Health Committee on May 2nd, 2016

[Don Davies, NDP, Vancouver Kingsway, BC]

We've had evidence before this committee that 20% of Canadians—you talked about people around this table having coverage—either have no coverage whatsoever or have inadequate coverage for prescription care. That's seven million Canadians.

In your view is that an acceptable public policy position for our country?

[W. Neil Palmer]

As I testified, sir, it could be more than that; it could be less than that. We really don't know. That 20% number is not very good.

Again, I would recommend that the federal government could make an important contribution there towards really understanding who these Canadians without coverage are.

[Don Davies, NDP, Vancouver Kingsway, BC]

I want to be clear. Are you disputing the 20% figure, or do you...?

[W. Neil Palmer]

I'm saying that the 20% number is weak. It could be more, sir. It could be less. I don't know. In fact no one knows for sure. That's the real problem.

[Don Davies, NDP, Vancouver Kingsway, BC]

I take it, sir, that you're probably aware that in the 1960s there was a raging debate in this country about whether or not we could provide universal health care coverage for every Canadian so every Canadian could go to a doctor or go to a hospital, and exactly the same arguments were being made then as you are making here today, that it's unaffordable and it ought not to be pursued.

Would you agree with me that the issue of affordability is only one aspect of this, but also the public policy benefits of making sure that every Canadian can get access to the medicine they need regardless of their ability to pay is also an important factor?

[W. Neil Palmer]

It was certainly an issue in the 1960s. My father was a physician, and I think physicians were very conflicted about the benefits or the harms as Canadian medicare was being rolled out.

An important difference then, sir, was that each province had its own plan. There was no national health care. Still today there is no national health care. Each province has its own system, and if back in the 1960s we had said we would have a national system, it would be a lot easier today to have a national pharmacare system, because we wouldn't have the patchwork of provincial systems the same way we have patchworks of physician systems and everything else from province to province. They are not the same from province to province.

[Don Davies, NDP, Vancouver Kingsway, BC]

I was going to ask about that. I thought you made the comment that we do not have a national health care system. Your position is that we do not have a national health care system in Canada?

[W. Neil Palmer]

That's correct. We have a medicare system that has five principles that the provinces respect in putting their own health systems in place, but if you move from one province to the next, it's not like it's automatic. You have to apply to get onto the next health care system.

[Don Davies, NDP, Vancouver Kingsway, BC]

We've heard from some prominent physicians and health policy leaders—for example, Dr. Irfan Dhalla from Health Quality Ontario and St. Michael's Hospital, and Dr. Danielle Martin from Toronto Women's College Hospital—that a national formulary and universal coverage would improve patient health. Would you agree with that?

[W. Neil Palmer]

I haven't seen the evidence to support that.

[Don Davies, NDP, Vancouver Kingsway, BC]

The committee also heard from Dr. Katherine Boothe, who's currently a pharmaceutical policy expert at McMaster University. She stated the following: “Both the U.K. and Australia have universal single-payer programs for pharmaceuticals and they both do a better job at containing costs than Canadian drug plans do currently.”

Do you disagree with that statement?

[W. Neil Palmer]

I would agree that costs are lower in those markets. The question is whether or not there are drugs available here that are not available there. You have to look at both aspects, but certainly costs are lower in those markets—again, through budgeting.

[Don Davies, NDP, Vancouver Kingsway, BC]

Dr. Sher, it sounds as though you've had some success in providing a universal publicly funded system through bulk purchasing for particular products important to Canadians—plasma products. Is there any reason, in your view, that the success you've experienced could not be replicated on a national basis for a broader range of medicines?

In other words, you've done it successfully: universal, free provision of these products to Canadians in bulk buying for plasma. Is there any reason we couldn't broaden that to more products?

