Health Committee on Sept. 27th, 2016

[The Chair, Liberal, Bill Casey]

I call the meeting to order.

It being 8:45, we will start the proceedings. We are going to hear from an array of witnesses today, and after that we are going to do some committee business.

Our witnesses today are Mr. Ake Blomqvist, health policy scholar from the C.D. Howe Institute, and Victor Elkins and Chandra Pasma from the Canadian Union of Public Employees. Appearing as individuals are Colleen Flood, professor, university research chair, and director of the Centre for Health Law, Policy and Ethics at the University of Ottawa, and Mélanie Bourassa Forcier, professor and director of health law and policy programs at Université de Sherbrooke.

I am going to invite Mr. Blomqvist to have his five-minute opening statement. After that, we'll go to the next ones, and then we'll have questions.

[Ake Blomqvist, Health Policy Scholar, C.D. Howe Institute]

Thank you. My name is Ake Blomqvist. I am an adjunct research professor at Carleton University and co-author of the C.D. Howe publication called “Feasible Pharmacare in the Federation”, which we have submitted to the committee. I am a part-time health policy scholar at the C.D. Howe Institute, but I am also presenting on behalf of my co-author, Colin Busby, who is an associate director of research at the institute. He is responsible for the work on health care and was supposed to be the main presenter, but he was called away unexpectedly because of a sudden and very serious illness in his family, so I am presenting on his behalf as well.

I have been writing about health policy in Canada for some 35 years and very much support the view that we advance in the paper, which is that the most constructive thing the federal government can do for pharmacare today is focus on things it can do independently and in support of reforms that are already under way in the provinces.

We don't think that an attempt to create a universal public single-payer plan would be helpful at this stage. Obviously we share the view that too many Canadians still report not filling prescriptions or not completing treatment courses for financial reasons and we recognize that the prices of drugs in Canada are still very high by international standards. Also, there are major issues with the quality of prescriptions in various places. We think that the proposals to overcome these problems through a national pharmacare plan would create very major difficulties.

A stand-alone plan managed by the federal government would be unwise, we think, because it would result in less integration in the management of the overall health care system and less incentive to make cost-effective choices among drugs and other inputs in health care. A federal pharmacare plan, for example, could not influence doctors' prescribing behaviour, something that greatly impacts the cost and effectiveness of any pharmacare plan.

We also don't think that using the approach of conditional federal-provincial transfers would be a good idea. Trying to get the provinces to create a set of single-payer public plans would quickly deteriorate, we think, into a federal-provincial standoff about money. It would also be complicated by the fact that the existing public drug plans in different provinces are so different from one another.

Instead of a big push to revamp our mixed public-private system, we think the federal government should work with the provinces to continue developing the pharmacare initiatives that several of them have already started. Ultimately, we believe that provincial reforms are likely to lead to some form of universal pharmacare coverage everywhere in Canada.

To be a bit more specific, we advocate a strategy with several components. There are things that the federal government can do independently of a national plan to lower drug costs in Canada. It should be applauded for joining the pan-Canadian Pharmaceutical Alliance, but it could go further and take a leading role in that alliance. It could also make arrangements to include private insurers in the alliance to bargain jointly with the public plans.

The federal government could also reform the rules according to which the Patented Medicine Prices Review Board regulates prices. It could do so by incorporating the idea of value-based pricing.

Second, the federal government can work jointly with the provinces on strengthening the use of drug formularies that are used in the public plan and strengthening the role of economic evaluation in designing these formularies.

The third strand is that the federal government can ask the provinces, as we propose, to ensure that every citizen has access to a default plan with an upper limit on the percentage of income that a family has to spend on drugs. This idea could be pursued in a way similar to what the federal government currently does with respect to carbon pricing—setting a reasonable minimum standard for provincial plans and offering partial financial support for provinces that meet that standard.

In sum, we think there are several ways the federal government can speed up the process of pharmacare reform that is already happening in the provinces. We think this approach would stand a much better chance of achieving significant progress than the big bang approach that many advocate.

