Evidence of meeting #4 for Health in the 42nd Parliament, 1st Session. (The original version is on Parliament’s site, as are the minutes.) The winning word was federal.

A recording is available from Parliament.

On the agenda

MPs speaking

Also speaking

Abby Hoffman  Assistant Deputy Minister, Strategic Policy, Department of Health
Gigi Mandy  Director, Canada Health Act Division, Strategic Policy, Department of Health

3:30 p.m.

Liberal

The Chair Liberal Bill Casey

We'll call the meeting to order.

There are a couple of housekeeping issues that I want to go over before we go very far. We asked the minister if we could have the reports on e-cigarettes and safety code 6, and she replied that we have to bring those reports back to this committee, discuss them, and pass them, and then she will respond to them. However, as they are now, they are expired.

I think the committee is interested in having responses to those two studies. If we want to do that, we have to bring them back, refresh them, and table them in the House of Commons in order for them to respond. Does anybody want to make a motion to do that?

Mr. Carrie.

3:30 p.m.

Conservative

Colin Carrie Conservative Oshawa, ON

Sure. I'll make a motion to bring those reports back so that we can have the minister give us a response.

3:30 p.m.

Liberal

The Chair Liberal Bill Casey

Could the analysts give each member a copy of those two reports, the one on e-cigarettes and the one on safety code 6, so that we will have them right away? We'll bring them back at a future date.

Also, the issue of marijuana came up in the last meeting. Dr. Leitch raised the marijuana issue in the last meeting, and we wrote to the Minister of Justice to ask if we could expect a reference for any legislation to come this way. We don't have an answer yet, but I just wanted to let you know that we're working on that.

In the meantime, we should move ahead with those two reports, and we'll get them under way.

We have two distinguished witnesses here today, and we're looking forward to hearing from them. Ms. Abby Hoffman is the assistant deputy minister, strategic policy, and Ms. Gigi Mandy is the director of the Canada Health Act division, strategic policy.

We'd welcome opening statements, if you have them. You have the floor.

3:30 p.m.

Abby Hoffman Assistant Deputy Minister, Strategic Policy, Department of Health

Good afternoon to all of you.

Thanks for the invitation to talk to the committee about the Canada Health Act generally, and the Canada Health Act annual report for 2014-15, which was tabled in Parliament just about a month ago, on February 25.

To start, I want put the Canada Health Act in context. I'll start by making a few comments about the role of the federal government in Canada's health care system.

As you likely all know, as a partner with many other players, most notably the provinces and territories, the federal government has a number of functions: we protect Canadians from environmental risks associated with unsafe food, health, or consumer products; we approve drugs for sale in the Canadian marketplace and monitor their safety; we respond to infectious disease outbreaks and various health emergencies; we support the delivery of health care to first nations and the Inuit, federal inmates, members of the Canadian Forces, and veterans; we promote and fund innovation and research in health care; and we inform Canadians about various health risks and beneficial practices that will help them make healthy choices.

With respect to health care specifically, while responsibility for the delivery of health care services rests primarily with provinces and territories, historically and currently, the federal government has exercised its spending power to support provinces and territories in the discharge of their responsibilities, and in so doing, to set the underlying principles and values for health care systems across the country.

As you know, the main vehicle through which the federal government transfers funds to provinces and territories is the Canada health transfer. By way of reference, in 2015-16, the current fiscal year, the federal government provided about $34 billion via the CHT, which represents a little over 23% of the total spending by provinces and territories. This transfer of funds to provinces and territories under the CHT is not automatic. In fact, in order to receive its full allocation, each province or territory must ensure that its publicly funded health insurance plan meets the requirements of the Canada Health Act.

The conditions and criteria of the act are, in effect, the national principles that guide the Canadian health care system: universality, comprehensiveness, accessibility of care, portability, and public administration. These principles indicate who shall be covered, for what, in general terms, and where within Canada and beyond our borders, as well as the basic character of provincial health insurance systems—that is, that those shall be publicly administered and operate on a non-profit basis.

Very importantly, the act also has provisions that discourage direct charges to patients for publicly insured health care services. These charges, defined variously as extra billing or user charges, are articulated in the act. These provisions are a critical element, giving meaning to the accessibility principle.

As the only federal legislation pertaining directly to the delivery of health care services, the Canada Health Act is a good example of the federal government using its spending power to set national standards and promote the primary objective of Canadian health care policy, which, as stated in section 3 of the act, is “to protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers”.

