dissuade doctors of the notion that the federal role is merely to transfer money to the provinces ($36 billion this year), maintaining that the government and "this minister of health" is determined to be engaged in health system transformation. The provinces have begun the slow process of negotiations with the federal government on a renewal of the Canada Health Accord to be signed sometime next year. But some health ministers have complained that the feds have given no indication about how much money they can expect. It's been more than a decade since the provinces and the federal government negotiated transfer payments and Philpott said that while the last round led to improvements like shorter waiting times in some surgical areas, "it did not buy change. So we should use this opportunity to trigger innovation."

Philpott said real change will incorporate digital health records and the banishment of anachronisms like fax machines. Patients should be seamlessly connected, in real time, to their health care providers, hospital, home care, pharmacy and lab. "What is it going to take to get there? Pragmatism, persistence and partnership. Changes require courage and practicality." Doctors gave her enthusiastic applause for stating that low socioeconomic status represents one of the greatest barriers to good health and "that is why this government believes that the economy and jobs and a stronger middle class will reduce social inequity." She said in 2016, the federal government has earmarked $8.4 billion in spending on social and economic conditions for indigenous communities. Earlier Tuesday, on the second day of the three-day annual meeting, doctors passed numerous motions that will now go to their board for further discussion before becoming official policy.

Delegates passed a motion introduced by Ontario doctor Stephen Singh of the Canadian Society of Palliative Care Physicians that aims to distinguish between palliative care ("neither to hasten or postpone death") and medical assistance in dying. Most palliative care doctors don't want to serve as gatekeepers to doctor-assisted dying, but they do want to consult with patients who have life-limiting illnesses in order to help mitigate their suffering.

The intervenor coalition includes Canadian Doctors for Medicare, Friends of BC Medicare, Glyn Townson, who has AIDS, Thomas McGregor, who has muscular dystrophy, and family physicians Dr. Duncan Etches and Dr. Robert Woollard, both professors at the University of British Columbia. A second intervenor group representing four patients also warned that the Charter challenge would lead to an inequitable health system across Canada. “This case is indeed about the future of the public health care system, in its ideal and actual forms,” said the group’s lawyer Marjorie Brown, according to a report in The Globe and Mail. Cambie and its co-plaintiffs, who made their opening argument last week, say the BC law barring extra billing, so-called dual or blended practices and the use of private insurance for publicly covered services violates Sections 7 and 15 of the Canadian Charter of Rights and Freedoms.

A successful Charter challenge in BC would mean an inequitable health system, where those who can pay get priority service, states an intervenor coalition.

Moreover, they claim the prohibitions exacerbate the under-funded public system’s problems, especially waiting lists for various treatments and surgeries. Allowing a “hybrid” system would relieve the strain. The coalition brief, echoing the BC government’s lengthy opening argument, said there’s no evidence that creating a two-tier system would reduce wait times. But there is a risk of hollowing out the public system as resources migrate to the more lucrative private alternative. Those who couldn’t afford private insurance could still find themselves waiting for treatment, thus undermining the principles of universality and equity spelled out in the Canada Health Act, Latimer said in her submission. Latimer also questioned whether the legislation falls within the scope of the Charter, more often invoked to overturn criminal laws, not those with socio-economic objectives.

“This legislation is intended to protect the right to life and security of the person of all British Columbians, including the vulnerable and silent rights-holders whose equal access to quality health care depends upon the challenged protections,” Latimer stated. There’s also a risk of sapping the public system of not only doctors but nurses, lab technicians, administrators and others drawn to the more lucrative private market, the brief said. Dual practices could also foster “cream-skimming,” where private clinics handle simpler but profitable procedures, leaving complex cases to the public system. The British Columbia Anesthesiologists’ Society, intervening to support the challenge, will be making arguments later in the trial, which is due to last at least until February 2017. The federal government is expected to begin making arguments in several months.