Finance Committee on May 17th, 2017

[Dave Gallson]

I think you hit it right on the head when you said that one size does not fit all. Mental illness is like a physical illness: the way it impacts me and the way it impacts you could be two different things, and we might need different medications.

One challenge we have seen is that there are new medications coming on the market that are much more effective for certain people. Public health care systems right now do not fund those medications. There is, then, a challenge out there.

Take a look at it from an employer's perspective. If you have an opportunity to assist your employee to get well faster and return to work, it's a win-win for everybody. Sometimes there are additional costs up front, but you always recoup them at the end of the day. From our perspective, it's very important that if a person comes forward with a mental health issue, they should get the best medication that is suitable for them at the earliest possible time.

That being said, there are many Canadians who don't have health care benefits, who don't have drug coverage that covers medications, and that is a challenge. There are many low-income people in Canada who are struggling to purchase their medications. We have medications that cost hundreds of dollars a month; we have medications that cost $2,000 a month. It's a big challenge for people.

[Jennifer O'Connell, Liberal, Pickering—Uxbridge, ON]

Thank you so much.

Mr. Bedard, you mentioned the $20 million for the centre of excellence and your concern with regard to its direction towards research rather than towards a physical space. Is that concern based on something you saw in this actual budget, or on conversations elsewhere, or on what's being reported?

I understand, and I think the chair also pointed out, that we're in a difficult position in terms of.... I think much of what you and Mr. Campbell both spoke about was those details and what comes next. But with regard to the centre of excellence, where are your concerns coming from? Are they specifically related to background in this budget or to those additional conversations?

[Aaron Bedard]

Well, I am an adviser on the Mental Health Advisory Group and did get to have a closer look at what was being proposed. It's a bit of a grey area, and it's not very well-defined.

I need to see it going towards physical bodies entering programs. There are existing programs right now that are designed with a low budget, such as the veterans transition program and the COPE program, as examples. The latter is a couples program, and the other a one-on-one program working in a peer group environment program. VTN has been around for 17 years now. It's a program that I've put dozens if not hundreds of people through, as a guy going out and finding the troops.

Money for this was included in the veterans platform for the election, costed specifically for physical bodies to get into a physical program. If the experts at large in Ottawa who have helped get this to look more like something that's going to go towards research....

This needs to go to bodies. That was the intent. I don't know how often you have someone come in here who actually is the person who got something put into an election platform promise, but here I am.

[Jennifer O'Connell, Liberal, Pickering—Uxbridge, ON]

Thank you very much.

[The Chair, Liberal, Wayne Easter]

My apologies to you both; we're going to cut it there.

Mr. Brassard.

[John Brassard, Conservative, Barrie—Innisfil, ON]

Thank you, Mr. Chair, and thank you for the opportunity to address the witnesses.

I'm going to get right into it. Obviously pensions is an issue. The Equitas Society is still fighting the pension problem. Concerning the option for pensions, in this budget there is no timeline for the government's commitment to return an option....

They're talking about an option. The Prime Minister never spoke about an option. Would you agree with that?

[Mark Campbell]

I'd agree that my understanding of the Prime Minister's promise—what we call the sacred obligation—was a return to lifelong pensions. There's only one lifelong pension to return to, and that is the former Pension Act.

[John Brassard, Conservative, Barrie—Innisfil, ON]

Is that clear among the veteran community as well?

[Mark Campbell]

No, the veteran community is extremely concerned, and I'm extremely concerned, that what in fact is going to happen will make no sense, namely, taking the trial balloon that has been floated, the idea of taking the pain-and-suffering lump sum—which is a distinct pillar, separate and apart from financial security for life—and trying to turn that lump sum that was specific to the pain and suffering into some form of amortized pension. It would be hundreds of dollars a month. That's not something you can live on, and it does not provide financial security for life, as income replacement in meeting the cost of being crippled does.

[John Brassard, Conservative, Barrie—Innisfil, ON]

Right. I want to talk about transition services as well, because this budget spoke about transition availability for spouses and common-law partners.

Mr. Bedard, this is for you.

There have been 10 parliamentary studies done, the latest in 2016 by the veterans affairs committee, with strong recommendations on how we can ease the transition of medically released service members into transition life. The DND ombudsman did a report. The veterans ombudsman did a report. In fact the veterans affairs committee report was endorsed and supported by the DND and the veterans ombudsmen.

