Health Committee on May 23rd, 2024

[Stephen Frank]

I don't think you could make that general statement, no. It's an extremely competitive space. Everyone's competing with a very broad suite, and employers make decisions based on what's in their best interests.

It's case by case. There are hundreds of thousands of employers out there who have different reasons for going with different providers.

[Marcus Powlowski, Liberal, Thunder Bay—Rainy River, ON]

An employer has to basically buy a plan for their employees. In the case of for-profits, what percentage of the money that goes toward that plan ends up in profits? You said it's small.

[Stephen Frank]

It's very small.

Again, I don't have that detail in front of me, but what I can say is that it's a mixed system, with for-profits and not-for-profits competing aggressively. The thing that unites them is we provide coverage for 27 million Canadians. All of them get much better coverage than they would on any public program, and we're very proud of the service that we offer to Canadians. We also know that, overwhelmingly, they don't want that disrupted.

[Marcus Powlowski, Liberal, Thunder Bay—Rainy River, ON]

I'm going to sound like someone in Peter Julian's party when I say this, but—

[Peter Julian, NDP, New Westminster—Burnaby, BC]

That's a good thing.

[Voices]

Oh, oh!

[Marcus Powlowski, Liberal, Thunder Bay—Rainy River, ON]

—why would you, as a company, as an insurer, want to enter the business if your margins are so small? Why form such a company?

I'm being a bit skeptical of the fact that you're saying, “Oh, well, you know, they hardly make any money at all.” Well, I don't think that when you're a corporate executive with those companies, you have that kind of mindset.

[Stephen Frank]

Well, it's a business that's important to us. It's a very competitive business. The margins are low. We're competing every day to offer the best service we can for Canadians.

I'll just reiterate that the 27 million Canadians who have that coverage today do not want to lose it. I think that as the government contemplates its go-forward plan with pharmacare, what the minister was talking about today makes a lot of sense. That's not what's reflected in this legislation, so I do think that amendments need to make sure that it maps to what we heard this morning from the minister. We would work very closely with the government to try to target the solutions to those who need it and to leave what's working well in place today.

[The Chair, Liberal, Sean Casey]

Thank you, Mr. Frank.

Mr. Blanchette‑Joncas, you have two and a half minutes.

[Maxime Blanchette-Joncas, Bloc, Rimouski-Neigette—Témiscouata—Les Basques, QC]

Thank you, Mr. Chair.

I'll continue my line of questioning.

Mr. Frank, you know that Quebec has had a pharmacare program for close to 30 years now. It's a good thing. We want other people in Canada to be able to have the same thing, if governments want to draw inspiration from it.

In Quebec, people have to pay a deductible ranging from $0 to $731, depending on their income. I'm trying to understand, from your point of view, the functionality of the program we're talking about right now. How can the plan work with a $0 deductible on the first dollar, keeping the same range of drugs, plus the possibility of adding innovative drugs? How do you see the situation?

[Stephen Frank]

What I can say is that we greatly value the Quebec system. We believe that it works quite well and that it could be a model for the rest of Canada. We completely agree with you. It's a system that works well between public and private. It provides exceptional coverage for Quebeckers.

I can't speculate on how it might work, based on what's described in this bill. In my opinion, it isn't clear. As I mentioned, the terms aren't defined and what is considered isn't very clear. That's one of the big risks: People can read the bill and come to different conclusions. As I mentioned, I think this bill should be revised so that its purpose is very clear and transparent.

I repeat that the Quebec system works very well, and it would be acceptable for us to have such a system in place elsewhere as well.

[Maxime Blanchette-Joncas, Bloc, Rimouski-Neigette—Témiscouata—Les Basques, QC]

Thank you for recognizing Quebec's expertise, Mr. Frank.

Since you're in the business, I'm curious to hear your take on this question: Where in Canada is the best pharmacare program?

[Stephen Frank]

Each province is completely different, but I can say that the system in Quebec works well. It's a good partnership between the public and private sector. It provides universal coverage for all Quebeckers. It's a system we're very comfortable with.

[Maxime Blanchette-Joncas, Bloc, Rimouski-Neigette—Témiscouata—Les Basques, QC]

Can you tell us who you think will decide which drugs will be allowed? Is it the Canadian Drug Agency? Is it the Institut national d'excellence en santé et en services sociaux, or INESSS, which is administered by the Government of Quebec? What's your view on that?

