Health Committee on May 23rd, 2024

[Joelle Walker]

We would look to some of the definitions around single payer, and specifically coordination of benefits. If you have a spouse, you might be familiar with a pharmacist having to coordinate and first apply to one spouse's plan and then coordinate with the other spouse's plan so that you don't have to pay out of pocket, but doing so in a way that the private plan is charged first. The public plan picks up the remainder of the difference, if there is one. If you don't have coverage, then the public plan would jump in first.

[Majid Jowhari, Liberal, Richmond Hill, ON]

Okay. Thank you.

With my remaining time, I would like go to The Society of Obstetricians and Gynaecologists of Canada.

I'm developing an understanding of the many different contraceptives that are available and how they best fit, depending on the situation. I think you touched on this, but can you give a sense of, or explain further, the fact that this current scope is covering a broad range of contraceptives and supporting products?

I think the IUD was mentioned as one of the items in the first panel. Can you expand on how this is helping Canadians, especially women who want to have the choice to be able to plan their lives better?

[Dr. Diane Francoeur]

Absolutely. Thank you for this question, because it's really, really important. I'll give you two quick examples that are easy to understand.

In 2006, I was president of the obstetrics and gynecology society of Quebec, and we made a presentation to the government to have the hormonal IUD covered. That was a long time ago, in 2006, and in other provinces it's still not covered. These methods have made an amazing change in the teenage pregnancy rate, because they are very, very effective. Once the IUD is there, it's there to stay. Now we can leave it there for up to seven years, unless the woman wants to remove it.

Every one of these methods has some advantages and some side effects that sometimes adolescents or women don't like. That's why having all medication covered will really help us fit the need.

As you said, now I have a Canadian position, and my heart is broken when I hear that, because since 2006 we've been putting in IUDs, and women are happy. There's a decreased rate of hysterectomies. There are a lot of good side effects, like decreased bleeding. It changes women's lives.

That's a good example of what needs to be done.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Francoeur.

Now we go to Mr. Blanchette‑Joncas for six minutes.

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

Thank you, Mr. Chair.

Thank you to the witnesses for being with us.

Ms. Walker, in your opening statement, you said that pharmacare should be about more than just the cost of drugs. It should also be about the care or counselling that goes along with the treatment.

Can you talk more about that? What exactly do you mean?

[Joelle Walker]

Yes, of course.

If pharmacists didn't need to monitor the medications people were taking or if their advice wasn't useful, drugs would be sold on store shelves, with no follow-up.

It's important to recognize that the work pharmacists do when they provide patients with prescription drugs is quite complex. They check for drug interactions. It is thanks to pharmacists that patients can be sure they are taking the right drugs. That is the kind of care I was talking about.

It is a pharmacist's job to review the list of medications that a person is taking. For example, if an elderly patient is taking multiple medications, the pharmacist has to make sure that the drugs are accurately listed in the patient's file. They have to do that for all patients. More and more pharmacists are providing those types of primary care services in pharmacies. That is part of the care that pharmacare involves.

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

Thank you.

You also said you had concerns about the drugs that the public system would cover. You're familiar with Quebec's system, which has been in place for 30 years now. It's worth pointing out to certain people here today and those who are following these proceedings.

The system isn't perfect, but it has a formulary of about 8,000 medications.

Given your expertise, do you think that's reasonable, or do we need to stop and think about the fact that many of the medications currently covered won't be under the new pharmacare plan?

[Joelle Walker]

I believe the Parliamentary Budget Officer mentioned this in his first report, but when it comes to the formularies in use, Quebec's is the strongest in the country.

The committee will be meeting with our colleagues in the Association québécoise des pharmaciens propriétaires tomorrow, and they'll be able to tell you all about the system.

The risk of certain people losing coverage for certain drugs is definitely heightened given that they could be moving from a private insurance plan to a publicly funded plan. The details will matter. It will be important to know what the proposed formulary will look like and whether it's the right use of the funding, which is limited. To begin with, consideration could be given to including drugs that support cardiovascular health for individuals whose medications aren't currently covered.

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

Nonetheless, do you have any recommendations so that coverage of certain drugs isn't eliminated when the new plan is introduced?

