I will continue, Mr. Chair.
My name is Marie-Claude Prémont. I am a full professor at the École nationale d'administration publique in Montreal, where I teach health and social services law, among other things.
I would like to thank the committee for inviting me to appear. I am pleased to tell you about Quebec's pharmacare system.
As the federal government is analyzing, through your great services, the issue of drug coverage across Canada, it might be tempting to follow the example of a province. That is what the federal government did in the late 1950s. It followed Saskatchewan's example and implemented the hospital insurance plan. Quebec has set an example that might appear innovative and inspiring to people.
Let me tell you right away that my primary goal today is to explain why I don't think Quebec's system is an example that should be followed. On the contrary, I would like to warn you about Quebec's type of system, which has been in force since 1997. Next year, it will have been in place for 20 years. Let's start by understanding the principles of the system.
First, it is important to understand that, when pharmacare was introduced in Quebec, a fundamental paradigm shift took place. Canada and all the provinces operate according to the logic of a universal hospital insurance and medical insurance system, whereas Quebec's pharmacare is a general, not universal, system, although everyone is covered. This is not a marginal distinction, but rather a fundamental one.
Let me explain. With a universal system, the primary insurance is public and everyone is covered in the same way. With a universal health care system such as the one in place right now, private insurance is prohibited. That is the case in Canada for 90% of people, who are covered under provincial legislation that provides for a plan forbidding private insurance.
With Quebec's pharmacare, unlike health insurance, private insurance has privileged markets, while public insurance is stuck with the least profitable and most challenging markets. So, in Quebec's system, it is private insurance that gets the first pick in terms of pharmacare.
Steven told us about the patchwork concept. Danielle reiterated that, right now, we are dealing with a patchwork system across Canada. Actually, Quebec's system is just setting in stone this patchwork of plans. That's the best description for Quebec's system: it is a patchwork of plans.
On the one side, there is a public system for the most vulnerable—seniors and the unemployed—and on the other hand, there is a multitude of private group plans that are provided by employers or associations. Let me repeat: Quebec's system has only further set in stone what was there before. It has then tried to plug the holes to ensure that the entire population is covered.
I will not dwell on the basic principles and terms and conditions, but I will instead draw your attention to the fact that, in Quebec's system, the premiums of private insurance companies are not regulated. In the past 20 years, we have seen a gradual increase in private sector premiums to the extent that more and more people are leaving the private plans to seek refuge in the public system, which is heavily subsidized.
Only the public part of the system is regulated, because people could not afford what the system truly costs without substantial subsidies.
Quebec's system has four major features.
The first feature is that the system operates on a systemic triage of risks. This means that good risks go to the private companies, which represent those who work. Those private plans cover 57% of Quebec's people. Conversely, the bad risks go to the public sector. We are talking about seniors or the disadvantaged, meaning 3.5 million people. This logic recognizes a role for the public sector in terms of social assistance. This is a residual logic in the sense that the public sector is there just to take care of the most disadvantaged. That is truly the fundamental feature of Quebec's system.
The second feature has to do with funding. We are seeing the funding being moved away from the tax system. This means that, instead of being funded by taxes, as is the case for medicare, the funding structure basically emulates the way the private insurance industry does things. There is a premium, a deductible and co-insurance. Furthermore, this mimicking of private insurance funding is a complete illusion.
When the public portion was put in place, we were told that the plan was going to be self-funded. However, as we can see—I checked the latest numbers from RAMQ—the contributions, made up of deductibles and co-insurance for the public portion, don't even cover 20% of the plan. That's why huge subsidies must be invested for the system to work. In terms of the private portion of the system, there is no relationship between the contribution made to the private plan and people's income. So the plan operates completely removed from the tax system.
The third feature is that tax tools that normally belong to public authorities have been made available to the private insurance sector. We are talking about mandatory insurance for clients and patients whose employer provides the service. We are talking about source deductions, like income tax, which are then forwarded to the insurance sector. Then, private insurers have the advantage of covering only group plans. As soon as an individual does not have access to a group plan, they must obtain insurance from RAMQ, the public system.
The fourth feature of the system—the last but not the least—is that the role of public authorities is completely overlooked, because the social solidarity between segments of the population has been completely dismantled. The system is not forward-looking, contrary to what people may think and contrary to what a public insurance system should be. People who contribute to a private system their entire lives receive no warning when they are removed from the system and are insured by public insurance as soon as they turn 65 years old. There is no inter-funding between the private and public portions of the system, and the coverage terms and conditions vary a great deal between the public and the private portions.
Quebec's general system is therefore a dead end, and this blocks any reforms, even if the costs have been pointed out on a number of occasions in Quebec.
Thank you.