In recent weeks, I've written about the U.S. gluten-free tax deduction, pros and cons of the system, and a hypothetical example of how your average American gluten-free family might fare. But enough about us. Let's talk about them. This week I'm exploring how other countries have adopted different strategies to offset the gluten-free premium paid for specialty food products and the financial burden that sometimes entails.
Like the United States, Canada offers a gluten-free tax deduction for those diagnosed with celiac disease or gluten intolerance and thus on a gluten-free diet for official medical reasons. However, there are some important differences.
In the U.S., the gluten-free premium is lumped in with other eligible out of pocket medical expenses; once those aggregate expenses reach 7.5% of your adjusted gross income, you then become eligible to write off the excess.
Canada, on the other hand, has specific guidelines for the gluten-free tax deduction. As in the U.S. of A., you take the cost of the gluten-free specialty product, subtract the average cost of the conventional glutenous counterpart, and write off the difference. But unlike in the States, there doesn't appear to be a threshold you must reach before you can start taking the deduction. In Canada, eligible foods include the usual suspects—gluten-free bagels, breads, muffins, cereals—but they also include "intermediate items," naturally gluten-free ingredients such as rice flour and spices that someone with celiac disease uses to prepare gluten-free foods.
But things can also get complicated in the land of the maple leaf. For example, if several people consume the gluten-free food, only the costs related to the portion of the food consumed by the person with celiac disease are allowed to be written off for the medical tax credit. I can just imagine the potential headache this would cause for a mixed family, where some members are gluten-free because of celiac disease and some are gluten-free because the family eats all their meals together. Plus, unlike Italy (more on that in a moment), Canada doesn't allow you to write off the extra time it takes to find and prepare gluten-free foods.
Finally, Canada's record-keeping requirements are quite similar to the U.S.—a letter from a medical practitioner that notes both a) a celiac disease diagnosis and b) a gluten-free diet requirement as treatment; plus, keep all your receipts. In true Canadian subtlety and politeness, the Canada Revenue Agency notes that you should keep this supporting documentation not in the event of an audit, but rather "in case we ask to see them at a later date." Makes it sound so civil and non-threatening, doesn't it?
In the Republic of Ireland, gluten-free foods fall under what's known as a Drug Payment Scheme. (Makes the national government sound like a dealer, no?) According to the Health Service Executive, a national agency providing healthcare and social services for everyone living in the country, the Payment Scheme sets a maximum monthly out of pocket that an individual or family would pay for prescription drugs, other medicine, and even certain appliances used by that person and his or her family. As of December 31, 2012, that out of pocket limit was 144 Euros, or about $194 under current exchange rates.
The Coeliac Society of Ireland notes that gluten-free foods can be prescribed under this system. Typically, your general practitioner would prescribe specific gluten-free foods from a General Medical Services list. The list includes items such as bread, rolls, bread mixes and flour, pasta, breakfast cereals, pizza bases, and baking powder. You'd then pick up your prescribed gluten-free foods not at the supermarket, but rather at the pharmacy. (You could also buy other GF foods from other sources, though they wouldn't be covered under the prescription plan.)
Like its neighbor Ireland, the United Kingdom also offers gluten-free foods based on a prescription coverage plan. According to Coeliac UK, a major national nonprofit, your general practitioner would usually be the one to write the prescription, while your pharmacist would be the one to fill it. However, in some parts of the U.K., you can do one-stop-shopping through your pharmacist.
As for what gluten-free foods you can get on prescription, that comes via an approved list determined by the Advisory Committee on Borderline Substances. Man, if you thought gluten-free foods had a stigma in the U.S., how would you like them to be classified as a borderline substance? At any rate, the ACBS advises the U.K.'s Department of Health, and their list can be found in Coeliac UK's online Food and Drink Directory.
Now here's an interesting point: the quantity of GF food you can receive under prescription is largely determined by a recommended number of units per month. For example, 400 g of GF baguettes and 250 g GF pasta would each count as one unit. Your recommended number of allowable units varies by age, sex, and other factors, such as if you're pregnant or breastfeeding.