[Stephen Frank]

I would say once again that, for us, it works quite well with INESSS in Quebec and now with the Canadian Drug Agency elsewhere in the country. We're not recommending any changes in that regard. I know that INESSS works very closely with the federal system and that it works quite well.

That said, what we see in the bill raises questions for us. Who's going to decide what's covered? What will the process be? Where will that list be published? How often is that going to be changed?

[The Chair, Liberal, Sean Casey]

Thank you, Mr. Frank.

The last round of questions for this panel comes from Mr. Julian for two and a half minutes.

[Peter Julian, NDP, New Westminster—Burnaby, BC]

Thank you, Mr. Chair.

Apparently, certain members from Quebec didn't understand what I said, so I will repeat it. A coalition representing nearly two million Quebeckers put out a statement today. All the major unions—from the Fédération interprofessionnelle de la santé du Québec, the Table des regroupements provinciaux d'organismes communautaires et bénévoles and the Union des consommateurs to the Centrale des syndicats démocratiques, the Confédération des syndicats nationaux and the Fédération des travailleurs et travailleuses du Québec—pointed out in their brief that the current pharmacare program in Quebec has failed to ensure that everyone has reasonable and equitable access to drugs. The organizations go on to say that the various charges people have to pay for prescription drugs are actually user fees that serve to deter people, causing them to skip doses or go without their medications because they can't afford them.

My question is for the Canadian Health Coalition representatives.

According to two million Quebeckers, Quebec's public-private system is broken. What does it mean when people tell us that the system is working, that things are fine and that the government should continue to fund the hybrid system instead of establishing universal pharmacare?

[Steven Staples]

Thank you for the question.

Who is it fine for? That is what we have to talk about. Is it fine for Canadians?

Clearly, we hear that people in Quebec are not happy with the system they have. Talk to one of the leading health economists, Steve Morgan from the University of British Columbia. He ran the numbers. He says that Quebeckers are paying for drug medication in one of the highest-cost jurisdictions in the world. In fact, per capita, they're only topped by the United States. They pay more than Switzerland. In fact, if that system in Quebec were translated to other provinces, costs would actually increase because of the problems in the system.

I take the word of experts and health economists who looked at the Quebec model very closely. Listen to what people are saying. Is that the system we want to have for the rest of the country, or do we want to go with the kind of single-payer national universal system envisioned in Bill C-64?

[The Chair, Liberal, Sean Casey]

Thank you, Mr. Julian.

Thank you, Mr. Staples.

Thank you to all of our witnesses for being with us today. There was certainly a great variety and diversity of expertise, all of which is valued and appreciated.

We're going to suspend until seven o'clock to allow this panel to take their leave and get the next panel installed.

The meeting is suspended.

[The Chair, Liberal, Sean Casey]

I call the meeting back to order.

I'd like to welcome our final panel of witnesses for this evening. Under the programming motion that is guiding us through these proceedings, we are not to sit past 8:30, and I'd like to wrap up a little before 8:30 so that we can pass the budget, just to give you an idea of the timeline.

We extend a big welcome to the witnesses who have joined us here this evening. We have, from the Canadian Pharmacists Association, Joelle Walker, vice-president, public and professional affairs.

We welcome, from the Heart and Stroke Foundation of Canada, Manuel Arango, vice-president, policy and advocacy. From the National Indigenous Diabetes Association Incorporated, we have Céleste Thériault, executive director; and from the Society of Obstetricians and Gynaecologists of Canada, we welcome Dr. Diane Francoeur, chief executive officer.

You're probably aware that opening statements are five minutes in length and are given in the order in which you're listed on the notice of meeting, so we're going to begin with the Canadian Pharmacists Association.

Ms. Walker, welcome to the committee. You have the floor.

[Joelle Walker, Vice-President, Public and Professional Affairs, Canadian Pharmacists Association]

Mr. Chair and members of the committee, thank you.

We are pleased to have the opportunity to share our views on Bill C‑64.

I will be giving my opening remarks in English, but I would be glad to answer questions in either English or French.