Canada has not done well in recent international rankings in health system performance. My personal view is that many of the shortcomings of our current system are due at least in part to our complicated model of divided federal-provincial jurisdiction over health policy. We think federal-provincial relations in health care are complicated enough already, and an undertaking to tear down and rebuild our system of pharmaceutical financing would just make them more complicated.

Thank you.

[The Chair, Liberal, Bill Casey]

Thank you very much.

We now go to Ms. Flood for five minutes.

[Colleen Flood, Professor and University Research Chair, Director of the Centre for Health Law, Policy and Ethics, University of Ottawa, As an Individual]

Good morning, everybody.

I'm the director of the University of Ottawa Centre for Health Law, Policy and Ethics. I want to thank you for listening to me today. I want to thank you for the work that you're doing here today and for your service generally. My brother-in-law in New Zealand is an MP, so I kind of feel your pain a bit.

I completely disagree with the former speaker, so I guess that's good. Maybe that's why you put us together. I am going to speak on why in fact we do need universal pharmacare—not necessarily national pharmacare, but certainly universal pharmacare.

To cut to the quick of it, essentially in most provinces we have a U.S.-style system for prescription drugs. Poor people are covered, working people are mostly covered through private health insurance, and provinces kind of pick up the elderly. Increasingly, they are de-insuring the elderly, particularly those they describe as the wealthy elderly, so they cover the poor elderly.

Then there is always a gap of people who are uninsured in Canada. That's about 18%. That has been persistent, and it isn't getting any less through provincial reform; it's getting worse. That's the problem that we have to deal with.

I'll give you one piece of research that I think is deep and profound on this issue. It is from the Institute of Clinical Evaluative Sciences in Ontario, probably the best research institute we have in the country. Work by Dr. Gillian Booth on access to prescription drugs for young and middle-aged people under the age of 65 in Ontario found that close to 1,000 young and middle-aged people who are diabetic die every year for want of access to something as basic as insulin, which, by the way, we invented. Banting and Best made one of the great Canadian discoveries, and we can't make sure through our governance system and our insurance systems that people get access to this most basic drug.

We also know that the U.S.-style approach results in U.S.-style costs. Ake has already spoken to the fact that we're a high spender, relatively.

Justice Emmett Hall, a smart man, said back in 1964, “prescribed drugs should be introduced as a benefit” and “its authorization should be an early objective of the Canadian Parliament”. That was 52 years ago. He didn't put it into the basic set of benefits back in the day because he thought it was too expensive and that we should wait for the cost of pharmaceuticals to come down.

Maybe he wasn't as smart as we thought: they haven't come down, and that's because they're not part of a single-payer plan. They're not part of a concerted effort on the part of government to purchase those drugs.

We know that every other developed country around the world that has a universal plan includes prescription drugs in its basic benefit package. We're standing out in the world for not doing that, so I disagree with Ake. I think we are a relatively poor performer these days precisely because we're not doing a good job on insuring pharmaceuticals, community care, and home care, and that's causing all sorts of other problems with our hospitals and physician services.

What can we do about it? I do agree with Ake that it's important that whatever we do is not too much of a burden on the provinces and is respectful of federal-provincial relationships and the Constitution. There are two basic scenarios in my mind.

The first is to expand the Canada Health Act to include community-based pharmaceuticals. Then you say, “You're just going to spend gazillions.” No, not necessarily, if you stipulate as part of the Canada Health Act that the provinces must have a fair process to decide what to include in the basic benefit package. They would be choosing then. For example, they may say that insulin is a higher priority than fixing my bunion. I can go and have my bunion fixed—and actually my doctor organized all of that in a few weeks, free—but people are dying for want of insulin. Surely no rational, reasonable kind of health care system would permit that.

I think if the Canada Health Act could be opened up to include community-based pharmaceuticals and a respectful requirement that provinces have a fair and transparent process to decide what is in and what is out, it would leave them to decide. That leaves them to decide that they'll fund insulin but they won't fund bunions. That's completely doable.

The other way is the kind of bigger bang approach, I guess, which is that the federal government itself would permit this.

Sorry; I should go back and say that the concern we presently have is that we all have private health insurance. We don't want to lose this stream of funding. The Canada Health Act does not necessarily require that everything be tax financed. Provinces charge premiums currently, and you could do this. You could finance this in part through CPP payments.

