Health Committee on Dec. 6th, 2016

[Prof. Larry Lynd]

We do have experience. We do it in British Columbia. We do it in Ontario. Other countries are doing that. We know we evaluate them differently. Specific panels with specific expertise to evaluate orphan drugs have been developed. That's certainly doable.

[The Chair, Liberal, Bill Casey]

Your time is up.

Mr. Webber, you have five minutes.

[Len Webber, Conservative, Calgary Confederation, AB]

Thank you, Mr. Chair.

I want to focus my questions to the citizens' panel, the members who are here. I read through this and found it quite interesting. I read the names of the people who are on the panel and their backgrounds and such, and of course your recommendations to have a universal, mandatory, public drug insurance system that provides the necessary coverage to all Canadians.

It sounds wonderful, doesn't it, to have a system here in a Canada where all the drugs are paid for and everybody has access to the necessary medicines that they require? But there is a price to that. Of course, you know that. You mentioned some equitable revenue tools in your paper here. Mr. Oliver brought that up, about the income tax, corporate taxes, and such.

In your panel discussions, when you brought in some experts, did you talk about the costs involved and what the costs may be to implement your recommendations? Are there any specific numbers? I would just like to know more about the actual cost of implementing what you're recommending.

[Peter MacLeod]

Sure. We looked at this largely in a comparative perspective, as to what it costs to receive comparable coverage in other countries with universal health care.

As you're well aware, there aren't any solid numbers in Canada because there hasn't been a determination as to what the right model is for Canada. The focus of our efforts was not to develop the fiscal model around this, but it was to at least gesture towards some revenue sources that the members of the panel felt would be productive.

[Len Webber, Conservative, Calgary Confederation, AB]

Again, I would love to drive the nicest cars on the street, but there's a price for that. Likewise with the universal medicare system here, there is a cost. People have to be cognizant of that. I know they are, but it just seemed that your panel was all about covering everyone. I would love to see that as well, but there is a cost to it.

[Peter MacLeod]

Certainly, the panellists were very sensitive to these costs. To be clear, their intent was to cover everyone but not to cover everything. That's where the role of an evidence-based national formulary is essential, to identify those medicines that are deemed to be both effective in health terms but also cost-effective as well.

Nevertheless, I think it was striking to realize that Canada continues to spend more as a country per capita to meet the pharmaceutical needs of its population than any other OECD country, barring the U.S. and, as my colleague has pointed out, Switzerland.

[Len Webber, Conservative, Calgary Confederation, AB]

Could you talk a bit about the patient paying a fee for medication, a portion of money that the patient would pay rather than collecting the revenue through corporate income tax or income tax? Maybe you could share a little on that.

[Peter MacLeod]

There's no question that many members of the panel thought that it would be advantageous to look at a system of copayments. That was really a values-based gesture, believing that everyone who can ought to contribute more directly to the cost of their care. Nevertheless, the panel hesitated to make that a clear recommendation because they were unsure of the potential consequences for low-income individuals and whether those copayments, even as low as a dollar or two, could constitute a barrier. Then you would have people not taking their medicines and being a greater cost to the system.

[Len Webber, Conservative, Calgary Confederation, AB]

Ms. James, you talk about the behaviour of Canadians, active lives, no smoking, and healthy food choices. For the individuals who do this, should they be rewarded in some way, perhaps through tax breaks? Do you have any thoughts on that at all?

[Lesley James]

I think Canadians who do that are rewarded with good health already, and that in itself is the reward.

Heart and Stroke believes that there are culprits that lead to poor population health, such as tobacco, sugary drinks, and processed food. It may be worth increasing the price of those options to fund health care coverage and universal pharmacare. A good way to offset the difference would be to tax the culprit, as opposed to the individual.

[The Chair, Liberal, Bill Casey]

Your time is up. That was a good question.

Mr. Ayoub, you have the floor.

[Ramez Ayoub, Liberal, Thérèse-De Blainville, QC]

Thank you, Mr. Chair.

I'll be asking my question in French.

Obviously, we talk a great deal about costs and efficiency. In an ideal world, if we didn't need to talk about economic issues, the choices would be easy.

My question is for the group of volunteers. They deserve our congratulations for the time spent on the study.

The issues discussed were universal coverage, cost effectiveness, the choice of the list of drugs, and a combination of private and public coverage. This sums up the fact that we have a choice and that we can draw a line between what's acceptable for many Canadians and what is exceptional for others. Where do we draw this line? Are you ready to draw a line? You don't suggest one line in particular because the issue is quite broad. I want to quote a passage from your brief. You said the following:

In order to be patient-centred, this list should be ample enough that it provides sufficient flexibility to take into account individual patient circumstances. This list will include the drugs proven to be most suitable for all conditions, including rare and catastrophic diseases.

You don't make a choice. That's also likely not your goal. However, what would be the government's role and what would be its ultimate responsibility in terms of economic and health costs?

