Health Committee on May 23rd, 2024

[Stephen Frank]

I was encouraged by the minister's comments and I think if we could see that reflected in the legislation, I think we'd be vehemently in accordance with what he has in mind, but we don't see that reflected in this bill. I think that's the issue that we have.

Terms have not been defined. They're used repetitively in different contexts in different ways, and they could be interpreted to mean different things in different sections of the act.

The preamble requires the minister to take into consideration some previous studies that have firmly recommended a universal single-payer pharmacare program, and the Canada Health Act is referenced throughout. When you read it in its entirety, it creates an enormous amount of uncertainty. Those terms have developed a meaning over time in Canada through the courts, through the provinces, to mean certain things. I think we take comfort in what the minister says, but we also would like to see that better reflected in the legislation.

We talked a bit about dental care today. A lot of care was taken with that program to ensure that it was targeted at those who didn't already have coverage, and protections were put in place to ensure that employers didn't drop plans. I think that this kind of care and attention needs to be brought to this legislation so that it actually, over time, doesn't drift away from the intent that the minister described for us today.

[The Chair, Liberal, Sean Casey]

Thank you, Mr. Frank and Mr. Naqvi.

Mr. Blanchette‑Joncas, you have the floor for six minutes.

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

Thank you, Mr. Chair.

I would like to welcome the witnesses taking part in the second part of this meeting.

My first questions are for the Parliamentary Budget Officer, Yves Giroux.

Mr. Giroux, I have looked carefully at your May 15 note on Bill C‑64, which states the following: “The PBO estimates that the first phase of national universal pharmacare will increase federal program spending by $1.9 billion over five years. This estimate assumes that any medications that are currently covered by provincial and territorial governments, as well as private insurance providers, will remain covered on the same terms.” This includes the Quebec program.

If I understand this analysis correctly, the $1.9 billion will benefit provinces that don't have a drug coverage program. Provinces like Quebec, which already have a drug coverage program, will receive less money.

[Yves Giroux]

That's a valid hypothesis. We may not have interpreted the program correctly. We gather that the program is meant to complement existing plans, not replace them. As a result, in provinces and territories where the existing plan is very generous, the top‑up will be relatively affordable. However, where the public plan is less generous, the costs to top it up will be higher.

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

Mr. Giroux, simply put, provinces that already have a drug coverage program, like Quebec, could be penalized as a result. That's my understanding.

[Yves Giroux]

That could be the case. However, the negotiations between the federal government and the provinces will determine this. We couldn't assume the outcome of these negotiations, so we opted for a more cautious approach.

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

I would even call it a hypothetical approach. There are a lot of hypotheses in politics, as you know.

That said, hypothetically speaking, we can conclude that, if negotiations between Quebec and Ottawa on money transfers don't go well, Quebeckers may have to pay more to subsidize the pharmacare program in the other provinces.

I'm trying to understand the situation. Based on your analyses, in such a case, would Quebeckers be taken for a ride perhaps?

[Yves Giroux]

We would have to look at the coverage by province to determine the potential for subsidies, underfunding or overfunding, depending on the province or territory.

We can see that the coverage of public plans varies greatly from province to province. Ms. Barkova informed me that, for certain types of oral contraceptives, for example, some provinces reimburse a maximum of 20 cents per tablet, even though the lowest price in the country is 60 cents. Some public plans cover certain drugs, but only to such a small extent that it's almost like having no coverage at all.

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

You can no doubt see where I'm going with this. I'm looking for solutions.

Under the current circumstances, what do you recommend or suggest so that Quebeckers get their money's worth and don't wind up paying more than they receive in services?

[Yves Giroux]

I'm not here to make recommendations.

However, the bill contains provisions enabling the minister to enter into negotiations with the provinces and territories, or even directing the minister to do so. This avenue is probably more promising, in my opinion. Obviously, we know when negotiations start, but we don't know how successful they are, or what kind of agreement they lead to, if any.

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

I completely agree with you about the negotiations, Mr. Giroux.

Personally, however, I like to have the necessary data when I negotiate. With this in mind, could you provide figures, province by province, based on existing programs, to ensure fair treatment during the negotiation of this new pharmacare program, which the minister describes as essential and even vital?

[Yves Giroux]

If the committee wants this, we can consider the possibility of doing this work, as long as the available data is thorough enough. Regardless, we could certainly come up with a good approximation, if the committee asked for it.