You could also funnel the funding from the private health insurers into a central plan. The private health insurers would essentially pay a premium to the central plan to do the buying. This is a proposal that Aidan Hollis at the University of Calgary has put forward. I think it's a pretty good one, and I detail it with a bit more specificity.

The final idea is that the federal government do it itself. That's the big bang approach. I actually do have a figure here; we did a bit of a back-of-the-envelope calculation. For about $5 billion, you could cover 150 essential drugs for all Canadians.

I could talk a little about that proposal, but there you have two viable proposals. I don't think either of them would break the bank, and they would put us back on a par with other competitive nations to make sure we deliver health care to the people as they need it.

Thanks for listening to me.

[The Chair, Liberal, Bill Casey]

Thank you very much.

On the 1,000 people...what was that statistic again?

[Colleen Flood]

It was that 1,000 people a year in Ontario under the age of 65 who are diabetic die.

[The Chair, Liberal, Bill Casey]

In Ontario. Thank you.

Now we are going to Ms. Forcier.

[Mélanie Bourassa Forcier, Professor and Director, Health Law and Policy Programs, Université de Sherbrooke-CIRANO, As an Individual]

Good morning.

My name is Mélanie Bourassa Forcier and I am a professor in the Faculty of Law at the Université de Sherbrooke, where I direct the master’s programs in health law and policy. I would like to thank the committee for inviting me to come and give my impressions on the development of a national pharmacare program.

Am I for or against a national pharmacare program? Basically, I subscribe to the two positions that have been presented to you today. I believe that they can be reconciled to a certain extent. Clearly, I am in favour of access for all to medication. However, assuming that the federal government does not want to revisit the provinces’ tax base in order to maintain their autonomy in their areas of jurisdiction, I am in favour of increasing federal transfer payments to the provinces. Those transfer payments would allow the provinces first, to ensure access for all to medications, second, to increase their pharmacare coverage, and third, to ensure the sustainability of their programs that could be threatened by the advent of biological medications that are particularly costly.

In addition, I would add that I am in favour of increasing federal transfers in order to ensure health care services that go beyond the archaic philosophy whereby medically necessary services are those centred on hospitals. It therefore seems important to me to broaden the definition of what can be considered medically necessary. I am likewise in favour of reducing the costs of medications. No one can be against that. However, you will have gathered that I am in favour of respecting federal and provincial areas of jurisdiction.

Let us discuss the savings alleged in contemporary studies on the establishment of a national pharmacare program. Basically, this is all about the savings mentioned in contemporary studies. The oldest studies on the matter, the Hill, Kirby and Romanow reports, focused on the idea of universal access and not on the savings that could result from the establishment of a national pharmacare program. Therefore, the savings alleged in the contemporary studies on the establishment of a national pharmacare program are essentially the result of volume—as Ms. Flood mentioned. Clearly, one single major insurer has much greater negotiating power than a multiplicity of insurers. Such are the laws of the marketplace.

Of course, consolidating power has its advantages: savings are considerable because of bulk buying, because there is a single set of rules, and because all Canadians have equal access. However, consolidation also means setting decision-making autonomy aside, sometimes at a cost. Without that cost, we would long ago have seen the advantage of joining with the United States to increase the volume of our purchases of a variety of goods. If the federal government had not held fast to that autonomy, Health Canada would long ago have accepted medications being put on the market after they had been approved in other jurisdictions, rather than conducting its own health testing. So yes, autonomy comes at a cost, but it also has a value.

Therefore, I am against a national pharmacare program that would be established pursuant to any federal legislation other than the Canada Health Act. I also want to remind you of the 2011 Supreme Court of Canada decision on the Reference re Securities Act. You may recall that the reference dealt with the constitutionality of an act designed to create a fully national program to regulate securities. Section 9 stated that the purposes of the act were to provide investor protection, to foster fair, efficient and competitive capital markets and to contribute to the integrity and stability of Canada’s financial system. In a word, the objectives were laudable and difficult to contest.