The CHA is an excellent example of how governments have worked together over time to solve complex social policy challenges. In the annual report, there is a description of the relevant history in some detail. I just want to touch here on a couple of key milestones.

Canada's commitment to a largely publicly funded health care system began in 1947 as an ambitious and visionary experiment in public hospital insurance in Saskatchewan. Ultimately, to support replication of the Saskatchewan arrangements, the federal government passed the Hospital Insurance and Diagnostic Services Act in 1957, which committed the federal government to share the cost of these services with provinces. By 1961, all other provinces and territories had adopted similar models.

A few years later, the same pattern was repeated when Saskatchewan expanded its public health insurance regime into coverage for physician services. The Parliament of Canada passed the Medical Care Act in 1966, and again, other provinces and territories followed suit by 1972. By that time, both hospital and physician services were available to Canadians through a universal, pooled risk health insurance scheme.

Although Saskatchewan's Tommy Douglas saw publicly insured hospital and physician services as simply the initial stages of a medicare system that would eventually include other elements of care such as dental or access to drugs, the focus of Canadian medicare has remained focused on hospital and physician services.

Moving ahead a little bit in historical terms, by 1979, it was apparent that the objective of federal support for physician and hospital services for Canadians was being undermined by additional charges levied directly on patients.

In response to this growing threat to universal access to care, in 1979, at the request of the federal government, Justice Emmett Hall undertook a review of the state of heath care services in Canada. His report affirmed that health care services in Canada ranked among the best in the world, but he warned that extra billing by doctors and user charges levied by hospitals were creating a two-tier system that threatened universal accessibility of care.

Justice Hall's report and the national debate it generated led to the enactment of the Canada Health Act in 1984. The act retained the basic principles contained in those two earlier pieces of legislation and reaffirmed the country's commitment to a universal health insurance program by adding specific prohibitions on extra billing and user charges. In effect then, the goal of the Canada Health Act is to ensure that medically necessary physician and hospital services, as well as certain surgical dental services are available to Canadians on uniform terms and conditions, and without financial or other barriers.

The federal government encourages provinces and territories to experiment and design health care systems that meet their own particular circumstances, so long as the principles of the CHA are respected.

Since the act was passed, adherence by provinces and territories to its principles has meant that the provincial and territorial health insurance systems are much more alike than they are different. The machinery of the administration of the act also contributes to the consistency of a nationally publicly funded health care system. For example, Health Canada chairs a federal-provincial-territorial committee on reciprocal billing, which helps resolve issues Canadians may face when moving to other provinces or when travelling.

Health Canada also hears from Canadians through correspondence and telephone calls. In some cases, departmental officials are able to assist Canadians as they navigate the health care system and we may even intervene on their behalf.

For example, and this is a recurring situation, Canadians who move from one area of the country to another do not always understand that they are required to register with their new province's health insurance scheme. This only comes to their attention when they try to secure care using an expired or out-of-province card from their old province of residence. Working with both implicated provinces, we have on many occasions been able to assist Canadians in maintaining their coverage.

Of course, when Canadians reach out to us to comment on the delivery of specific services, we refer them to provincial and territorial ministries who have jurisdiction in this area.

I want to stress on the issue of compliance by provinces and territories that the health insurance plans of the provinces and territories generally respect the criteria and conditions of the Canada Health Act. In fact, the legislation in most provinces, governing their health insurance schemes, often goes well beyond the requirements of the Canada Health Act both in terms of the range of services covered and mechanisms to ensure compliance with the values and principles of universally accessible health care.

Many jurisdictions, as you likely know, cover to a certain degree vision care, pharmaceuticals used outside of hospitals, ambulance services, and so on. When provinces and territories provide care outside the scope of the act, they are not bound by the requirements of the act. They are free to arrange those services on their own terms and conditions, and according to their own priorities. This allows jurisdictions to target specific populations such as children, the elderly, or specific regions, and to require some sharing in costs by patients.

We recognize that while the CHA may establish important principles, provinces and territories are responsible for administering their multi-faceted systems that are usually governed by considerably more complex legislation detailing every aspect of how their health insurance scheme is administered, and how their health care system is organized, financed, and governed.

While the core principles of the Canada Health Act have enduring value, as health care evolves, the legislation has been subject to periodic clarification and interpretation to ensure its application to new circumstances.