Our testimony tonight is really aimed at providing the committee with a very practical perspective on what could happen at the pharmacy counter as changes are contemplated and considered as part of the legislation. My testimony will focus on three points.

The first is around the role of pharmacists in pharmacare. As anyone who has used a prescription drug will know, the pharmacist is the last person the patient will see before they get their medications. While the act of dispensing is complex, pharmacists do a lot more than simply fill prescriptions and sell medications; they provide critical care and counselling that are integral to the effective use of medications. Their daily interactions with patients place them in a unique position to understand their needs, educate them on proper medication use and advise on potential drug interactions. Pharmacare really should not be just about the cost of the drugs, but also the care that goes along with them.

Pharmacists also play a significant role in drug plan management and navigation, and that's not often seen by many patients. Every day, they submit millions of claims on behalf of their patients, they spend time on the phone with insurance plans and they help patients identify alternative treatment options that are covered by their plans. For this reason, it's essential that we have a pharmacist on the government's proposed committee of experts.

The second point I'd like to make is around how best to target medication coverage. Contraceptive and diabetes medications are two very important drug classes, and there's no doubt about that. There's also no doubt that there are too many people in Canada who don't have access to these drugs for cost-related reasons.

However, the focus of Bill C-64, which aims to provide free contraceptive and diabetes medications to all Canadians, irrespective of their existing coverage, could warrant reconsideration. The intent of reducing the burden of these drugs is the right one, but our view is that the projected cost of over a billion dollars could provide even more comprehensive coverage if directed toward expanding coverage for a broader range of medications for those who currently lack adequate coverage, rather than replacing coverage for those with existing drug plans. We believe such an approach would be more feasible, fit better with the needs of provinces and limit disruptions, all while ensuring universal coverage for all.

That brings me to my third and last point. While change is sorely needed to ensure universal pharmacare, the potential for significant disruption can't be overstated. As members of this committee can likely attest from the recent changes to the PSHCP, or Public Service Health Care Plan, changing drug plans can be very disruptive for plan members and for pharmacists. Switching patients from a private drug plan to a public drug plan can be equally disruptive, so changes must be implemented carefully to avoid confusion and reduce administrative burden.

The reality is that public drug plans across Canada are far less comprehensive than private plans, which means that if the legislation shifts patients from their private plans to a public plan, pharmacists and physicians will likely have to spend a considerable amount of time switching patients to new therapies, especially if their drug is no longer covered under a public plan; filling out paperwork to get special exemptions; and communicating these changes to patients.

In conclusion, I'd like to provide a personal example. I'm on a birth control pill that is not on the current list proposed by the federal government, and it took me three years to find the pill that worked for me and didn't have side effects that I would have had to live with daily as a woman.

This raised some very real questions for me when I looked at the intent of the bill. Will my employer continue to cover contraceptives if that's not covered? I'll certainly lobby for it, but it's definitely a question in my mind. Will my pharmacy continue to stock products that aren't broadly covered? If there are exemptions, will my pharmacist have to apply for that exemption on my behalf, as they often do with many drug plans?

I hope this gives you a sense of frontline issues that could arise.

I thank you and welcome your questions.

[The Chair, Liberal, Sean Casey]

Thank you, Ms. Walker.

Next, representing the Heart and Stroke Foundation of Canada, we have Mr. Arango.

You have the floor.

[Manuel Arango, Vice-President, Policy and Advocacy, Heart and Stroke Foundation of Canada]

Thank you very much.

Heart and Stroke applauds the Government of Canada and Parliament for introducing Bill C-64, which will lay the groundwork for equal access to life-saving drugs for all.

People in Canada appreciate our universal health care system, but the reality is that Canada is the only country with medicare that does not include prescription drugs as part of its universal health care program. The current patchwork of public and private plans in Canada has created fragmented drug access, leaving millions struggling to afford their prescription medications. I don't think there's any disagreement with this.

While many people in Canada have some form of drug coverage, it is often insufficient and poses affordability issues. The 2019 Hoskins report indicated very clearly that 7.5 million people in Canada had either no coverage or insufficient drug coverage.

As well, the 2021 survey on access to health care and pharmaceuticals during the pandemic found, once again, that one in five people did not have insurance to cover any of the cost of their prescription medications in the previous year.