As the Supreme Court pointed out, the act as worded did not unilaterally impose a unified system of securities regulation. Instead, it permitted provinces and territories to opt into the program if and when they wanted. The court held that the act was unconstitutional because it exceeded the powers of the federal government and represented an interference into provincial areas of jurisdiction. I remind you that the same court, in its 1997 decision in Eldridge, once more confirmed provincial jurisdiction over health.

However, the same court, still in the securities decision, insisted that it was possible for provinces to cooperate contractually to establish a national securities program.

In my opinion, the pan-Canadian Pharmaceutical Alliance is the way to reach such a consensus on the supply and coverage of medications in Canada.

However, I will conclude by insisting that it is important for the federal government to maximize the development of its own jurisdiction, given its clear impact on the costs Canadians pay for medications.

In my opinion, therefore, the federal government should intervene more broadly in the area of public health. With patented medications, the federal government has the power to intervene—as has been mentioned—through the Patented Medicine Prices Review Board. The board is currently in the process of reviewing its mandate, but it is still important to act quickly, especially with a view to regulating the prices of biological medications. There is also the issue of preventing sudden increases in the price of medications.

Unfortunately, as you know, the board does not have the power to regulate the prices of non-patented medications. However, the federal government's jurisdiction over competition may be a factor here. The Competition Bureau’s mandate is too limited, in my opinion. A registry of all mergers and acquisitions in the pharmaceutical industry, as well as an examination of the impact of agreements between pharmaceutical companies on competing in the marketplace could certainly ensure greater competition and lower prices.

Thank you for your attention.

[The Chair, Liberal, Bill Casey]

Thank you very much.

Now we'll move to Mr. Elkins, from the Canadian Union of Public Employees.

[Victor Elkins, Regional Vice-President for British Columbia, Canadian Union of Public Employees]

Good morning.

My name is Victor Elkins. I'm the president of the Hospital Employees' Union and a regional vice-president for B.C., sitting on CUPE's national executive board.

It's my pleasure to speak to you this morning on behalf of the 630,000 CUPE members across the country, which includes 150,000 members in the health care sector, working in hospitals, long-term care residences, and community health centres or providing home care.

I want to share with you why CUPE members support a national health care program and why we most certainly do not support simply patching up the status quo.

You have already heard from many witnesses who spoke of the gaps that exist in our current prescription drug regime. Canadians are paying way too much for prescription drugs, and too many people are falling through the cracks, with no coverage or simply inadequate coverage.

Some have suggested that all we need to do in response is extend the current system so that everyone has coverage of some kind, whether public or private. This kind of model exists in Quebec today, but a hybrid model is not the answer, because if we rely on private insurance, drug coverage costs are simply unsustainable. Private coverage is highly inequitable, inadequate, and needlessly expensive.

Let's go over each of these points in more detail.

Private coverage is fundamentally inequitable. The lower a person's income and the more precarious their work, the less likely they are to receive benefits from their employer. In fact, according to an analysis by the Wellesley Institute, nearly all employees in Canada earning $100,000 or more a year receive health benefits, but of those earning $10,000 or less, only 17% get benefits. Since those with lower incomes are also at greater risk of health problems, such as cardiovascular disease, depression, and diabetes, this means that those who are most likely to need prescription drugs are the least likely to have employer-related coverage.

Unionized workers are also more likely than non-unionized workers to receive benefits. However, while CUPE and other labour unions have been highly effective at achieving prescription drug costs and other health-related benefits for our members, that doesn't mean the solution to Canada's prescription drug problem lies at the bargaining table. Obviously, we want to see our members, and all Canadians, have good drug coverage, but ideally decisions about what kind of medications people have access to shouldn't depend on the outcome of negotiations between employers and unions: they should be decisions made by patients and their doctors.

We want medically necessary health care, such as medications, to be available to all Canadians, regardless of where they work or whether they do not work. Prescription drugs should be provided on the same basis as any other form of treatment recommended by a doctor. We are calling for this based on principle, but also because the rising cost of prescription drugs is not sustainable and cannot be addressed without a national drug plan.