[Joelle Walker]

We think Bill C‑64 is a bit vague when it comes to the coverage of certain drugs under private plans. We need clearer information on that. Today, the minister suggested that they would continue to be covered, but the current bill makes no mention of that. It really needs to be laid out.

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

Ms. Walker, I feel the same way and I'd like to know the same thing. I would go so far as to say it's confusing. It's like the government is building the plane while flying it. It can try, but I'd rather be safe than sorry.

With pharmacare being introduced so summarily by the federal government, what consequences could the pharmacy industry face? Do you have a sense of that?

[Joelle Walker]

It will have consequences for every facet of the industry. It will depend on the details.

First, I talked a bit about the fact that pharmacists will have to spend a lot of time communicating these changes, given how significant they are.

Second, the government's cost projections should capture the cost of closing the coverage gap between the public plan and private plans. It's also important to make sure that pharmacists continue practising their profession and are compensated for all the counselling they provide.

The difference between a public plan and a private one can be quite significant. For instance, Ontario's dispensing fees are quite low as compared with the national average. If everyone took up that model, it would have a major impact on pharmacies, especially independent pharmacies and rural ones.

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

Thank you.

On your association's website, you say this:

Given Canada’s constitutional make-up and the provincial and territorial management of health care, we believe that a pan-Canadian mixed payer approach to drug coverage is more feasible, will face fewer barriers to implementation and can be achieved more quickly than through a complete overhaul of drug plans across the country. This approach can provide comprehensive coverage to those who need it, and minimize disruption for those with existing plans.

Can you tell us more about your vision for a pan-Canadian mixed payer approach?

[Joelle Walker]

It's clear that not all the provinces are at the same point when it comes to pharmacare. In Quebec, people already have drug coverage, even though the system may not be perfect. The situation really varies from province to province, from British Columbia to Newfoundland and Labrador.

We think the most practical and impactful approach, starting now, is to provide funding to the provinces so they can each strengthen their existing plans according to their needs. As we know, each province has its own needs.

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

Thank you.

Can you tell us specifically the kinds of problems that could arise after the transition from one system to the other? Have you thought about that?

[Joelle Walker]

Yes, we have, and I can give you a few examples.

When the federal non-insured health benefits program was transferred to British Columbia, around 17% of the medications that were covered under the federal program were no longer available through the province's publicly funded program. Those kinds of changes have to be made to ensure that patients don't lose their coverage suddenly.

I mentioned OHIP+ in Ontario, which had similar problems. Parents were showing up at the pharmacy to get a prescription filled for their child only to find out that the drug was no longer covered. Generally speaking, public plans provide less coverage. Pharmacists were having to fax doctors—because we still communicate with doctors via fax—but they weren't always available to respond. That gives you a sense of the problems that can arise.

[The Chair, Liberal, Sean Casey]

Thank you, Ms. Walker.

Go ahead, Mr. Julian, please, for six minutes.

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

Thank you, Mr. Chair.

Thank you to the witnesses for their input, which is extremely useful.

Quebec's current drug insurance plan, a hybrid public-private system, has come up a number of times. Recently, a major coalition representing two million Quebeckers called on Parliament to pass Bill C‑64.

The coalition is made up of all the major unions in Quebec, from the Fédération de la santé et des services sociaux and provincial groups to the Union des consommateurs. In its brief, the coalition states that the current pharmacare program in Quebec has failed to ensure that everyone has reasonable and equitable access to drugs. It also states 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. Higher drug costs are putting more strain on private plans, and as a result, workplaces are terminating their insurance plans and workers are losing all their coverage.

Quebec's system is broken, and these organizations are asking us to pass the bill quickly.

Under hybrid systems, many people can't afford to get the drugs they need. When it comes to women having control over their own reproductive health, Dr. Francoeur, what does it mean to have a universal, as opposed to a hybrid, system?

[Dr. Diane Francoeur]

The major benefit is that it takes money out of the equation. In other words, it gives us the opportunity to discuss the benefits of the plan for a specific individual. We want the same model as the one implemented in British Columbia. That said, patches weren't included in that province's model.

