Bill C-64

Pharmacare Act

An Act respecting pharmacare

This enactment sets out the principles that the Minister of Health is to consider when working towards the implementation of national universal pharmacare and obliges the Minister to make payments, in certain circumstances, in relation to the coverage of certain prescription drugs and related products. It also sets out certain powers and obligations of the Minister — including in relation to the preparation of a list to inform the development of a national formulary and in relation to the development of a national bulk purchasing strategy — and requires the Minister to publish a pan-Canadian strategy regarding the appropriate use of prescription drugs and related products. Finally, it provides for the establishment of a committee of experts to make certain recommendations.

[John Adams]

We hear many concerns and criticisms of the version of the model proposed in Bill C-64, and I've heard additional criticisms from my fellow panellists today. We're hearing mixed messages about whether this is such a good idea or not, as proposed.

As the parent of two sons and two daughters, I care about sexual reproduction and sexual health all the way around. Also, as I used to be prediabetic and am no longer, I care about medicines for diabetes. The drug that turned me from a prediabetic into a non-diabetic is not on the list as proposed by the Minister of Health at the moment. Those are specific examples. There's a great deal of uncertainty.

Also, in previous government initiatives at the federal, provincial, territorial and indigenous levels, there have been unanticipated or unintended consequences. Therefore, you should make haste slowly. I think the bill is a useful start, but this legislation is in need of improvement and has many opportunities to be improved.

[Maxime Blanchette-Joncas, Bloc, Rimouski-Neigette—Témiscouata—Les Basques, QC]

Thank you, Mr. Adams.

I'm glad you acknowledged that distinction, which, as you know, goes beyond pharmacare. We could definitely conduct another study on that subject alone, but I'm not sure it would be in the Standing Committee on Health. But we'll have that discussion at a later date.

Mr. Adams, you say in your brief that no patients in Canada should lose the drug coverage they currently have with a private plan as a result of the reforms and programs under Bill C-64 and that the changes made must not leave patients in a worse situation than before the reforms were introduced.

Would you please explain your concerns to us?

[Yasir Naqvi, Liberal, Ottawa Centre, ON]

I want to come to Dr. Norman. Thank you for being here and bringing the perspective of Action Canada to this conversation.

On the same theme of cost savings in the health care system, can you talk about what kind of impact we can see from having universal access to contraceptives, which is contemplated in Bill C-64?

[Stephen Ellis, Conservative, Cumberland—Colchester, NS]

Thank you very much.

Dr. Morgan, I'll turn to you. The other thing is that often we've heard in the last couple of days testimony related to the length of time it takes a medication to get on formularies on behalf of Canadians, often thousands of days. We have Health Canada, PMPRB, CDA, CADTH and pCPA, etc. It would appear to me that it would also have been a good idea in this Bill C-64 to add some oversight of those agencies, specifically the newly formed CDA.

Do you think that would be of benefit here, or do you have some other ideas around the necessity to get drugs to market on behalf of Canadians?

[Stephen Ellis, Conservative, Cumberland—Colchester, NS]

Thank you for that.

Through you, Chair, to Dr. Gagnon, were you involved in the drafting of Bill C-64?

[Dr. Steven Morgan]

I was not directly involved in developing this piece of legislation or the bill at all.

I've worked with government and advised different people within the bureaucracy and government over many years, but I was not involved in drafting Bill C-64.

[Stephen Ellis, Conservative, Cumberland—Colchester, NS]

Thank you very much, Chair.

Thank you to everyone for being here.

It's certainly with interest that we'll pursue this next round of questioning.

I don't want to start a fight between Dr. Gagnon and Dr. Morgan, because your bios both say that you're Canada's leading expert in pharmacare systems. It's a good thing you're not both in the room. It might be interesting.

That being said, I'll start with you, Dr. Morgan.

You've written 150 papers about pharmacare and how to implement it. I'm interested to know how much consultative time you spent with the government on this Bill C-64.

[John Adams, Board Chair, Best Medicines Coalition]

Mr. Chair and health committee members, thank you for the invitation to be a witness at these historic hearings regarding pharmacare for Canadians.

Our Best Medicines Coalition represents 30 patient organizations, from Parkinson's, arthritis, hemophilia and blindness to cancers and other complicated and rare diseases. Together, we represent the interests of millions of patients and their caregivers.

I'm happy to have moral support from JK Harris of the Canadian Breast Cancer Network and one of our member organizations, who's here today. Thank you very much, JK, for being here.

BMC's aims are simple.

Number one is to fix the postal code lottery by ensuring all patients have access to the medically necessary medicines they need and ensure patients are meaningful participants in the development and oversight of pharmacare policies.