Prescription drugs represent the largest portion of employee-paid health benefits, and the rising cost of prescription drugs is placing an increasing burden on employers and employees. The current patchwork system cannot contain these costs. Part of the problem is that the very nature of the system gives it no mechanism or incentive to contain costs. There are 24 separate insurance companies negotiating individually with the large pharmaceutical companies over the price of each individual drug, and the costs of those drugs are simply passed on to employers and employees, so where is the incentive to keep the costs low?

The current system also allows drug companies and pharmaceutical companies to play Canadians against each other. For instance, there is some evidence that cost savings demanded by public drug plans are just being passed along to private plans. In Quebec, documents that were leaked to the media revealed that when the public plan negotiates a decrease in the price of generics, pharmaceutical companies compensate by passing these costs off to the private plans. As a result, the average cost of a public plan for generics decreases by 5.5 %, but the average cost for private drug plans increases by 6.4%.

Private insurance is also more expensive because of high administration costs and the necessity to provide profits to shareholders. Because of these two expenses, there is a significant gap between what Canadians pay in premiums to private insurance companies and what they receive back in benefits. In 2011, this gap was nearly $6.8 billion.

This gap is also growing over time. If the ratio between premiums and benefits had stayed at the same level that it was in 1991, Canadians would have saved $3.2 billion in 2011. This difference in cost is going to administration and the pockets of shareholders, not to better drug coverage for Canadians.

Finally, as costs increase, private plans aren't moving to contain them but are shifting them to workers instead. The number of plans with maximum annual or lifetime limits is growing. Thirty per cent of employers now have a maximum limit of some kind on their drug plans. This just means that people who actually need the drugs the most are the ones who are cut off and forced to either turn to a public plan for catastrophic coverage or pay out of pocket. More employees are now also required to make copayments or to pay dispensing fees.

Some employers are turning to flexible plans, which require workers to guess at their level of need and to pay out of pocket if they had the misfortune of guessing wrong. Some employers have cut off benefits entirely for certain employees or for retirees, as U.S. Steel Canada has recently done to pensioners in Hamilton.

The solution to all these challenges for Canadians, for workers, and for employers is a comprehensive public drug plan that covers all Canadians, regardless of where they live, where they work, their age, or their income.

However, we are concerned that recent trade deals the Canadian government has negotiated, though not yet ratified, will limit the federal government's ability to contain costs and ensure the safety of Canadians. Both the TPP and CETA are projects that could cost Canadians about $850 million to $1.6 billion annually in increased prescription drug costs. The provinces will be reimbursed for the extra costs, but private plans and Canadians who pay out of pocket will have to swallow them.

You can read more about our recommendations in our written submission, but briefly, what CUPE recommends is that the federal government create a national drug plan that provides Canadians with universal, equitable access to prescription drugs with no copays or deductibles. The program should be publicly administered and publicly delivered. We also urge you not to ratify the TPP and CETA trade deals.

We thank you for your time. I look forward to your questions.

[The Chair, Liberal, Bill Casey]

Thank you very much.

I think we've had 48 presentations up to today, and you are still adding information, new information that we hadn't heard. I just want to thank you for your contributions. They have all been very helpful.

We are going to start questions now. We'll start our first round at seven minutes.

Mr. Kang, go ahead.

[Darshan Singh Kang, Liberal, Calgary Skyview, AB]

Thank you, Mr. Chair.

I want to thank the panel members for coming here and shedding more light on this big issue that the committee is studying.

My first question is for Professor Bourassa Forcier.

The implementation of medicare in Canada required government to take the patchwork of insurers and create a single-payer system. There have been suggestions by the previous witnesses that a similar process must be used to implement a national single-payer pharmacare strategy.

Respecting the constitutional divisions of power between the federal and provincial governments, what is the federal government's scope of action to implement national pharmacare, which could include a single-payer model and a single formulary?

[Mélanie Bourassa Forcier]

Actually, I have said that I am in favour of the federal government intervening in order to facilitate access to medications for all. My impression is that, for the intervention to be legitimate constitutionally, it has to be done pursuant to the Canada Health Act. Now, that act must be brought up to date.

As you have already heard or read in the briefs presented to you, when the Canada Health Act was passed, the most expensive medications were provided in hospitals. We now see that situation moving. Most medications, even those for the treatment of cancer, are provided in an out-patient situation, and are therefore excluded from the terms of the Canada Health Act.