Now there's a new study going on, by Shaping Purpose. Granted, the government is not paying for this, but there is some suspicion that it is going to punt the issue of these recommendations down the road so that the government doesn't have to commit to it at this point, in spite of the platitudes and the niceties and all that stuff.

Are you concerned about this new study; that we're not actually going to be able to help our veterans transition properly and that they're just punting it down the road?

[Aaron Bedard]

I've seen enough study and enough research. I've been to one of these CIMVHR conferences. They love their research money and they want to divide that apple a million and one ways. We're sick and tired of the research. Give us the apple. It's time.

As for the statement from the ombudsmen that they want to have all your benefits in place before release, I honestly don't know how they're ever going to get there. Here I am, 11 years later and just recently finally approved for a traumatic brain injury—11 years later. Many young veterans aren't as good fighters as I am. Ninety percent of them have too much pride to even want to fight more than one appeal: “Enough of this. I'm not going to deal with this. I want to be proud of my medals and I don't want to have to live out constantly reviewing and fighting things.”

[John Brassard, Conservative, Barrie—Innisfil, ON]

Very quickly, I want to speak about the earnings loss benefit and the reaction among the veterans community that they are not getting as much as they thought they were going to get because of the indexing. Could you comment on that?

[Mark Campbell]

I can speak to the lump sum for pain and suffering, in fact. Yes, that $360,000 is the benchmark for the courts in Canada for pain and suffering.

There is general agreement—in the policy advisory group, at least, there was almost unanimous agreement—that this figure is adequate for dealing with pain and suffering because it's reflective of what your average Canadian receives for pain and suffering, and my pain and suffering are no more important than your pain and suffering: pain and suffering are pain and suffering.

The way the lump sum top-up was actually implemented—by taking the consumer price index and applying it—resulted in less than half of what people were expecting to receive, so there was a serious problem with managing expectations right up front. We didn't find out about the consumer price index application to the lump sum top-up until literally days before it was announced.

[Aaron Bedard]

It wasn't announced. Our veterans community was finding out from their case managers. The day before the budget day and the formal announcement of it, I had to corner the veterans ombudsman. I had to redirect three questions before I finally got it out of him that it's going to be less than half.

[The Chair, Liberal, Wayne Easter]

Thank you.

I'm going to allow Ms. Petitpas Taylor one question. She doesn't very often ask questions. It's going to take time from the next round.

[Ginette Petitpas Taylor, Liberal, Moncton—Riverview—Dieppe, NB]

Thank you very much, Mr. Chair.

Monsieur Bedard and Mr. Campbell, first of all, thank you for being here today, and thank you for your service to our country.

Monsieur Rodrigue and Mr. Gallson, thank you for being here as well, and thank you for your presentations. I follow the work that your groups do.

This topic is very relevant to mine, because I'm a social worker and was a front-line social worker for 24 years. I worked in the policing area as well. I'm very familiar with this topic.

Monsieur Rodrigue, I'm wondering if you could perhaps elaborate on the return on investment from the $5 billion in investments that our government has done. Could you elaborate a bit on the return on investment with respect to mental health?

[Michel Rodrigue]

Yes. Our argument is to use evidence-informed practices that have been proven to be effective to reach the objectives and provide individuals with a better quality of life, and that are cost effective or cost neutral as well. In the study we released about a month ago, we identified nine of those.

I'll give you a good example. In Quebec, they ran a long-term suicide prevention program that was determined to be more efficient and less costly than doing nothing.

It prevented 171 deaths.

It also contributed to saving people in almost 4,000 suicide attempts.

For children, we have the Better Beginnings, Better Futures program in Ontario. In terms of cost, it provides, over the long term, a return on the investment and better outcomes for the children and their families.

What we're trying to convey is that there are wonderful activities taking place in provinces and territories. It would be critical to validate those approaches and to then use them across the country, because they are validated and they have demonstrated that they're efficient. They lead to better outcomes for children, their families, and others. Also, they're cost neutral or they provide a return on investment.

[The Chair, Liberal, Wayne Easter]

Thank you.

Thanks to all of you for your presentations. We have to go the next panel.

I just would say to the veterans that I'm not sure how we can deal with this and whether we can send the minister a copy of the testimony you presented and the questions you answered, or what, but we'll try to find a way to see if there's anything we can do to push your issue beyond the budget bill itself.