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

Thank you for your usual co‑operation, Mr. Giroux.

I'd now like to talk about a study you conduct each year. This study is the report on the fiscal sustainability of the Canadian provinces and the country as a whole. Fiscal sustainability isn't easy to achieve everywhere. You probably know what I'm getting at, Mr. Giroux. According to your 2023 report, five provinces are sustainable, relative to the percentage of GDP and estimates of the financial gap between the provinces and subnational governments. The five other provinces are categorized as unsustainable, as are the territories. You can see where I'm going. Fifty per cent of provincial governments, including Quebec, face a potential long‑term financial risk when additional public spending is introduced.

My question is hypothetical, but nevertheless based on your analysis of the fiscal sustainability of the various governments. Based on past experience, if the federal government rolled out a significant program such as pharmacare and decided to pull back and reduce its funding, how would this affect the fiscal sustainability of Quebec and the provinces?

[Yves Giroux]

Based on a hypothetical scenario where the government provides a large percentage of the funding for a national program and progressively decreases its share over time, for example by not indexing its contribution or through a reduction, as we have seen in the past, the provinces would inevitably need to make difficult choices. They would have to either reduce the coverage or continue to cover the costs. There would be financial pressure on the provinces that opt to continue the coverage as initially agreed.

[The Chair, Liberal, Sean Casey]

Thank you, Mr. Giroux and Mr. Blanchette‑Joncas.

Mr. Julian, you have six minutes.

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

Thanks very much, Mr. Chair.

I mentioned earlier that this is a historic moment and a historic hearing, and I cited a number of important organizations.

I want to give a shout-out to Canadian Labour Congress president Bea Bruske. They submitted a memo to this committee saying, “The [Canadian Labour Congress] calls for the speedy passage of Bill C-64, an act respecting pharmacare, before the House of Commons and the Senate adjourn for the summer, so that millions of Canadians can access contraception and diabetes drug and device coverage, giving them some relief from the high cost of living.” I would note that Elizabeth Kwan from the CLC is here in the room today.

I also want to give a shout-out to the Canadian Health Coalition and thank Mr. Staples for being here.

Mr. Staples, we've heard from one party in the House of Commons—the Conservatives—and a number of lobbyists that the system we have in pharmacare now works well in Canada. You deal with frontline workers, such as nurses. Is it true that everything is fine when it comes to access to medication?

My second question to you is about the issue of a pharmacare program. Is it true that a pharmacare program will help save health care dollars?

[Steven Staples]

Thank you very much.

Mr. Julian, I share your concern. When I hear witnesses say that the system's working very well, I ask, “For whom is it working very well?” We just heard from Mike Bleskie. It doesn't sound like the system's working very well for him. It seems to be working for industry and for insurance companies, but it's not working well for all Canadians. That's why this pharmacare act is so important. We must get Bill C-64 through.

Also, we heard that the Canada Health Act, in the view of industry, creates uncertainty. I would differ. I think the Canada Health Act is very important. For 40 years, it's made a guarantee that Canadians, when they need medical care, will get it, not based on who they work for, what insurance program they have or how much money they have, but because they need it. I'm very passionate that the CHA creates certainty for Canadians, and we want that system. We don't want a U.S. system.

When I hear frontline workers talk, and they do.... We had 100 frontline health care workers come here in February. They met with many members of this committee, and I express my gratitude for all of you who took time out to meet them at a very busy time. These are people who are working with all kinds of issues in their hospitals and in their health care environments, but they took time to come to Ottawa to talk about the importance of pharmacare with all the challenges that they face in the health care system.

Do you know why? What I hear them say is that filled prescriptions mean empty emergency rooms. They know that if people are getting their medications, if they're not cutting their meds, if they're not making choices today on whether to take their medicine or not, they don't end up presenting themselves with far worse conditions in the emergency wards. That's where a lot of cost savings can come in that we're not hearing about.

Of course there are cost savings for individuals. Of course there are cost savings through bulk purchasing; we can get those prices down to the median of OECD countries because they're so high, but there are also savings in the health care system.

St. Michael's Hospital did a study. It took 700 patients who had trouble economically in paying for their medication, and these patients went out into the world after they were diagnosed. The hospital mailed free medication to half of them. The other half it just let fend for themselves, based on that system that we were talking about a minute ago, however that system works out. Well, they found that those people who had free medication provided to them did far better. They recovered faster. In fact, they could even put a number on it; every patient who received free medication saved the system $1,600 per year. That's an important factor in looking at how we can save money in a national universal single-payer program.

