Health Committee on Sept. 27th, 2016

[Colleen Flood]

There are not really any differences in how private health insurance markets work.

I think any scholar in health policy would tell you that those are how health insurance markets work unless government forces them not to. Unless government regulates private health insurers and forces them not to drop the old and the sick, that is what will happen.

My aunt lives in New Zealand, the country I am from. She bought private health insurance as a school teacher for her entire life. At 80, she's finally in hospital. They asked her the last time that she was in hospital, and she said 1928, when she was born. At this point in her life, when she finally needs her drug insurance coverage and her private health insurance benefits, she can no longer afford them because they are too expensive. She contributed her whole life for nothing.

[The Chair, Liberal, Bill Casey]

Thank you, Dr. Carrie.

Go ahead. Mr. Davies.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you, Mr. Chairman.

Thank you to all the witnesses for being here today.

I have some data here before me. One in four Canadians say that they or someone in their household cannot afford to take their prescribed medications, resulting in skipped doses, split pills, or unfilled prescriptions. The source for that is the Angus Reid Institute, which conducted a survey in July 2015, a year ago.

Number two is that on an annual basis, approximately one in 10 Canadians do not fill their prescriptions at all because of cost. My source for that is Michael Law et al. in an article that was published in the Canadian Medical Association Journal in February 2012, four years ago.

Finally, Canadians spend $6 billion a year out of pocket on prescription drugs. That's 22% of total spending on all drugs, and my source for that is Pharma 2020's quite well-known peer-reviewed article that was written in July 2015 by a couple of pre-eminent Canadian health economists.

My question is this: does anybody on this panel doubt that there are Canadians right now in this country who are not able to fill their medication prescriptions because of cost? Does anybody doubt that?

Ms. Pasma, do you doubt that?

[Chandra Pasma, Senior Research Officer, Canadian Union of Public Employees]

No, I don't doubt that, but I just want to respond to that point if I can.

[Don Davies, NDP, Vancouver Kingsway, BC]

I will come back to you.

Mr. Elkins, do you doubt that?

[Victor Elkins]

No, I do not doubt that at all.

[Don Davies, NDP, Vancouver Kingsway, BC]

Ms. Forcier? Ms. Flood?

[Mélanie Bourassa Forcier]

No.

[Colleen Flood]

[Inaudible—Editor]

[Don Davies, NDP, Vancouver Kingsway, BC]

Mr. Blomqvist?

[Ake Blomqvist]

No, I'm sure of it.

[Don Davies, NDP, Vancouver Kingsway, BC]

Ms. Pasma, I'll let you elaborate a bit if you want.

[Chandra Pasma]

Thanks, Mr. Davies.

I appreciate the opportunity to respond, because you raise a good point. We know that there are Canadians who can't afford their prescription medications. We know there are Canadians who are dying because they can't afford their prescription medications. I'm not really sure what difference it makes if we know the exact number and we can put an exact decimal point on that number. If it's 25% or if it's 25.5%, I don't see what difference that makes.

The reality is those people are out there, and that is simply un-Canadian. Our system is based on the concept that if you need health care, you get health care, and right now if you need prescription drugs, you do not necessarily get prescription drugs. You can have surgery because you need surgery, you can see a specialist because you need a specialist, and you can die because you need insulin. That is not Canadian.

[Don Davies, NDP, Vancouver Kingsway, BC]

I was picking up on Dr. Carrie's line of questioning.

The best evidence that I've heard at this committee is that 10% of Canadians right now have no coverage in this country. Of that I have no doubt. I have no trouble believing that is true of people who are unemployed, low-income people, people who work for employers who do not provide extended benefits coverage, part-time employees, and young people. I have no issue believing that 3.5 million Canadians are walking around today with no access to medicine if they get sick.

Another bit of evidence we have heard at this committee is that a further 10% have intermittent or unstable coverage. They might have some coverage when they work. They may have high deductibles or copayments, so effectively 20% of Canadians do not have regular, consistent, full coverage for prescriptions. That's based on recent data that I've seen.

I want to pick up on your point, Ms. Pasma, because I want to put this to the panel as well. I'm going to quote from the CUPE submission, which, by the way, is excellent.

It says:

For nearly 50 years, thanks to Canada's cherished public healthcare system, Canadians have been able to access the medical care they need at no cost, no matter where they live, where they work, or how much money they have. Canada's public healthcare system has delivered high quality care and great outcomes for patients. Canadians are rightfully proud of our system and its values of universality, accessibility and equity.

However, there remains an astonishing exception to these values—access to prescription drugs. When you visit your doctor and receive a diagnosis, all treatments that are deemed “medically necessary”—such as a cast, surgery, hospitalization or referral to a specialist—are publicly funded because they are covered by the Canada Health Act. However, when the treatment prescribed is medication, there is no universal coverage. Instead, access to prescription drugs in Canada is based on a patchwork system that varies depending on where you live, where you work, how old you are, and what your income is.

I'm going to put a simple proposition to you. We have the Canada Health Act that covers medically necessary coverage. Why do we draw a line when the treatment prescribed is not stitching a finger but rather going to the pharmacy and getting a pill? Should we not just extend our Canada Health Act to provide access to medically necessary prescriptions?