[Dr. Graham Sher]

It's a very good question, Mr. Davies. My answer, just very briefly, as certainly I am no expert in national pharmacare in all its various dimensions, is that I do believe the model we operate is worthy of extensive analysis and research. I believe it is replicable in some ways for certain classes of drugs. It is not the panacea to every issue that a national pharmacare program needs to grapple with, and it's not just about bulk purchasing and price benefits. It's really those other dimensions that I spoke to: ensuring security of supply and patient choice and physician input, and equitable access right across the country.

I think there are several dimensions. We're simply offering our model, open to all those interested, for worthy analysis. I do believe components of it are relevant for some of the debates around national pharmacare.

[Don Davies, NDP, Vancouver Kingsway, BC]

Fair enough. I understand you when you say that it's not replicable for everything, but certainly you can envision other products, pharmaceuticals that Canadians need, being covered by a similar system.

[Dr. Graham Sher]

Absolutely, and particularly for expensive drugs for less common diseases. I think there's tremendous merit in examining our model for that.

[Don Davies, NDP, Vancouver Kingsway, BC]

I see. We do have, I think, some witnesses coming on Wednesday to testify about rare diseases.

[Dr. Graham Sher]

I believe you do, yes.

[Don Davies, NDP, Vancouver Kingsway, BC]

We'll follow up with them on that question.

[The Chair, Liberal, Bill Casey]

Mr. Oliver.

[John Oliver, Liberal, Oakville, ON]

Mr. Palmer, I just wanted to focus in on some of your testimony. The coverage gap, which Mr. Davies referred to as well, is one of the biggest concerns I have. We don't have universal coverage for pharmacare, and some Canadians, depending on their employment, either do or don't have coverage. About six million, or 22% of Canadians, right now are privately insured. They're paying out of their own pockets. Another significant portion are uninsured, and because many don't fill prescriptions as they can't afford them, we really don't know the extent of those who are under-insured or unable to provide.

We've heard other witnesses state that the catastrophic drug coverage programs really don't work—there was very good and compelling testimony on this—and that the public-private mix isn't working. What is your answer? You were very critical of a comprehensive pharmacare program in Canada. You were quite critical of it but there was no response to the coverage gap. How would you actually address that?

[W. Neil Palmer]

As I testified, sir, I think the first issue we have to get a handle on is with regard to who doesn't have coverage. Most of the information that's been gathered to date has either been part of an opinion survey or an add-on question in some health surveys where there wasn't a lot of follow-up to understand who these individuals are and what type of coverage they don't have. It's often a question like, “Have you not filled a prescription because of cost?” Similar questions asked in New Zealand got a 6% positive response, and there they have universal care.

We need to understand what drugs are not being covered, and for which people. If you asked half the university students here if they had drug coverage, the answer would probably be no, in many cases, when in fact they do. They don't know they have coverage. So who are these people? We need to understand that.

Then we need programs put in place. It could range from the P.E.I. program, which provides coverage for generic drugs for anybody in the province with a provincial health card. That at least gets them over the basic coverage. Then we need to look at the catastrophic plans like Trillium, which is essentially a copay of 4% of income, and bring that number down to something that's more affordable.

What is that percentage? I don't know. That's what we need to do. We need to do the work to understand that.

[John Oliver, Liberal, Oakville, ON]

I have to say that all the things you're describing still result in inequitable coverage for Canadians, depending on their employment status and their private insurance, so that concerns coverage.

[W. Neil Palmer]

I'm not sure how it's inequitable. It's somehow very good—

[John Oliver, Liberal, Oakville, ON]

We've heard from other witnesses that catastrophic coverage still leads to incredible costs for people who aren't working and are unemployed or poor.

The second question I had was dealing with a statement you made in your report that unions will not be happy exchanging “their private drug plan for an inferior public plan”. I was curious about why you had concluded that a public plan would be inferior.

I'll make this a two-part question. I'm assuming that you perceive a private plan with an open formulary to be a better plan, but we've heard from other witnesses that these lead to over-prescribing or inappropriate prescribing. I'm wondering how you reconcile that with the public plan's being inferior and, if you're going down the road of better availability of drugs, how you deal with the open formularies and the problems with open formularies.