Administration of the act, by way of example, has been informed by three very important key interpretation letters over the past 30 years.

In 1985, Minister Jake Epp's letter elaborated in great detail on the provisions of what was then still new legislation.

A decade later, in 1995, Minister Diane Marleau communicated the federal policy on private clinics, which expanded the definition of hospital to include facilities where patients, at that time, had to pay facility fees to receive services covered under medicare. Her letter was intended to put an end to those kinds of patient charges.

Finally, in 2002, Minister Anne McLellan wrote to the provinces and territories to outline a Canada Health Act dispute avoidance and resolution process. The objective of this initiative was to encourage ongoing communication, in the interest of avoiding disputes in the first place. In the event that such a dispute did occur and was not resolvable through our normal informal processes, a formal process to deal with these disputes was set out.

When instances of possible non-compliance with the Canada Health Act arise, our approach to the administration of the act emphasizes transparency, consultation, and dialogue with provincial and territorial health ministries. We rely on the goodwill of provinces and territories as we work through issues of concern, because under the act we do not have any direct investigative powers.

The application of financial penalties, through deductions under the Canada health transfer, is considered only as a last resort when all other options to resolve an issue collaboratively have been exhausted. These penalties are documented in the annual report, which you may have seen.

As you may have seen in the annual report that was tabled in February, from the time of the passage of the Canada Health Act until March 2015, over $10 million has been deducted from provincial or territorial transfer payments as a consequence of extra billing and user charges. That may seem like a small amount. I'll just note that the $10 million does not include close to $245 million that was deducted from 1984 to 1987 and subsequently refunded to the provinces and territories when they agreed to eliminate extra billing and user charges. That refund mechanism, which is no longer in effect, was intended at the time to act as an incentive for provinces and territories to come into compliance with the act. That's why the provision was time limited.

I want to be clear that our goal in administering the Canada Health Act is not simply to levy penalties. In fact, it's not really to levy penalties at all, but rather, to achieve compliance and therefore ensure access to insured services for Canadians, without barriers associated with ability or willingness to pay.

Let me quickly make a couple of comments about the annual report.

Tabling the report is a legislative requirement. It must be tabled in the first 15 sitting days of each calendar year. Although it is tabled in the federal Parliament, the content of it reflects the collaborative effort of provincial, territorial, and federal governments to inform Canadians about their publicly funded health insurance plans.

The federal section of the 2014-15 version of the report describes the Canada Health Act, our approach to administering it, and compliance issues that were on the table during the 2014-15 reporting period. As you may have seen, the bulk of the report is actually taken up by overviews of provincial and territorial health insurance plans. This information is provided to us at our request by provinces and territories. This data shows how each of those plans meets the conditions and criteria of the act, along with relevant statistics on publicly insured hospital, physician, and surgical-dental services in each jurisdiction.

However, it's important to note at the same time that while the report contains a lot of information about medically necessary physician and hospital services, which are subject to the criteria and conditions of the act, the report's scope does not extend to reporting on the status of the Canadian health care system as a whole. It is simply a report on the extent to which provincial and territorial health insurance plans comply with the conditions and the criteria of the act.

As I come close to the end of my remarks here, let me comment briefly on compliance issues. In terms of specific issues noted in this year's report, you will see a commentary on a deduction to British Columbia's CHT payment in the amount of a little over $241,000. This deduction was taken in respect of extra billing and user charges at private surgical clinics in B.C.

The report also notes a number of other recent and long-standing compliance issues. These issues vary from following up on stakeholder allegations of extra billing, to insisting that patients cannot be billed directly when they elect, for example, to have robotic-assisted surgery. Over the last year, we've approached provinces where hospitals were charging patients directly for preferred hospital accommodation when ward space was not available. We've also raised concerns in some parts of the country about membership fees at primary care clinics which, in our judgment, had the potential to pose a barrier to access to insured services.

I'm happy to say that our compliance work is generally conducted as a two-way street. From time to time provinces come forward and ask for advanced assessments of initiatives they are considering, to ensure that those conform to the requirements of the act, or at least they know in advance what might ensue if there's an issue or a proposal that might fall outside the act.