We'll suspend for a minute and ask the next panel to come forward.

[The Chair, Liberal, Wayne Easter]

Could we reconvene, please?

My apologies to our witnesses for the delay, and my apologies for what is going to be a very tight time frame.

We're here, as you know, to deal with Bill C-44, an act to implement certain provisions of the budget.

To start off, we have with us the Canadian Cancer Society and Mr. Cunningham, its senior policy analyst.

Mr. Cunningham, the floor is yours.

[Rob Cunningham, Senior Policy Analyst, Canadian Cancer Society]

Thank you, Chair and members of the committee.

My name is Rob Cunningham. I'm a lawyer and senior policy analyst with the Canadian Cancer Society.

Thank you for giving me the opportunity to speak today on behalf of the Canadian Cancer Society.

Most of my testimony will deal with clause 51 in Bill C-44 in supporting the tobacco tax increase found there, but first I would like to mention two other items in the budget.

I would like to convey our support for the investment in home and palliative care that is included in the budget. It's been estimated that 80% of those receiving palliative care are cancer patients. This will make a real difference and improve the lives of cancer patients and their families.

Second, we support the introduction of a new and more flexible employment insurance caregiver benefit. Caregivers provide assistance and key services to thousands of cancer patients every year in Canada while bearing a significant personal and financial burden. This new benefit will help and has our support.

Turning to tobacco, it remains the case that smoking causes 30% of cancer deaths in Canada. We've made progress, but more than five million Canadians still smoke. It's the leading preventable cause of disease and death. Higher tobacco taxes are the most effective strategy to reduce smoking, especially among kids, who have less disposable income, are less likely to be addicted, and are more responsive to price.

You have a handout from us. The graph shows the comparative provincial and territorial tobacco tax rates. The blue shows the rate. The mauve shows the GST and the PST, the provincial portion of the HST. We can see that in Ontario and Quebec the rate is much lower than in other provinces. The green shows budget announcements that are not yet implemented, where there's a scheduled date to come. On the far right of the graph is the federal tobacco tax, which is now lower—by quite a bit—than that of most provinces. The yellow is the 53¢ increase per carton in the budget, so it's small, but every bit helps. This just gives a bit of context for this increase.

The next page shows the trends in federal and provincial government tobacco tax revenue, not including GST, HST, or sales taxes. There are objectives to increase public revenue, in addition to benefiting public health, and we've seen an increase in tobacco tax revenue. That's the idea. The blue line shown there is after inflation, so it's not as much, but in both cases I think it's quite impressive, because there's been a decrease in the smoking public, yet tobacco tax revenue is going up.

The third page shows a newspaper headline saying that in Australia a package of cigarettes is going to be costing $40 in 2020.

The final page compares Australian and Canadian tobacco taxes. Quebec, on the far left, has the lowest tax of any province in Canada, while Manitoba has the highest. In Australia today, it's far higher at $148 per carton—the Canadian and Australian dollars are almost at par—with further scheduled increases by 2020. It's going to go up quite a lot more. Based on Australia, we haven't come close to the ceiling of what is possible. In Canada, we—

[The Chair, Liberal, Wayne Easter]

Mr. Cunningham, I'm going to try to hold you to five minutes if we can, because the time for asking questions is going to be really tight. You have two minutes left.

[Rob Cunningham]

There is some contraband that exists. Compared to 2009, it has gone down. There are some contraband prevention measures available that we would support, such as better controls on the raw materials like filters and leaf tobacco, to have them being intercepted prior to getting to the unlicensed factories.

There was the end of the tobacco manufacturers' surtax, and our recommended preference would have been for that to stay, in addition to the higher tobacco taxes. We certainly support the higher tobacco taxes.

Of course, this is part of a bigger federal government strategy that we applaud. Health minister Jane Philpott is moving forward to have a strengthened federal tobacco control strategy. The current one expires in March 2018. Consultations have taken place for that to be enhanced.

A part of this strategy, which includes taxation, legislation, and programming, is plain packaging, as you know, of course, to remove the promotional aspects from the package as Australia, Britain, and Ireland have done. I have some examples with me of packages from Australia. This part of the strategy is complementary to the tobacco tax increase in this bill.

Let me close by reiterating our support for the tobacco tax increase.