Clearly, if the federal government expands transfer payments and broadens the term “medically necessary” that appears in the Canada Health Act, additional conditions will have to be included in the act so that the provinces can obtain the new federal transfers. Those conditions could indicate, for example, that all residents of each and every province are assured of reasonable access to medications. Because of the transferability condition written into the act, we could ensure a degree of consistency in the supply of medications, which is possible to do under the Canada Health Act.

We would then be choosing a flexible program that is acceptable constitutionally. I am sure you are aware of the latest positions of our Minister of Health, Dr. Barrette. That is, that provinces would not automatically agree to abide by new conditions governing medications. But the provinces could still at least take advantage of federal transfers that would allow their pharmacare coverage to be broader.

[Colleen Flood]

Can I answer as well?

[Darshan Singh Kang, Liberal, Calgary Skyview, AB]

Yes.

[Colleen Flood]

I think the Supreme Court has ruled on several occasions and in recent times that conditionality in transfers between the federal and provincial governments is acceptable. It is, as I said, quite feasible to include community-based pharmaceuticals inside the Canada Health Act and ask the provinces to determine a list of essential medicines. That's not one big national formulary.

If the federal government wished to create one national formulary and one national purchaser, that would require the consent of the provinces, so that's a different ball game. However, the way we've usually done business is through the Canada Health Act or a conditional kind of transfer, and that approach allows the provinces to have flexibility in how they design their health care systems, which could permit, for example, the funnelling of private health insurance premiums or some sort of premium payment through CPP. A model such as you have in Quebec could be okay with this, provided it meets certain conditions, which I would say would be no payment at point of service and no user charges for essential medicines, just as for hospital and physician services. That would be in the spirit of the Canada Health Act. I think it's completely constitutionally permissible.

If the federal government wished to run a big bang federal program, I think that is feasible, but it would have to be voluntary. The provinces would have to agree to participate in it. I would imagine that given their current fiscal situations, most of them would. Quebec may choose not to, but most of them would. I think that would be permissible.

[Mélanie Bourassa Forcier]

Could I add something?

I'd just relate it to something.

We established the pan-Canadian Pharmaceutical Alliance, representing the first ministers of each province and now the federal government. The alliance's function is primarily to negotiate the price of generic medications. With Quebec, and now also the federal government, joining the alliance, we now have much greater bargaining power. With generic medications, the positive effect of volume purchasing can be reflected in the prices we are able to negotiate.

As for the price of innovative medications, negotiating lower prices is difficult, if only because they are patented. It is still possible, by means of confidential product listing agreements. These are becoming more and more common, especially with private insurers.

I agree with Ms. Flood. It has also been suggested that private insurers should join the alliance in order to increase the negotiating power. While still keeping a hybrid, public-private scheme, it is possible to interest private insurers in the negotiations in order to facilitate the purchase of a greater volume at a consequently lower price.

[The Chair, Liberal, Bill Casey]

Thank you.

Dr. Carrie is next.

[Colin Carrie, Conservative, Oshawa, ON]

Thank you very much, Mr. Chair, and thanks to all the witnesses here today.

As the chair rightly pointed out, we're getting new information all the time, and my questioning is to see if you have more information for us.

Madam Flood, you mentioned the provinces would be gung-ho for more money for a national pharmaceutical-type program, but the minister has been very clear that there will be no more money in the transfers. There's nothing in the budget even for the promises they made for $3 billion in palliative care.

We've had credible witnesses who stated quite clearly that if we move toward a monopolistic type of system, the day one costs would be anywhere from $10 billion to $14 billion. We know that private insurance companies in Canada do cover a significant amount of health costs.

Here is one of the challenges. If we hear people saying they want to move to a single payer, there's no real definition of the problem. You have some statistics. You mentioned 18% of Canadians don't have coverage, but for what percentage of those people is the lack of coverage even a problem? You mentioned the thousand people who die in Ontario every year from complications of diabetes. My dad died from complications of diabetes, but he had full coverage, excellent coverage. We're having a problem defining the actual problem. There's no update for statistics.