Furthermore, a poll commissioned by the Heart and Stroke Foundation and the Canadian Cancer Society in 2024 found that one in five people in Canada do not have sufficient prescription drug coverage. One in four had to make difficult choices to afford prescription drugs, such as cutting back on groceries; delaying paying rent, mortgage or utility bills; and incurring debt. The same poll also found that one person in 10 in Canada who had been diagnosed with a chronic health condition was more likely to visit the ER due to a worsening health issue because they were not able to afford their prescription medications.

A study in 2016 also found that 16% of people in Canada went without medication for heart disease, cholesterol and high blood pressure because of cost.

With the introduction of this bill, the foundation is being laid for the first phase of national universal pharmacare through single-purchaser coverage of diabetes and contraceptive medications. This will ultimately provide equal drug coverage for all people in Canada, regardless of their gender, race, geography, age or ability to pay.

We do feel that this needs to be expanded in the future to cover drugs for heart disease and stroke. The reality is that millions of people in Canada live with heart disease and rely on daily prescription medicines to help keep them alive and to manage their conditions at home. In fact, in 2022, 105 million prescriptions were dispensed for cardiovascular diseases, making it the second-highest disease category for prescriptions.

Universal coverage of essential medicines will reduce pressure on the health system by cutting costs, because treating a condition such as high blood pressure, which is a leading risk factor for stroke, is more cost-effective for our health care system than the specialized care required to save a life after a stroke.

The Heart and Stroke Foundation has made a number of recommendations for amendments in its submission, but I would like to highlight one today. It pertains to subclause 8(1), regarding a national formulary.

We recommend that a definition be inserted here for “essential medicines”. In particular, essential prescription drugs should initially be defined as those included in the CLEAN meds trial. That's one way to define essential medicines.

We feel that the government must take quick action to close the gap in coverage that leaves out essential medicines for chronic diseases, including heart disease and stroke, that affect many in Canada. We also recommend that the minister prioritize the signing of bilateral agreements with provinces and territories in tandem with the progression of the bill and to pass this bill before the House adjourns for the summer.

Finally, I would like to address some other key points and misinformation about pharmacare. The reality is that the federal government, as a single drug purchaser, would be able to negotiate much lower prices compared to the myriad private and public plans. This would have a significant deflationary impact on the average drug price.

We heard comments earlier on about bulk purchasing. It's very well known in the world of business procurement that a company that buys 100,000 widgets from a manufacturer is going to get a much better price per widget than is a company that buys five widgets per year from the manufacturer. The reality of bulk purchasing and the fact that it leads to lower prices is well known throughout the world. In New Zealand and Australia, with respect to drug purchasing, or even just in general if you look at Costco, bulk purchasing leads to lower prices.

Another point is the notion that coverage is going to be decreased through a national pharmacare program. In fact, it's going to be the opposite. We're going to get enhanced coverage. The reality is that we have 7.5 million people who have no coverage or inadequate coverage. The objective is to increase coverage for those people. It's just not a reality that we're going to get reduced coverage. If the government, the federal payer, is covering a diabetes generic drug, whether that's in the private plan, the public plan or the federal plan, it doesn't matter: It's going to be covered one of those three ways. I don't foresee a reduction in potential coverage. It's the opposite. We're aiming for the opposite.

To conclude, the Heart and Stroke Foundation applauds the federal government and Parliament for the introduction of this legislation and for proposing an affordable plan that will give 7.5 million uninsured and under-insured people access to prescription drugs for diabetes and contraception. We really hope that in the future this can be increased and expanded. As my colleague mentioned, I think we do want an expansion of this formulary in the future, but this is a good start.

Thank you very much.

[The Chair, Liberal, Sean Casey]

Thank you, Mr. Arango.

Next, on behalf of the National Indigenous Diabetes Association, we have Céleste Thériault.

Welcome to the committee. You have the floor.

[Celeste Theriault, Executive Director, National Indigenous Diabetes Association Inc.]

Thank you, Chair.

Good evening, everyone. My name is Céleste Thériault and I'm the executive director of the National Indigenous Diabetes Association, located on Treaty No. 1 lands in Winnipeg, Manitoba. It's an honour and a real privilege to be speaking about this bill in front of you as it relates to indigenous people in Canada.

