Health Committee on May 23rd, 2024

[Steven Staples, National Director, Policy and Advocacy, Canadian Health Coalition]

Thank you, Mr. Casey. It's a pleasure to be back here.

Dear members of the committee, my name is Steve Staples. I'm the director of policy and advocacy for the Canadian Health Coalition.

Our organization was founded in 1979. Our members work to defend and improve our public health care system. We comprise citizens, frontline health care workers' unions, community groups, students and public health care experts.

Members of the Canadian Health Coalition welcome the introduction of the pharmacare act, Bill C-64. This landmark legislation is an important first step in continuing progress toward a universal national pharmacare program.

Canada is the only country in the developed world that has a universal health care system that does not include universal coverage for prescription drugs outside of hospitals. Pharmacare is needed urgently to improve the lives of those living in Canada. As we have heard, one in five people reported to Statistics Canada that they do not have access to prescription drug coverage. Importantly, low-wage workers, immigrants and racialized people are hit the hardest.

In addition, the overall cost of drugs to the health system must be reduced. According to the PBO, prices for prescription drugs in Canada are roughly 25% higher than the median for OECD countries, and a single-payer pharmacare system with the power of bulk purchasing is the best route to negotiate lower prices from pharmaceutical manufacturers.

Canadian Health Coalition members heartily endorse the recommendations of the 2019 national advisory council on the implementation of national pharmacare led by Dr. Eric Hoskins, which was referenced earlier.

A nationwide program to achieve public coverage for contraception and diabetes medicine and related equipment, delivered by a single-payer approach through provincial health systems, is a historic step in the direction recommended by Hoskins in his report on pharmacare, but there are many more steps to achieve universal coverage of a national formulary of medicines.

We urge the government to ensure that the legislation adheres to a single-payer, national universal public delivery in partnership with provinces and territories, along with adequate funding and accountability measures, in accordance with the principles of the Canada Health Act.

I would like to share the remainder of my time with my colleague, Mike Bleskie.

[Mike Bleskie, Advocate, Type 1 Diabetes, Canadian Health Coalition]

Through you, Mr. Chair, I thank you for the opportunity to be here.

My name is Mike Bleskie, and I have been a type 1 diabetic for 19 years. I'm also a gig worker in my 30s. As such, like many, I don't have private health insurance, and I either cannot qualify or cannot afford to pay for a plan myself.

Although Ontario's benefits cover a portion of my personal expenses, my out-of-pocket costs stand at about $450 a month, mostly from my continuous glucose monitor, which is not covered in Ontario, and my pump supplies. That leaves me with hard decisions about the cost of food and rent at the beginning of every single month. It also leads to situations in which I'm forced to consider rationing my supplies, which can lead to health complications.

My experience talking to nurses, doctors and other diabetics across Canada tells me that I am far from alone. Insulin is not a luxury for us; it is a basic necessity for every single type 1 diabetic. Without the proper treatment, we are exposed to complications like debilitating nerve pain, amputation and permanent blindness. A universal single-payer pharmacare system is the only policy that guarantees that every type 1 diabetic in Canada, regardless of their economic circumstance, can access live-sustaining therapy when they need it. Policies that attempt to fill gaps only leave more gaps that need to be filled later, such as what we have seen in Ontario with OHIP+ .

I urge this committee to support this bill promptly so that we can get insulin into the hands of diabetics as soon as possible. I'm also asking this committee to ensure that syringes, pen needles, pump cannulas and continuous glucose monitors are fully covered as part of the diabetic supply fund contained in Bill C-64, as these items represent the biggest expenses to most diabetics and, in many cases, are not part of public coverage in most provinces.

I appreciate your time, and we welcome your questions.

[The Chair, Liberal, Sean Casey]

Thank you both.

Next, we go to the Canadian Life and Health Insurance Association and Mr. Frank.

Welcome to the committee. You have the floor.

[Stephen Frank, President and Chief Executive Officer, Canadian Life and Health Insurance Association]

Good afternoon. It's a pleasure to be here.

My name is Stephen Frank, and I'm pleased to be here today in my role as president and CEO of the Canadian Life and Health Insurance Association. An important part of my job is representing the 27 million Canadians who are covered by workplace and other health benefit plans.

Canada's life and health insurers believe that all Canadians should be able to access the drugs they have been prescribed. To achieve this, we know that both public and privately-funded plans are a necessity. Unfortunately, Bill C-64 falls short of its goal to ensure that all Canadians have access to the medications they need. It puts what's working well today at risk.