Thank you, Chair and members of the committee.

[The Chair, Liberal, Wayne Easter]

Thank you very much, Mr. Cunningham.

We now have Ms. Pullen, director of policy, advocacy, and strategy for the Canadian Nurses Association.

[Dr. Carolyn Pullen, Director, Policy, Advocacy and Strategy, Canadian Nurses Association]

Thank you. I've timed my speaking to less than five minutes.

I'm a registered nurse myself, and I'm here representing the CNA, the professional association for close to 140,000 nurses in Canada. I'm pleased to speak today about the measures related to nurse practitioners in Bill C-44. The measures are under part 4, division 11, which focuses on support for families through benefits and leaves in both the Employment Insurance Act and the Canada Labour Code. As for part 1, we are pleased that the Income Tax Act now includes nurse practitioners, NPs, under the list of health care providers who can certify eligibility for disability tax credits. This measure was effective on budget day.

As our president noted on budget day, these changes are long-awaited breakthroughs for patients and nurse practitioners, and we hope they set the precedent for similar modernization of other related legislation. We're thankful that the Minister of Finance included these measures in Bill C-44. Along with the Canadian Association of Advanced Practice Nurses, we encourage members of the committee to accept the amendments that have been proposed for both the Employment Insurance Act and the Canada Labour Code. The amendments formally acknowledge nurse practitioners and enable them to fulfill their important role as primary care providers, particularly for Canadians who live in rural and remote locations in Canada.

Members of the committee are also aware that the Standing Senate Committee on Social Affairs, Science and Technology will be discussing a pre-study on division 11 of the bill, and we encourage them to support these amendments as well.

In order for us to have a sustainable health care system where services are accessible to all Canadians, health professionals must be permitted to practice to the full extent of their regulated qualifications. For nurse practitioners, these qualifications include the ability to perform comprehensive patient assessments and to complete related documentation. I'll give you a brief overview of the nurse practitioner role to illustrate the benefits of these amendments. Nurse practitioners are registered nurses with additional, graduate-level education and extensive, specialized health care experience. It's a protected title, and it has been regulated across Canada since the early nineties. Today, almost 5,000 nurse practitioners provide care to over three million Canadians. Within their scope of practice, they conduct physical assessments, order and interpret tests, admit and discharge to hospital, and prescribe medication. As you know, they can provide medical assistance in dying. They complete advanced practice examinations, and they must be registered with their nursing regulatory body in order to practice.

While nurse practitioners work in diverse settings, urban and rural, they are commonly the first point of contact for primary care, particularly in rural and remote communities. Like many primary care practitioners, it's not unusual for nurse practitioners to have a patient panel of over 10,000 patients. It's very broad in scope. If you just look within the first nations and Inuit health branch, the nurse-to-physician ratio for primary care in rural and remote communities is more than 26 to one. This illustrates the scale of care provided by nurse practitioners. They truly are the gateway to care.

It's clear from this how outdated legislation, drafted before nurse practitioners were recognized as a protected title and became key primary care providers.... These barriers are real, and they prevent access for many Canadians, particularly indigenous peoples, for whom the most local care is likely through a nurse practitioner. Including nurse practitioners among those who can complete documentation such as the medical certificate for employment insurance or compassionate care benefits gives patients increased access to benefits to which they are entitled. Unnecessary personal costs to individuals will be avoided. Duplication of services between nurses and physicians will be reduced. In the end, red tape will be cut. Canadians will have better access to care and better value for their tax dollars.

Finally, our expectation is that these cost-effective changes will trigger a similar modernization of legislation at the provincial and territorial levels. Similar modernization must still be made to include NPs as qualified medical practitioners under the Employment Insurance Act, specifically to include NPs in sections 54 and four sections of the employment insurance regulations. Further, five sections of the Canada Labour Code and proposed subsection 207.2(4) in Bill C-44 must similarly be amended.

In closing, I encourage members of this committee to support the bill, as its measures will improve access to care for over three million Canadians. As well, we are of the belief that the additional sections that do not add NPs must be implemented in this important bill.

Thank you to the committee. I look forward to your questions.

[The Chair, Liberal, Wayne Easter]

Thank you, Ms. Pullen.

We will now hear from the Child Care Advocacy Association of Canada. Ms. Ballantyne is the executive director.