We at BMC recognize that Canada is the only developed nation with a universal health insurance system that does not include universal coverage for prescription drugs used outside of hospitals. This gap results in disparities within and among provinces, territories and indigenous jurisdictions where individual programs provide varying levels of drug coverage. This is what we call the postal code lottery.

As a result, one in 10 Canadians reportedly do not take their prescribed medications due to out-of-pocket costs. This highlights significant inequities in access to necessary medications. Up to 7.5 million citizens—one in five Canadians—don't have prescription drug insurance, have inadequate insurance to cover their medication needs or do not enrol when eligible.

Cost and coverage aren't the only problems.

Here's the bad news for anyone in the Ottawa bubble: Sixty-four per cent of Canadians believe that the federal government is not transparent enough about its health care policies. This lack of transparency erodes public trust and hinders the effective implementation and uptake of health initiatives.

Then there's data. Inconsistent reporting and lack of transparency in health data hinder the measurement of performance and outcomes, decrease opportunities for identifying gaps in data and services, and impede the capacity of the health system to integrate patient voices.

There's also a lack of representation of patient voices within governments and government-funded organizations in generating and implementing drug policy. One result is a health care system that is less responsive to patient needs. This can potentially compromise the quality of care and lead to a disconnect between patient expectations and the care provided.

In addition, existing complicated patient pathways cause significant stress and anxiety for patients and their caregivers, potentially exacerbating health conditions and leading to worse health outcomes. Thirty per cent of Canadians experience difficulties in navigating the existing health care system, leading to significant delays in receiving necessary medical attention. Changes in pharmacare must not create new barriers to innovations to address the unmet needs of patients.

The involvement of patients should be done with more than an expedited and truncated consultation on such a foundational expansion of the social safety net of Canadians. Patients should be built into the programs and the structure, not just with an occasional consultation. For example, patients—and that's plural—should be on the board of the Canadian drug agency.

We have eight friendly recommendations for amendments to the bill. I'm right at the clock, so if somebody could do us a courtesy, we'd love to have those eight submitted. They're in our written submission.

I want to highlight two key points of patient interests.

First, create a chief patient officer at Health Canada. Second, create a patient ombudsman who reports directly to Parliament. Only MPs and senators can make this ombudsman role come to life.

The chief patient officer at Health Canada would work within the organization. It should be someone with lived experience whose role gives them authority to ensure that the patient experience and expertise is recognized and used to drive reform and improve patient outcomes. This person should further be supported by an advisory committee with diverse patient representation, which this legislation doesn't quite contemplate yet.

The patient ombudsman would work outside the organization and report independently to Parliament. Besides reporting on any failures to uphold the act and regulations, this ombudsman would also assess barriers and concerns as expressed by patients when it comes to accessing medications and would recommend changes.

These amendments to Bill C-64 would enable and reinforce transparency and accountability. It's not enough for any government to say that they want universal access to medications. Bill C-64 should speak to the role patients must take in improving equitable access to medications.

With your questions, I'd be pleased to go into detail on all eight of the proposed amendments we suggest to better support patients.

The Best Medicines Coalition calls on Parliament to do its best for Canada's patients. On behalf of all patients, nothing about us without us.

Thank you.

[Dr. Wendy Norman]

Thank you.

I'll just say, then, that adolescents and people whose insurance is held by a parent or a coercive partner are in a particularly difficult situation and much less likely to access coverage if they need it.

There are few investments in health that have the potential to offer both health system savings and improved equity and health equity for children and families. Bill C-64 would support improved health for people throughout Canada.

I apologize, Mr. Chair, for going over the time.

[Dr. Wendy Norman, Public Health Agency of Canada Chair, Family Planning Research, Action Canada for Sexual Health and Rights]

Thank you, Honourable Mr. Chair and members of the committee. Thank you for the opportunity to speak today to your study of Bill C-64.

I am a family doctor and a UBC professor, and I have had the honour to serve for the past decade with the Public Health Agency of Canada as the chair for Canada for family planning research. I'm the co-chair on Statistics Canada's expert committee for sexual and reproductive health. I have worked with Health Canada to advance several of the programs within the sexual and reproductive health themes over these past several years, and as a long-time collaborator with Action Canada for Sexual Health and Rights.

There are two points I hope to bring expertise and experience to and highlight for you today. The first is that universal access to free contraception to prevent unintended pregnancy will support immediate, lifelong and intergenerational impacts for individuals and families, and society as a whole, that improve health and health equity throughout Canada.