In the year in question we provided two such assessments. One concerned a proposal by a charitable foundation to pay for a nurse practitioner clinic dedicated to the clients of a community resource centre. The province was concerned that providing preferred access to clients would pose accessibility concerns under the act, but we advised the questioner that since the services were not provided by physicians nor in a hospital there were no concerns under the act.

The second assessment concerned a proposal by a group of ophthalmologists who wanted to charge patients for tests when they were performed in a physician's office instead of in a hospital. In that case there was a concern about the Canada Health Act, since the tests form part of a physician service, and no direct fees may be charged for such services when they are insured by a provincial or territorial health insurance plan. That proposal was abandoned.

Lastly, before turning to questions I'd like to touch on a recurring criticism that we certainly hear, and that is, that the Canada Health Act is an outdated piece of legislation that impedes innovation and modernization of health care systems. Not surprisingly, we have another view.

We'd like to remind members of the committee that the act allows provinces and territories the flexibility to experiment with various governance, organizational, delivery, and financing arrangements, provided those experiments meet the Canada Health Act test of no direct patient charges for insured services.

For example, many provinces are experimenting with family health teams, where physicians and other health care professionals work together to manage various aspects of patient care.

Other provinces have made care for those suffering from chronic conditions in remote areas less burdensome through tele-monitoring of patients' conditions.

Since no direct charges are made to patients in either of these cases there is no concern under these alternative delivery models. We think they are examples of the way in which the act is sufficiently flexible to accommodate delivery models that, frankly, were not envisaged in 1984 when the act was passed.

Let's just make this our concluding comment in these initial remarks. Our general view is that we think the values that underpin the act—those of equality, fairness, and solidarity—are just as relevant today as they were in 1984, and they will remain relevant as we continue to improve our health care system to meet the evolving needs of Canadians.

Mr. Chairman, I'll stop there, and both Gigi Mandy and I will be happy to take the members' questions.

Thank you.

3:50 p.m.

Liberal

The Chair Liberal Bill Casey

Thank you very much.

It sounds to me like you must make a lot of judgment calls in the run of a day.

We'll start our questioning with Dr. Eyolfson.

3:50 p.m.

Liberal

Doug Eyolfson Liberal Charleswood—St. James—Assiniboia—Headingley, MB

Thank you for that very interesting and informative presentation.

One of the things you spoke of was how the Canada Health Act does exclude some services, in particular out-of-hospital pharmaceuticals and ambulance services. Would you see the exclusion of these services as a problem for the long-term viability of the Canada Health Act?

3:55 p.m.

Assistant Deputy Minister, Strategic Policy, Department of Health

Abby Hoffman

I'll start, and Gigi may want to comment.

They don't impact the viability of the act in that it's still the case that a very large portion of health care spending in Canada goes to hospital and physician services. They are, obviously, governed by the conditions and criteria of the act.

I think it is the case that the result of the Canada Health Act's focus on physician and hospital services does mean that across the country other services, such as the ones you've mentioned and many others, are either not covered at all, or if covered, are covered in different ways in different parts of the country. The good news is that in many provinces they've evolved to pretty much the same level of development, so a lot of these services are covered in some manner or another. Drug coverage is clearly an issue, as well as access to other services in the community, for example, home care.

The fact that there are differences across the country is an issue of concern, even if provincial and territorial funding in these areas is quite robust. At this point, that is simply the state of play across the country.

3:55 p.m.

Liberal

Doug Eyolfson Liberal Charleswood—St. James—Assiniboia—Headingley, MB

Could Health Canada measure the potential benefit of universal coverage for pharmacare in cost savings to the health care system, versus the outlay of cash initially to establish such a system?

3:55 p.m.

Assistant Deputy Minister, Strategic Policy, Department of Health

Abby Hoffman

Are you speaking specifically about drugs, or are you talking more—

3:55 p.m.

Liberal

Doug Eyolfson Liberal Charleswood—St. James—Assiniboia—Headingley, MB

I'm talking more about drugs. Is there any analysis that might look at the cost of funding out-of-hospital pharmaceuticals versus the costs saved to the health care system by improving outcomes in those who can't afford them? Has any analysis like that been done?

3:55 p.m.

Assistant Deputy Minister, Strategic Policy, Department of Health

Abby Hoffman

There's no algorithm that makes a precise calculation of the consequences of forgone access to drugs among those Canadians who cannot afford to fill prescriptions. We do know from various surveys that it's not a huge portion, but there is a critical mass of Canadians who actually say they do not fill or renew prescriptions because they simply cannot afford to. We do know that there are downstream costs to the health care system, incremental costs associated with that. We would note from any of these studies that have been done that they are likely larger than the costs associated with providing drug coverage for those individuals.