[Colleen Flood]

I agree with that. I think we should. It has to be clear that it doesn't mean everything is covered. I think it means that some things that are presently covered may not be covered if we have to expand to afford that. I think that's the quid pro quo, and that has to be clear to Canadians and to provinces.

I also think the Canada Health Act does permit a great deal of flexibility within it. It allows, for example, provinces to charge premiums to people. A form CPP is a way of collecting the funding. There is even, as I mentioned, the possibility that private health insurers would pay a premium to a provincial buyer, a provincial insurer. You'd funnel the money through in that way. It would be a way to move forward on this fiscally if there was difficulty in paying for it. Maybe temporarily, but maybe permanently, that could be the arrangement.

[Don Davies, NDP, Vancouver Kingsway, BC]

I'm having difficulty understanding why some people have a conceptual difficulty with this.

We talked about the federal-provincial issues, the constitutional issues, and the economic issues. We have the Canada Health Act and we have medicare in this country. If you think this is a tough issue, we got that in the 1960s. Is pharmacare not just a natural measured extension of exactly the system that we have that has solved all of those problems?

The federal government makes money available to the provinces, respecting provincial jurisdiction. The provinces have access to that money as long as they agree to respect the principles set out in the Canada Health Act.

[Colleen Flood]

It was the plan back in the 1960s that pharmacare would be included. Unfortunately, we froze in time in 1966, pretty much when we merged the Hospital Insurance and Diagnostic Services Act and the Medical Care Act.

The problem for the provinces is that they're paying up to 50% of their total budgets on health care. That's why they're starting to de-insure the so-called wealthy seniors and put in place copayments and these kinds of things. They need federal support to be able to expand in this way.

[Don Davies, NDP, Vancouver Kingsway, BC]

Madam Forcier, can I ask a question directly to you about the Quebec model?

[The Chair, Liberal, Bill Casey]

Sorry, Mr. Davies; your time is up.

Mr. Oliver is next.

[John Oliver, Liberal, Oakville, ON]

Thank you very much.

Thank you very for your presentation. As others have said, there has been a lot learned again today. It's amazing how complex this topic gets the longer we look at it.

It is regrettable in terms of data and statistics that we lost our Stats Canada comprehensive survey form and don't have reliable data now on some of the key economic situations that our Canadian families are in. That's a regret, but I'm happy to see the long-form census being reinstated.

My first question goes to Mr. Blomqvist.

We've heard from different groups here about big bang versus incremental, and obviously your recommendation is for an incremental approach, with some kind of a default plan for low-income families based on percentage of household income and drug costs exceeding that.

The presentation here from CUPE, to quote a little bit of it, said, “Our current patchwork system also allows drug companies and pharmacies to play individual actors against one another.”

If we do the incremental approach, we simply lock in the current inefficiencies that are there in Canada, along with their cost.

I was curious as to whether you looked at all at what was happening in Europe. There are managed competition models, such as in Sweden. There the people have to have private insurance, but it's a heavily regulated private market. Do you have any thoughts about an incremental model based more on better control of the private market?

[Ake Blomqvist]

Our paper gives a menu of areas where we think the federal government does have a major role to play, and the pricing of pharmaceuticals is one of those.

It is true that the patent system is the main reason pharmaceuticals, especially brand-name pharmaceuticals, are so expensive. The patent system is a piece of legislation that we have created to give a monopoly to pharmaceuticals and owners of patents. If you give a legal monopoly to specific sellers, then presumably they have to accept that they will be regulated.

In our opinion, the federal government can take a lead role with respect to the pan-Canadian Pharmaceutical Alliance. They can include private insurers in the negotiations for lower prices and exercise buying power on behalf of not just public plans but also private plans in getting better prices from the pharmaceutical companies.

Furthermore, there are opportunities for the patent PMPRB—

[John Oliver, Liberal, Oakville, ON]

I'm sorry. I've read through your document. I was curious more about your reaction to what Sweden has done and what some of the other jurisdictions have done around managed competition.

[Ake Blomqvist]

I'm all in favour of managed competition with respect to setting certain limits that would provide rules that pharmaceutical companies can follow, including issues of compulsory enrolment in group insurance plans, along the lines that are now the backbone of the system in Holland, for example. It is becoming the backbone of the American system as well.

[John Oliver, Liberal, Oakville, ON]

Thank you very much.

[Mélanie Bourassa Forcier]

I might add a little something.

I have just started a project to evaluate the transparency of the private insurance market. The study is not yet complete, but we are realizing that, compared to other western countries, the private insurance market in Canada is the least regulated, even though we have more and more regulation requiring conformity. However, there is no requirement for accountability and the reasons for which premiums increase are not at all transparent.

When employers receive information about their employees' use of health care, they have the expense side, but they have no idea of the profits the insurance companies are making. They do not know what the increases will be for their employees in the future. That means that a number of small employers have to drop their private insurance and push their employees towards the public system, which, if they live in Quebec, is obligatory when there is no access to private insurance, or towards nothing at all, if they live in the other provinces.