My question is to C.D. Howe, because many of our witnesses have stated that the statistics are quite old. There have been some suggestions they may not even be recent enough to be relevant, given the shifts in recent years with employment and different coverage.

Do you find it difficult to find recent stats and studies to support investigations? Should the federal government update statistics before we make any final decisions? I ask because this is a huge program, and the government is under constraints; I think there is a $30 billion deficit, and this one line item would be $14 billion.

Beginning with C.D. Howe, what are the statistics that you can glean from, and are they recent?

[Ake Blomqvist]

All I'm familiar with is that most of the evidence that is cited on the difficulties that Canadians have accessing health care are based on answers that people gave to questions in various kinds of survey questionnaires. I'm not clear on how reliable that data is and exactly how it should be interpreted.

Colleen is citing evidence on people who died. As to how you attribute the cause of death and to what extent it had to do with lack of access to necessary medications, I don't know. It's a little bit difficult to see what kinds of studies one would have to undertake in order to have a good answer to that question. For example, what are the health consequences of lack of access to medications? Exactly how one would do that, I'm not sure, but obviously one could do it better.

[Colin Carrie, Conservative, Oshawa, ON]

Are you even aware of any studies that provide up-to-date statistics on these things?

[Ake Blomqvist]

Being up to date, in my opinion, is not the major issue. The major issue has to do with how you interpret people's responses to survey questions.

All of you, I'm sure, have answered survey questions of various kinds. You're asked on a scale from zero to five whether you have had severe difficulties, some difficulties, whatever, and you know how arbitrary the answers are that people give to questions of that type.

I'm not sure that it would be all that important to get evidence on this issue. There are fairly simply rules that the provinces could implement to make sure that nobody is constrained for financial reasons from getting necessary drugs at the point of service.

One of the few areas where Colleen and I agree has to do with the fact that there probably should be some kind of a guarantee in every province that a person could get access to prescription drugs at no cost at the time they fill the prescription. Where we then disagree is whether at tax time it would be a good idea to recoup some of the payments that have been made.

[Colin Carrie, Conservative, Oshawa, ON]

We've had witnesses quote some statistics that are 30 years old. They said that over the last 30 years we've had a huge demographic shift, with more Canadians moving into the senior category.

Certain patchworks are out there. For example, Ontario has the Trillium bonuses for people to have access. We've also had a shift away from full-time jobs. There are many more part-time jobs. I think the union representatives would be aware of that. I think it's really important that we have updated statistics, because how can you fix a problem if you're not even defining it properly?

My question is to Madame Flood, maybe, and Madame Bourassa Forcier.

Are you aware of any updated studies that would give us statistical analysis to define the problem? There has been a huge shift in the last 20 or 30 years, and there is going to be a huge shift in the next 10 years.

[Colleen Flood]

I'm sure that the variety of witnesses you've heard have been bringing various pieces of evidence to you that will need to be synthesized. I have no doubt that the results you will see are that there are significant problems of access for Canadians to essential medications across this country and that this lack of access is causing morbidity and even mortality in some circumstances.

The research study that I referred to is about six years old. It clearly shows the difference between Ontarians who are over the age of 65 and have drug insurance and those under the age of 65. In those situations, we're talking about young and middle-aged people who are suffering morbidity and mortality who are diabetic.

Other work that my colleagues have done shows that people without drug insurance are not going to see their family doctor because they know they will very likely need a prescription, so there's no point in even going to the family doctor in the first place. This is leading to bad health outcomes as well. That study is a few years old.

As the CUPE representative said, we also know from what we see in other countries that the most likely result for the aging population is private insurers seeking to de-insure the elderly. The United States has a plan for the elderly called Medicare. It covered everybody, because of market failure back in the day. Private insurers weren't covering the elderly for the things they needed. Its basic benefit package includes pharmaceuticals for everybody. I mean, we're not even competing with that.

[Colin Carrie, Conservative, Oshawa, ON]

I'm curious, though. You mentioned that the one study you did was six years old, and it was for one chronic condition, diabetes. I'm sure there are similarities between Canada and the U.S., but there are also differences.

Moving toward a monopoly—