Secondly, our modelling in Canada and examples in practice across the globe indicate that universal, comprehensive, single-payer, first-dollar coverage of contraception is required to address the needs of people at risk of unintended pregnancy. In Canada, 40% of pregnancies are unintended, and contrary to what you might expect, most unintended pregnancies result in unplanned births. The devastation of facing an unintended pregnancy and managing whatever outcome can have lifelong and intergenerational consequences not only for that pregnant person and their partner, but for the unplanned children and the children and other relatives already in the home.

The most comprehensive, most effective contraceptive methods have the highest upfront costs. The least expensive contraception has the highest rates of unintended pregnancy. In the case of longer-acting contraception, such as implants and intrauterine devices, which are our most effective methods, the cost can be over $400 up front. For many, this need for contraception conflicts with the money they need for rent or food. Due to their much higher effectiveness to prevent unintended pregnancy, however, those same “most expensive” methods have the lowest overall cost for government.

More effective contraceptive methods offer families a better and safer start for their planned and appropriately spaced children, while supporting family members to pursue advanced education, to better their opportunities, to contribute to the workforce and our economy, and to service their communities. In contrast, people unable to afford to manage their own fertility face lower educational achievements, lower household income and higher exposure to intimate partner violence. Their children, in turn, suffer lower rates of food safety, adequate shelter and graduation from high school.

Through a Canadian Institutes of Health Research-funded, UBC-led study from 2015 to 2019, the Government of B.C., Action Canada and a wide range of our collaborators modelled the cost effectiveness for prescription coverage in B.C. We found that among people who experienced unintended pregnancy and sought abortion, only about 30% had access to any form of subsidy for contraception, and the contraception cost was the factor most related to those subsequent unintended pregnancies.

For over two years, we worked with the B.C. government on variations of patchwork contraception coverage and compared them to comprehensive coverage through the modelling process. We looked at all kinds of models to address specific gaps. In every case, as soon as we moved from universal, comprehensive, first-dollar, single-payer systems, the rates of unintended pregnancy went up and the overall health system costs went up.

With a model of universal coverage, the B.C. government most effectively reduces unintended pregnancy while lowering overall health system costs by over five dollars for each resident of the province each year.

Evidence from health systems around the world indicate that a universal, first-payer prescription subsidy, rather than partial, fill-the-gap coverage is required to support health equity. Analysis after the institution of the U.S. Affordable Care Act determined a savings of over seven dollars for each dollar invested in contraception and contraception counselling. Similarly, Public Health England has found it's saving nine pounds for each pound it spends on universal prescription contraception.

An important factor here is that contraception is a stigmatized prescription. This is particularly true among equity-deserving populations and those in our society who face the most intersectional barriers. Our study found that reproductive-aged people, and particularly women at the ages of highest fertility, are the least likely to have stable, full-time jobs providing prescription benefits.

In fact, in analyzing the impact of the new B.C. policy for free contraception, we found that prior to its institution, 40% of those who bought contraception had to pay out of pocket completely, and another 20% had private coverage that required copayments. This isn't even looking at all of the people who weren't able to access contraception at all because of cost. Once B.C. implemented their policy, these out-of-pocket costs decreased to less than 10% of those accessing contraception.

We know that among those—

[Dr. Steven Morgan, Professor, School of Population and Public Health, University of British Columbia, As an Individual]

Thank you.

I'm an economist and professor of health care policy who has studied pharmacare systems for 30 years. I have published over 150 peer-reviewed research papers on related topics, and I serve on the World Health Organization's technical advisory group on pricing policies for medicines. I have no financial ties to commercial interests in this sector, and I have no have financial ties to health professionals, unions or other groups who also take an active interest in this file.

I am here simply because I wish to help Canada develop the institutional capacity necessary to fairly and efficiently provide access to necessary medicines in a very complex sector that involves some of the world's most powerful corporate interests and very serious, truly global challenges regarding the reasonableness and transparency of pricing.

I want to start by saying that we do not need another study of whether or how Canada should implement a national pharmacare program. These questions have been thoroughly investigated by four separate inquiries since the mid-1990s. All of these inquiries have recommended that carefully selected, medically necessary prescription drugs be included in Canada's universal single-payer public health insurance system.

The latest of these studies, the June 2019 report of the advisory council on the implementation of national pharmacare, was conducted by a council of experts from across the country and chaired by Ontario's former health minister, Dr. Eric Hoskins.

The Hoskins council, as it is known, consulted with provinces and territories. It consulted with first nations. It consulted with patients, health professionals and other stakeholders in the sector. It consulted with Canadians from coast to coast. It concluded with a detailed and feasible plan for implementing a universal single-payer public pharmacare program that would save Canadians billions of dollars every year while improving access to medicines from coast to coast and reducing strains on our health care system.