Yes, there are downstream costs in terms of deteriorating health, possible admission to hospital, and utilization of other health care services. I think it's actually the reason that now, as you know, under the discussions about a shared health agenda and the potential of a new health accord, access to pharmaceuticals is one of the key components of that effort. There is a lot of concern about both the cost implications and the toll that it's taken on the health of those individuals who simply cannot afford drugs.

The people we're talking about are individuals who do not qualify for provincial/territorial public drug plans, which are mainly focused on older Canadians or people on social assistance. We are talking about people whose employment status is such that they don't have access to private insurance. There's that still quite sizable portion of the population who pay out of pocket for their own drugs. And a portion of those people—about a quarter of the total, some smaller portion, but nonetheless a significant portion—simply cut back on drugs that they should otherwise be using.

3:55 p.m.

Liberal

Doug Eyolfson Liberal Charleswood—St. James—Assiniboia—Headingley, MB

Based on your experience, if there were to be some level of expanded coverage for out-of-hospital pharmaceuticals, can you see what kinds of high-level administration challenges there would be, other than the initial outlay of funds?

4 p.m.

Assistant Deputy Minister, Strategic Policy, Department of Health

Abby Hoffman

The design of any kind of program that would try to bring in some sort of coherent coverage regime would have to deal first of all with who's eligible, under what conditions, how are they being reimbursed for drugs, on what kind of formulary, and with what kind of copays or patient contributions.

One thing initially one would want to guard against is people finding a new initiative so attractive they remove themselves from either their existing employment-based supplementary benefits coverage, or they remove themselves from some other public plan.

The complexities around the design of drug plans are quite significant. The provincial programs, the federal government's program for first nations and Inuit, and the non-insured health benefits programs are complex things to design. I think ultimately most people would argue whether somebody has access to an employment-based program, or they have access to a publicly financed plan, the parameters should be the same.

A lot of people talk about having for example a common formulary for access to drugs for all Canadians regardless of how they have their coverage financed.

4 p.m.

Liberal

The Chair Liberal Bill Casey

Mr. Carrie.

4 p.m.

Conservative

Colin Carrie Conservative Oshawa, ON

I want to thank Dr. Hoffman for being here. Whenever we have such a famous and inspirational Canadian in front of us, I think we're honoured by that.

My first question to you is basically an update. I think you're aware of Quebec's Bill 20. I was wondering where that legislation is at, and what the department's viewpoint is on it.

4 p.m.

Assistant Deputy Minister, Strategic Policy, Department of Health

Abby Hoffman

You're talking about the intent to develop a schedule of fees that patients would be charged, or I would say the owners of clinics would be allowed to impose on patients for certain services delivered in clinics.

At the moment our understanding is the legislation has been passed. A schedule of permissible fees is being developed. Up to this point, that fee schedule has not been published. An effective date, in our understanding, is possibly in late spring. In the May to June period, that schedule would be published, and the regulations would be in effect that would allow providers to levy these fees for services in a particular facility; that is, in clinics.

Of course it hasn't happened yet, so nobody has been charged anything. We certainly would say that is a fairly direct challenge to the Canada Health Act.. Interestingly, as we understand the arrangements, some of those same services if provided in a hospital would be provided to patients without any fee being imposed. This would be a fee that would be charged in particular settings where these services would be delivered.

4 p.m.

Conservative

Colin Carrie Conservative Oshawa, ON

Thank you for that.

For my second question, you mentioned in your presentation that the Canada health transfers are up to $34 billion, or somewhere around there.

Out of curiosity, in about the last 10 years has the federal government ever lowered or cut these transfers, or have they always gone up every year?

4 p.m.

Assistant Deputy Minister, Strategic Policy, Department of Health

Abby Hoffman

The transfers are subject to arrangements between the federal government and the provinces. Currently the year-over-year increase of the total pot of the Canada health transfer is 6%. There is a complex formula. It's less complex than it used to be because it's now on an equal per capita basis for determining how much each province gets. The only reason I'm suggesting that it's complicated is because when there was a move from an old formula to equal per capita then adjustments had to be made to move forward into that new regime.