In Northern Ireland, Scotland, and Wales, the prescription is free. Yes, you read that correctly. In England, some individuals will qualify for free prescriptions, but most will have to pay. Under a typical scenario, you'd pay 7.65 Pounds for each line item on your prescription. If your gluten-free prescription included four line items (e.g. bread, pizza base, pasta, and crackers), you'd pay roughly 30 Pounds. However, England also offers pre-payment certificates (PPC). You pay, in advance, a set fee for either 3 months or 12 months worth of prescriptions, and the PPC covers all of your prescriptions for that period. The 3-month PPC costs 29.10 Pounds and the 12-month PPC costs 104 Pounds, or about $163. That's a great deal. Think about it—you pay a one-time fee of $163, and that covers 100% of your gluten-free food prescription for the year. Not bad.
Finally, to Coeliac UK's credit, they've established a strong position on the prescription plan. They believe that offering gluten-free food under a prescription plan is an essential national health service, but they also believe that gluten-free cake mixes and other similar foods shouldn't be covered under such plans, because they're not in line with healthy eating recommendations. In fact, to that end, less than two weeks ago the Express and Star ran a story about how the NHS prescription plan in Dudley was scaling back both the amount and range of its gluten-free offerings. It was part of an effort to trim some 1.4 million Pounds from the regional commission's budget (last year, they had spent about 200,000 Pounds on foods for celiac patients in their district), but when the commission looked for gluten-free foods to cut from the prescription plan, one of the first food categories to go was gluten-free cakes.
Of course, you'd still be able to buy them yourself out of pocket at the store, and an official for the commission even noted that gluten-free products purchased at retail stores were frequently cheaper than the unsubsidized cost of similar products that were part of a prescription plan.
And last, but not least, Italy, that supposed Shangri-La of gluten-free eating. Unlike many of its other European and North American counterparts, Italy doesn't go the route of a gluten-free tax deduction or gluten-free prescription food (though gluten-free foods are widely available at pharmacies, rather than markets). Instead, Italy provides a monthly stipend to offset the cost of gluten-free foods for those with celiac disease. The stipend varies by region, but sources I've seen note $184 per month and $200 per month.
(That's potentially up to $2,400 per year the government puts in your pocket to offset the cost of gluten-free foods, a value far exceeding any small tax relief you'd get in the U.S. from spending an equivalent amount of your own money on GF foods, then reducing your taxable income only by that amount which exceeds 7.5% of your AGI.)
Gluten-free foods eligible to be purchased with your stipend are found on a list maintained by the Ministero della Salute (Ministry of Health), and the Ministry has established standards for how a product earns gluten-free designation and inclusion on the list. From what I can gather with the help of Google Translate (my Italian isn't stellar, despite my Sicilian heritage) the stipend and other measures are implemented in conjunction with the regional chapters of the Italian Celiac Association.
In addition to the stipend, you're also awarded extra time off work each month to offset the time it takes to find and prepare your gluten-free food. (Is that really necessary?) Plus, schools, hospitals, and other public facilities must provide gluten-free food options.
Why is Italy so aggressive when it comes to such matters? Simple: the "standards for the protection of persons suffering from celiac disease," a comprehensive set of measures passed in 2005.
So what does this all mean?
On the one hand, nothing. I simply wanted to offer a detailed and comprehensive look at how countries other than the United States have addressed the issue of providing financial relief associated with the heightened costs incurred via gluten-free specialty foods. On that basic level, this look at Canada, Ireland, the U.K., and Italy is illuminating.
But on the other hand, I have a personal perspective to offer. I question whether giving people extra time off work to find and prepare gluten-free foods is really necessary. I applaud Coeliac UK for taking a stance and saying that certain gluten-free foods shouldn't be subsidized by the government because they're not compatible with a healthy diet.
Most importantly, however, I think that these various approaches have serious implications for how we think about our food, our condition (celiac disease or similar), and our health. When food is assigned to you via a prescription, and when you obtain that food from a pharmacy, it changes your relationship to food. I can't imagine that it doesn't. Food in some sense becomes a drug, an impersonal treatment. Instead of finding health through diet, you end up treating a disease through a healthcare system. While I think each country has taken laudable steps to meet the needs—financial and otherwise—of its medically gluten-free populations, it also partially makes me sad to see food treated in this way. But that's just me.
Given the spectrum of "solutions" and potential implications, what's your take? Are you happy with the U.S. approach? Would you prefer a tactic taken by one of the countries in these examples? Or would some other strategy offer a better resolution? Are you a reader from one of the countries I've highlighted in this blog post? If so, please share your experiences!