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

Thank you very much.

I want to go on to Mr. Bleskie, and I hope you get questions from the Conservatives, because you're a real-world person who lives in the situation that exists right now, which is catastrophic for so many Canadians.

What would happen if you simply don't have any contracts, if you do not have money for a month? What would happen to you if you're not able to purchase the medication and devices?

I also want to ask where you buy your diabetes supplies.

[Mike Bleskie]

In my case, I have very little of a safety net left, so it would mean dipping into my line of credit. That's basically what it comes down to, because, once again, I'm part of the Ontario drug benefit. That is basically what is offered to all Ontarians who are low-income, and that low-income assistance for prescriptions covers only the insulin itself. It doesn't cover all the other aspects. For those who are taking injections, it doesn't cover syringes or cover needle tips. It does cover a glucometer, but for those who, like me, are using an insulin pump, it doesn't cover the CGM, which I actually need in order for the pump to work properly.

When it comes to purchasing my supplies, I can give an example here. I end up buying my stuff directly from the suppliers in many ways—

[Stephen Ellis, Conservative, Cumberland—Colchester, NS]

Mr. Chair, I hate to do this to the witness, but we've already discussed previously at this committee that there are not going to be any props and that we are not going to be doing a show-and-tell here. I think that that's been well established. It may well be helpful, but I think that we need to continue to follow the rules here.

[Mike Bleskie]

Okay, then I'll do without.

In terms of the individual aspects that I have to order, I have to order CGM on a subscription model directly from the company, Dexcom. That is $200 per month, and then they ship it every three months. That is basically a three-month contract that I have to renew all the time.

When it comes to the individual pump supplies, the company that makes my pump, which is called Tandem, offers only one supplier, a company called Diabetes Express, which is a subsidiary of Bayshore HealthCare, which is a subsidiary of Shoppers Drug Mart. They are the only people that I can order those supplies from, so I have to wait for those things to come in from Toronto. In one case, I actually ended up nearly missing a shipment because there were delays in the mail system.

If I was able to actually have more access—

[The Chair, Liberal, Sean Casey]

Thank you, Mr. Bleskie.

Next is Dr. Kitchen, please, for five minutes.

[Robert Gordon Kitchen, Conservative, Souris—Moose Mountain, SK]

Thank you, Mr. Chair.

Thank you very much, everyone, for being here. I appreciate your presentations.

It's interesting that we heard one of our members repeat something I've hit on a number of times, which is basically targeting efforts where the need supposedly is. Mr. Frank, you hit that nail right on the head. You talked about the use of that $1.5 billion and putting it into a situation where it may be more effective.

Ultimately, when we look at statistics that suggest that 1.1 million Canadians don't have any type of plan, and that up to 3.8 million Canadians are either not aware of a plan they could have, don't have the funds, or choose not to do it, we see that roughly 10% of the population of Canada don't have access to it.

On putting that $1.5 billion toward that population, I wonder if you could expand on where you think that might be of great value.

[Stephen Frank]

I'll run some simple math on this. It's going to depend on how broad a list of medications you cover, but the typical cost for someone on the ODB program here in Ontario is roughly $1,900 a year. If you took that $1.5 billion, and it was an annual thing, you could probably cover most of that gap and provide access to the ODB.

This is just an illustration of the choices we can make to target federal funds where they will make the most impact. Using money to simply replicate what's already in place for 27 million people is, in our view, not the best use of scarce federal resources. In fact, switching people off a private plan and onto a public one risks their actually having weaker coverage than they have today.

We are completely aligned with the vision the minister outlined this morning. I'm not aware of anybody who's suggesting the system can't be improved. I don't think anyone has argued that today. However, we should be targeting our efforts where the need is, not risking disrupting what's working for the large majority of Canadians. As you said, that's 90% of Canadians today.

[Robert Gordon Kitchen, Conservative, Souris—Moose Mountain, SK]

Thank you for that.

We've heard throughout today a lot of comments and talk that this legislation isn't clear and that it doesn't define things appropriately. It puts in definitions for a minister, but it doesn't put in a definition for a first payer. It's very unclear in many ways.

Mr. Keon, you also talked about issues that we're not defining, particularly when we talk about bulk purchasing. If there's a way to take a look at that bulk purchasing, are there any suggestions you might have to add to that?