I'll talk a bit about the National Indigenous Diabetes Association. We refer to ourselves as NIDA, and we're a charitable, non-profit, member-led organization established in 1995 as a grassroots initiative by women on the side of Lake Winnipeg who were advocating because diabetes was taking too much from their people. That was almost 30 years ago. It is inclusive of first nations, Inuit and Métis in Canada.

This bill really provides the beginnings of a comprehensive pharmacare program for all Canadians and represents a significant step towards addressing social health inequities across Canada, including within indigenous populations.

I may refer to indigenous people—first nations, Métis and Inuit—with a pan-indigenous term to represent them, but they are distinct nations with distinct interests. They suffer disproportionately from socio-economic constraints and illnesses, but they stand to benefit substantially from the provision of much-needed diabetes care, especially Métis individuals who are not covered under NHIB, the current non-insured health benefits program, and so the current government of the day is really commended for this first step and for including diabetes medication in that first step.

That said, we should be continuing to do this in a good way. What does that mean?

It means talking with indigenous nations, political leaders and individuals with lived experience to make sure that no one gets left behind. We know changes that affect indigenous people in Canada should be done with us—“nothing about us without us”, and I would like to mention that because of the short period for big decisions between the tabling of the bill and this consultation, we didn't have adequate time to consult all of our members of interest on the implications of the bill. Our organization by no means can talk on behalf of all indigenous nations across Canada, so there should be continuous and ongoing meaningful dialogue with many indigenous people and nations, especially with our political leaders. The Minister of Health talked about not only provincial and territorial governments but also our indigenous governments, which have some sovereign right to having their voices heard on this legislation.

It's vital that we roll out this new program very carefully and really consider the context of the existing benefits, particularly through NIHB, the non-insured health benefits, which presently are the right of status first nations and Inuit beneficiaries in Canada and provide for medications for the treatment of diabetes and for other pharmacological care. However, it's not all of them, and that is to the detriment of the individual.

It also remains unclear whether the NIHB and the new pan-Canadian pharmacare program will be responsible for providing medication coverage to these individuals. However, the minister said earlier today, all the programs would kind of remain in place, so we believe that would be helpful.

The coverage of medications for first nations and Inuit can be bureaucratically burdensome, and we know this. Individuals and health care providers on reserve are already administratively overwhelmed, so we need to ensure that the policy is reducing those burdens and that our providers can directly impact patients and deliver patient care in a good way. We don't need to burden them with getting their patients' medications covered.

We also want to make sure there's a comprehensive list of medications, allowing both the prescriber and the patient to be advocates in the health care journey of diabetes management. Of course, we want to steer away from a two-tiered health care system, where the best and strongest medications are only available to those with deep pockets, privilege, and secure employment with strong health benefits.

Similarly, we want to ensure that no indigenous person is left behind, because Métis individuals are not included in the NIHB. This bill means that Métis will have much greater access to care through this bill. We have to remember that when we walk forward in this legislation. We need to be at the bare minimum of equal or better than current coverage for all indigenous people in Canada.

We must make sure that we are working together to ensure that there is equal access to brand name medications for diabetes care when the generics are not available, again supporting timely access and ease of use for indigenous people so that those living with diabetes can keep their healthy blood flowing now and several generations from now.

As an indigenous woman, I would be remiss if I missed the opportunity to also comment on the contraceptives. As someone who had to use three IUDs to get my last one successfully put in, I know IUDs are quite expensive, and that would be not have been possible for me had I not had some support in place to be able to do that and make that a reality. All indigenous people need to be able to access whatever form of contraception need and to to determine what is best for their own person, and the funding should be provided for each of those types, without exceptions, just as it should be with diabetes care, as it is an extremely personal journey.

We look forward to a Canada where first nations, Métis and Inuit have equitable access to life-saving medications, although more consultation is required to move forward in a good way. We invite further collaboration on this vital project to ensure that no one is left behind. We want to ensure that everyone, from our indigenous elders to our youth to our lived-experience people in indigenous nations to governments and politicians, is adequately involved in the decision-making process of this bill, not just, as I said, our provinces and territories.

Let's continue to work together in a good way to ensure that we are raising health outcomes for all indigenous people in Canada and representing a significant step forward in addressing social health inequities across Canada—