Mr. MacLeod, you can answer first.

[Peter MacLeod]

I was actually going to invite Jean-Pierre to speak, if I could, and then I'll speak second.

[Ramez Ayoub, Liberal, Thérèse-De Blainville, QC]

Please go ahead.

[Jean-Pierre St-Onge]

That's a very good question.

During the five days, I noticed that there was no consistency from one province to another. I learned about the situation of low-income people and seniors who receive family assistance. This leads me to conclude that the most vulnerable people in the 55-to-65 age range are those who don't have group insurance or who lose their jobs.

For example, in my own area, it happened to three couples my age. I'm 63 years old, and I'm sad to see them liquidating all their savings to pay for their drugs because they don't have insurance. I'm an ordinary individual, and I can see the situation in my area. I know three couples in this situation.

It bothers me to think about the rest of Canada. It's sad to see people who have worked their whole lives reach retirement age thinking they'll be able to live better and then fall ill. These things can't be predicted. As Mr. James said, people can do things to help themselves, but I think we can do something to find a solution. If there's a will, we'll find a suitable way.

[Ramez Ayoub, Liberal, Thérèse-De Blainville, QC]

Do you want to expand the coverage for most chronic diseases, or for the most common ones? The coverage for more specific and less prevalent diseases is more expensive. The fewer the patients, the higher the cost of the research and drug. It's a matter of math. Canada has a population of 36 million. The United States has a population of over 300 million. When research is conducted, the market is completely different. How do you deal with this aspect? What's your solution?

What do you think, Mr. MacLeod?

[Peter MacLeod]

Thank you.

The two ends of the spectrum really were of central concern to the panel. We need to provide those necessary medicines through a basic list in the first instance, which would deal with many of those chronic and pervasive conditions and relieve the pressure on Canadians who lack sufficient coverage. They also think—and I think it's the reason why many provinces have moved to provide some degree of catastrophic coverage—there needs to be, as quickly as possible, action taken to absorb those costs and relieve Canadians of the burden that comes with a rare disease.

[Ramez Ayoub, Liberal, Thérèse-De Blainville, QC]

I think my time is up. Thank you very much.

[The Chair, Liberal, Bill Casey]

Your time is up.

That completes our five-minute round.

Now, Mr. Davies, you have three minutes.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you, Mr. Chair.

Mr. MacLeod, I want to refer again to your report, where you say:

A national pharmacare system should provide coverage for drugs on a comprehensive, evidence-based complete list. Medicines should be selected for this list based on medical and cost effectiveness. New drugs will be evaluated using the same criteria before they are added to the formulary. In order to be patient-centred, this list should be ample enough that it provides sufficient flexibility to take into account individual patient circumstances. This list will include the drugs proven to be most suitable for all conditions, including rare and catastrophic diseases.

You go on to say, “This national pharmacare system should be provided through public insurance.... However, all essential, medically necessary drugs will be covered for all Canadians under the public system.”

You have further said that there's room for some private coverage to purchase optional private drug insurance. I'm interested in finding out what kinds of drugs would be covered under the private system, given the results of the panel's report.

[Peter MacLeod]

There are, of course, many different pharmaceuticals available, depending on the condition. Sometimes it's the difference between a generic and a brand-name medicine. I think it's the intention of the panel to move the generic medicines into a public system, and perhaps not retain exclusivity but that you would offer a degree of patient choice around some of these brand names through private insurance.

[Don Davies, NDP, Vancouver Kingsway, BC]

Do I have it right that the basic thrust of the panel's report is that all medically necessary prescriptions that are evidence-based should be covered under the public system?

If someone wants to purchase a brand name over and above the generic, or some form of experimental medication, they are free do to so. The goal here is to make sure that every Canadian has access to medically necessary prescriptions under the public system. Do I have that right?

[Peter MacLeod]

That's exactly right.

[Don Davies, NDP, Vancouver Kingsway, BC]

You probably heard from my colleagues in the Conservative Party that there's a bit of a philosophical divide on this committee around expense, and what I'm hearing your panel suggest is very similar to the medicare system.

Sometimes I think I'm being transported back to 1962, where people are arguing, “It's too expensive to cover every Canadian for basic medical coverage. Sure, it would be nice to have everybody be able to go to a doctor or a hospital and get the coverage they want, but we just can't afford it.” I think right now medicare is one of the most cherished values of Canadians today, and not many Canadians would argue that we should dismantle our public health care system.

Am I right in seeing this as a natural extension? The next stage of pharmacare will gradually expand universal coverage to the medicines that Canadians needs?

[Peter MacLeod]

I believe so. The fact that Canada is an outlier in this area has to be of some significance. Other countries wouldn't have adopted universal public coverage if the health outcomes were lower and if the costs were higher. Canada, being a highly decentralized country with health responsibilities resting with the provinces, perhaps has made it more difficult and has diffused responsibility amongst governments for seizing the initiative on this file.