Workplace benefit plans are an essential pillar of the Canadian health care system. In the most recent year, Canada's life and health insurers paid for over 35% of prescription drug spending in the country. Our plans cover more drugs than even the most generous public plan.

In fact, 85% of Canadians say that their health insurance plan saves them money. They don't want to see their plan disrupted. Given the choice, they would overwhelmingly prefer that the government focus on providing coverage to Canadians who don't have it.

On behalf of the majority of Canadians who already have drug coverage, I ask members what this proposal will mean for the average Canadian family. Despite much of the discussion about this bill by various stakeholders, it goes further than contemplating a new pharmacare program for diabetes and contraceptive drugs: It requires the federal government to begin the rollout of a broad pharmacare program for an essential medicines list no later than 12 months after the bill gets royal assent. There are material and many unknown risks to disrupting existing programs for millions of Canadians.

The Minister of Health has stated that people who have an existing drug plan are going to continue to enjoy the access they have to their drugs. If that's the minister's intent, it's not at all clear from this bill. As many of the questions reinforced today, its text is ambiguous. It repeatedly calls for universal single-payer pharmacare in Canada with no mention of workplace benefit plans. Read in its entirety, the bill could result in practical and even legal barriers to our ability to provide Canadians with the drug benefits that they currently have.

For the majority of Canadians, therefore, this plan, as it's currently written, risks disrupting existing prescription drug coverage paid for by employers, limiting choice and using scarce federal resources to simply replace existing coverage, while leaving a huge gap for uninsured Canadians who rely on other medications beyond diabetic drugs and contraceptives.

There is a better way.

For example, using the $1.5 billion that has been allocated to this program to target those without coverage would allow the government to provide thousands of medications to several hundred thousand Canadians who currently lack drug plans. In other words, we could, as a country, use scarce federal dollars wisely to make a profound impact on the lives of those who do not have drug plans, while protecting the benefits that are currently working so well for the vast majority.

In conclusion, we believe that this legislation needs to be significantly amended to focus on ensuring universal drug coverage for all Canadians by addressing any gaps in the drug insurance that currently exists and to be clear with Canadians about what exactly we're trying to do.

I look forward to your questions. Thank you.

[The Chair, Liberal, Sean Casey]

Finally, we have the Parliamentary Budget Officer, Monsieur Giroux.

Welcome to the committee. You have the floor.

[Yves Giroux, Parliamentary Budget Officer, Office of the Parliamentary Budget Officer]

Good afternoon, Mr. Chair and members of the committee.

We are pleased to be here today to discuss our analysis of Bill C-64, an act respecting pharmacare.

With me today I have Lisa Barkova, our lead analyst on pharmacare.

If memory serves, this is the first time that I'm appearing before the House of Commons Standing Committee on Health as a parliamentary budget officer, but this is not the first time that the office has responded to requests from the committee regarding pharmacare. In fact, in response to requests from this committee, in September 2017 my predecessor produced an estimate of the cost to the federal government of implementing a national pharmacare program.

Furthermore, following requests from parliamentarians, my office prepared an updated cost estimate of a single-payer universal drug program in October 2023.

Recently, on May 15, 2024, we published a cost estimate for Bill C‑64, which you're studying today.

As the first phase of a national universal pharmacare program, Bill C‑64 proposes to provide universal first‑dollar coverage for a variety of contraceptive drugs and for the treatment of diabetes.

The purpose of the program is to enhance and expand the coverage provided by provincial and territorial plans, not to replace it.

We estimate that, if implemented, Bill C‑64 would increase government 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.

Ms. Barkova and I look forward to answering all your questions regarding our analysis of Bill C‑64 or other work done by my office.

Thank you.

[The Chair, Liberal, Sean Casey]

Thank you, Mr. Giroux.

Thank you to all of our witnesses today for being respectful of the time limits. I really hope that it's contagious and that it carries over to the parliamentarians in the room for the rest of the meeting.

Dr. Ellis, you have six minutes. Go ahead, please.

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

Thanks very much, Chair. I've set a timer.

Thanks to all the witnesses for being here.

Mr. Keon, through the chair, maybe I'll start with you.

You talked a bit about bulk purchasing. For the medications on the list here that are potentially covered, can you explain to Canadians whether it's likely this is going to result in significant savings and lowering of the prices that currently exist?

[Jim Keon]

Thank you.