No jurisdiction has received less in any year through the CHT than they received in a prior year. In cases where there had been deductions associated with issues of compliance under the Canada Health Act, the amounts are as much symbolic as they are material. In recent years none of the deductions to CHT for non-compliance have significantly eroded what any jurisdiction has received as CHT.

4:05 p.m.

Conservative

Colin Carrie Conservative Oshawa, ON

Thanks for clarifying that, because I've heard that some people out there are stating that the federal government has cut transfers.

How effective have previous increases in the federal health care funding been in promoting health care system reform efforts? Also, what kind of accountability is there with the transfers? I know the federal government has been giving 6% per year. For example, in Ontario I think for a few years their increases in spending have only been 2%, so they're getting 6% and spending 2%. Just out of curiosity, do you think the accountability measures that are there are good enough, or is it something that needs to be looked at?

4:05 p.m.

Assistant Deputy Minister, Strategic Policy, Department of Health

Abby Hoffman

There's one accountability measure, as I mentioned, related to the CHT, and that's the requirement to comply with the Canada Health Act. I think it's fair to say that the transfers for health are, obviously, in respect of health, but they're also part of the fiscal arrangements of the country. Ultimately, as far as the CHT is concerned, it's up to each province or territory to decide how they spend that money.

I should just note one thing from a pure mathematical standpoint. You may be right that the Canada health transfer has gone up in percentage rates that exceed the growth in health care spending in particular recipient provinces. But it's worth remembering that the federal government's contribution is somewhere in that 20% to 24% range. I'm not belittling the value of 6% on 23%, but obviously the bulk of the burden of spending on health care is still borne by provincial treasuries.

Also, I'll just say that under the 2004 accord there were reporting obligations, which provinces and territories accomplished. They do not, however, constitute iron-clad guarantees about either reporting or what the recipient province or territory will do with the money. I think this is simply a matter of respecting the jurisdictional responsibilities the provinces, territories, and federal government respectively have.

4:05 p.m.

Conservative

Colin Carrie Conservative Oshawa, ON

I know we've made major investments in stuff like the Canadian partnership organizations, such as the Canadian Partnership Against Cancer, the Mental Health Commission of Canada, and other national associations working to address Canadians' biggest health challenges. I was wondering if you could let us know the biggest successes achieved in these areas and how you think the organizations should be adapting to new challenges as we go forward.

4:05 p.m.

Assistant Deputy Minister, Strategic Policy, Department of Health

Abby Hoffman

Mr. Carrie, are you talking specifically about organizations like the Canadian Partnership Against Cancer?

4:10 p.m.

Conservative

Colin Carrie Conservative Oshawa, ON

Yes.

4:10 p.m.

Assistant Deputy Minister, Strategic Policy, Department of Health

Abby Hoffman

I'll just say—and this may or may not be known to members of the committee—that there are eight organizations that Health Canada funds, which play various roles in the health system. There's the cancer partnership, the Canadian Institute for Health Information, the Mental Health Commission, the Canadian Centre on Substance Abuse, the Patient Safety Institute, the Canada Health Infoway, and so on.

These organizations, which we describe as “shared governance organizations”, are managed.... In fact, most of them were created by the federal government, but they have federal, provincial, and territorial representation on them. They are intended to be highly responsive to needs identified across the country.

Unlike the CHT, which, as I mentioned, is a lot of money with an important accountability but really only in the area of the Canada Health Act, these other organizations have a specific responsibility in their particular area of interest. The Canada Health Infoway is specifically in the business of advancing electronic health records, and that sort of thing. The cancer partnership is dedicated to getting everybody in the cancer community working to the same objectives with the most important advances in cancer control and prevention.

I don't know if I would characterize it as saying that we have more control over those organizations. That's not really the main point I want to make. What I simply want to say is that they are clearly focused on their main business. There are not issues around whether or not, for example, the Canadian Partnership Against Cancer is spending money on something other than cancer. They can't, they don't, and they won't. They are really focused on their task.

The total cost to the federal government of these organizations I've just mentioned, in terms of budgetary allocation, is less than $400 million a year, which is not a large amount in the grand scheme of health care spending in Canada, which is in the hundreds of billions of dollars. They really do very important work with, as I say, relatively small resources, because of the very focused mandates they have and the governance that helps direct the work they do.

4:10 p.m.

Liberal

The Chair Liberal Bill Casey

Mr. Davies.