The foundations of Bill C-64 are backed by thorough discussion and analysis. I believe Bill C-64 can, if the government actually wishes to do so, move us toward the fair and efficient pharmacare system that has been recommended by commissions time and time again.

However, as it is written, Bill C-64 will not do this. This is because it does not make absolutely clear what type of pharmacare program the bill would establish. This ambiguity in Bill C-64 allowed the Parliamentary Budget Officer to conclude that the system that would be created would be a fill-the-gaps pharmacare system involving a patchwork of literally thousands of private and public drug plans. Indeed, even the Minister of Health testified yesterday that he would create such a program with the powers that Bill C-64 would give him.

This would be disastrous for Canada because patchwork pharmacare systems inject needless and costly inefficiencies into the system. They impose significant inequitable financial burdens on individual households and employers, they diminish a country's purchasing power on the global market for pharmaceuticals and they isolate the management of medicines from other key components of the health care system.

It would be especially problematic to have for-profit insurers involved in the core of a national pharmacare system. This is something that only the United States permits. It is problematic because insurers can actually profit from higher drug prices through higher administrative fees charged to plan sponsors. They can also profit by pocketing secret price rebates that they can and do negotiate with drug manufacturers and pharmacies.

If the first stage of national pharmacare is allowed to be a fill-the-gaps program involving a mix of private, public, for-profit and not-for-profit insurers, subsequent stages of national pharmacare will almost certainly be locked into that model too.

If, contrary to the recommendations of its own advisory council on the topic, the government wishes to implement a fill-the-gaps system, then it can leave Bill C-64 as it is, because that is what this legislation will deliver. In this case, the NDP should understand that their supply and confidence agreement has been broken.

If, on the other hand, the government does indeed wish to implement the recommendations of its own advisory council on this topic, then it must amend Bill C-64 to set out crystal clear standards for a national program that will prove that Canadians are, in fact, stronger together. That is what Canadians deserve, but as the bill is currently written, that is not what Bill C-64 will deliver.

Thank you.

[The Chair, Liberal, Sean Casey]

I call the meeting back to order and welcome our final panel of witnesses.

In accordance with our routine motion, I'm informing the committee that all remote participants have completed the required connection tests in advance of the meeting.

Joining us for this panel as individuals are Dr. Marc-André Gagnon, associate professor at the school of public policy and administration at Carleton University, and Dr. Steven Morgan, professor at the University of British Columbia, who is appearing by video conference. On behalf of Action Canada for Sexual Health and Rights is Dr. Wendy Norman, Public Health Agency of Canada chair of family planning and research. From the Best Medicines Coalition, John Adams is the board chair.

We're going to invite you to offer opening statements of five minutes in length.

Before we do, I will remind everyone that if they want to submit amendments for Bill C-64, the deadline is in 25 minutes, as was pointed out at the start of the meeting.

We're going to proceed now with opening statements in the order listed on the notice of meeting, so we're going to start with Dr. Gagnon for five minutes.

Welcome to the committee, Dr. Gagnon. You have the floor.

[Sonia Sidhu, Liberal, Brampton South, ON]

Thank you, Mr. Chair.

My question goes to JDRF.

Yesterday we heard from Heart and Stroke that more than 600 people in Canada die every year from ischemic heart disease because they cannot afford their medication. We also heard testimony from a type 1 diabetes patient, Mr. Bleskie, who said that insulin is not a luxury; it's a necessity. We also heard that they have to pay $1,600 a year per patient, so there is a lot of savings from this legislation.

Ms. Diniz, from our work on the framework, we know how important this legislation in front of us is to all patients and their families.

What are you hearing from the young type 1 diabetes patients and their parents? What expectations do they have from the committee when it comes to Bill C-64? Can you explain that?

[Brendan Hanley, Liberal, Yukon, YT]

I will quickly go to you, Mr. Williams.

You have a very interesting background from your experience with Innovation Canada, with Research Canada and with a political career.

I don't have time to go over the preamble but, in this bill, we talk about supporting modernization of the health care system with drug data and improving coordination. We talk about the national strategy for rare diseases.

Is there room for improving collaboration and innovation within the context of Bill C-64? Do you see that there is potential there?

[Brendan Hanley, Liberal, Yukon, YT]

Thank you.

Ms. Eagan, I was intrigued by your comment in your opening remarks about updating the Canada Health Act. Then you mentioned the importance of, for instance, coverage for outpatient cancer therapies. We know how big of an issue that is. Have you done any analysis on what it would actually take to update it? Can you tell me a bit more about what your vision is?

I know that's outside of the scope of Bill C-64, but I am intrigued.