If a person has been through bariatric surgery and has issues with their intestines or with taking a medication, they can't use a pill, because it may be less effective. With a patch, the medication enters the body directly. It's much more reliable. This example explains why it's sometimes necessary to choose one method over another.

Our president, Dr. Amanda Black, conducted a study of young Ontarians aged 20 to 29. It clearly showed that unwanted pregnancies were associated with methods that failed to meet the needs of young people. When young women wanted implants, they couldn't have them. When they asked for an IUD, they were told that another method was covered by the plan.

I'm from Quebec. I'm obviously familiar with the province's drug coverage. It's better than nothing. However, it isn't true that everything is free. Young girls who don't want their parents to know about their pill use have no choice. They must report everything. It isn't true that everyone will be covered. If the girls are covered by their parents' insurance, their parents will have access to a statement. Unfortunately, this often constitutes just another step to protect them against an unwanted pregnancy that will change their adult lives.

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

Thank you.

Mr. Arango, I want to come to you. All of your testimony was very important.

I was particularly touched by your speaking about heart and stroke and the 600 Canadians who die every year because they can't afford to pay for their medication. What I hear you saying is that we can't stop with diabetes medication and contraception: We have to move as quickly as possible to cover heart disease medication and medication that prevents strokes.

I know of constituents who are paying $1,000 a month for heart medication that keeps them alive. They have to make that difficult choice every day: Do I put food on the table and keep this roof over our family's head, or do I stay alive?

What impact would it have if universal pharmacare were extended to all the medication that the Heart and Stroke Foundation and the research prescribe for people with heart and stroke issues?

[Manuel Arango]

It would be very significant, because in fact 16% of the 1.6 million people that live with heart disease and stroke cannot afford these drugs.

What they end up doing is splitting pills, skipping doses, not renewing their prescription or not even filling the prescription in the first place. Of course, if they don't have proper access to those drugs, they end up going to the ER, and then it's much more expensive to treat.

I understand that Rome was not built in a day and this first step won't cover necessarily CVD drugs, cardiovascular disease, but in the future, we would like to have that covered.

I should mention as well, though, that someone with diabetes has a threefold increase in their risk of dying from heart disease. Diabetes is an important comorbidity for heart disease and stroke. Addressing that as a first step is really key.

If I may, I really would like to address the point regarding the potential threat that's been raised of loss of coverage through private and provincial plans.

The reality is that if the federal government is providing a generic diabetes drug, I do not believe that the person who needs that drug is going to care whether it comes from a private plan, a provincial plan or a federal payer. As long as they get that generic drug, they're going to be happy, in my opinion.

Of course, they would be very concerned if we had brand name drugs that address adverse effects for them being removed from the private plan or the provincial plan. I can't see that happening. The demand would be really great to have that brand drug coverage in those private and provincial plans, so I don't think it's a very realistic scenario that those drugs are going to disappear.

[The Chair, Liberal, Sean Casey]

Thank you, Mr. Arango.

Next we have Mrs. Goodridge. Please go ahead for five minutes.

[Laila Goodridge, Conservative, Fort McMurray—Cold Lake, AB]

Thank you, Mr. Chair.

Thank you to all the witnesses for being here today.

Celeste, I really appreciated that as you were sharing your testimony, you were talking about doing things in a good way. It was very reminiscent of the many conversations I've been blessed to have with many of the elders in my region on how the intention has to match with the steps.

Given that you have been unable to consult with all of your appropriate stakeholders prior to doing that, do you believe that we have put you into a space where you perhaps are not moving in a good way, even just having to be here on such a short timeline?

[Celeste Theriault]

No. Any time an indigenous person has an opportunity to raise their voice and their opinion when it's been chronically neglected through our colonial structures and systems, we must take that opportunity to voice those concerns.

I really hope that every bill looks at the indigenous component, whether that's pharmacare or whether that's any other thing that the House is trying to pass.

[Laila Goodridge, Conservative, Fort McMurray—Cold Lake, AB]

I appreciate that.

I guess what I was trying to ask was whether you would have preferred more time to be able to consult with a variety of stakeholders to assess the impacts of this bill.