We do not think it will. We do not think it should. We have negotiated a very broad agreement with the pan-Canadian Pharmaceutical Alliance that covers public drug plans. It's the same price that private insurers pay. It is a price negotiated with experts from the provinces that is intended to provide good savings, good prices to Canadians and a sustainable revenue base for our industry, so no, we don't think it will provide savings.

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

Thank you very much for that, Mr. Keon.

Mr. Frank, in this pharmacare pamphlet there's the concept of the universal single-payer plan. The minister and the officials who were here previously couldn't tell us what that meant. They said, “Well, it's a term that's been used a lot. Everybody knows what it means.” You've been at this a while, and I would suggest that for the benefit of all Canadians maybe you could shed some light on what that term means.

[Stephen Frank]

I think if there's one point to underline today, it's that this bill is ambiguous. We actually don't know what it means, because it is not a defined term.

The building of this bill, when you read it in its entirety, references the Canada Health Act. The preamble makes references to previous studies that have been done. “Single payer” is mentioned multiple times, as is “universal”. Those as a package have been well understood in the courts, and over time in the provinces, to mean a single payer—not federal, provincial or private, but a single payer. “Universal” means it's the same for everybody. Our concern is that it could also be interpreted to mean that private industry is no longer able to provide coverage.

When we read this legislation, because of that lack of clarity and because those terms aren't defined, we are concerned with the way it's drafted and we think it needs to be amended, at a very minimum, to reflect whether the vision of the minister is what the government's intent is. We would be supportive of that, of targeting their efforts on where the need is, but I don't think that we can be confident that this is what the legislation reflects, so we are quite concerned.

We do believe there are some significant amendments required to reflect what we heard the minister saying earlier today.

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

Thanks for that.

Through the chair, Mr. Frank, our understanding is that there are perhaps about 1.1 million Canadians who lack sufficient coverage. Is it fair to say that could perhaps mean that of the 40 million Canadians, 39 million Canadians currently have coverage that could be in jeopardy?

[Stephen Frank]

I can speak only to what we as a private industry cover. Today in Canada there are 27 million Canadians with private drug coverage. It's very broad coverage, much broader even than that of the best public system available across Canada, and they value that coverage greatly—90% of them value their coverage to a high amount or to a great amount—so they want to protect it and they are very strongly opposed to having it put at risk. Overwhelmingly, if you ask them what their preferred approach is and you give them a choice, they would like government to target their efforts to where the need is.

We listen to our clients every day. We provide excellent coverage for them. There are 27 million of them who are very happy with what they have, and they don't want to see that put at risk. Everyone would agree that people should have access to the medications they need, so let's target where the problem is and let's not disrupt what's working well for so many.

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

Thank you very much for that.

Through the chair to Monsieur Giroux, thank you for being here and thank you for your analysis.

We know that federal government spending is ballooning out of control. That does not mean that pharmacare is not important. We've heard now from Mr. Keon that there are not going to be any savings here, so this will continue to be an expense to the federal government and, of course, to taxpayers.

We don't have that much time, but maybe you could outline that expense, which is going to be a recurring expense to taxpayers, with respect to Bill C-64.

[Yves Giroux]

Yes. In fact, we estimate the cost to be about $1.9 billion over five years.

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

I'm sorry, but is that “billion”, with a “b”?

[Yves Giroux]

Yes, I said “billion”, so that means about $400 million per year ongoing, and increasing with population and inflation over time, roughly speaking.

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

Finally, sir, and through you, Chair, is it not true that this government has added more to the federal debt than all other governments combined? I think I've heard that said. Is that true, according to your analysis?

[Yves Giroux]

I'd have to look at the precise numbers, but if it's not true, it's not far off, due in large part to the pandemic, of course.

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

Thank you, sir.

Thanks, Chair.

Again, what we've heard is that this government is adding significant amounts to the debt, and we have heard about the struggles of Canadians having to pay for that, of course.

When we look at this again, Mr. Frank, on behalf of all Canadians, could you help us understand the differences between private and public plans at the current time with respect to the percentage of medications that might be covered by a private plan?

[Stephen Frank]

A typical private plan will cover almost any medication that has a notice of compliance, so it would cover upwards of about 15,000 different drugs. A typical public program would cover less than half of that. That's the delta you tend to see.

What you will tend to see in the diabetic space in particular is that private plans will cover many of the more innovative, cutting-edge things things like weekly injections, fast-acting mealtime injections and insulin specifically for diabetic comas. These are things that are not covered by the public plan but that we do cover privately.

When we looked at the list that was published with this pharmacare act, we were concerned by how narrow it was. I think others have noted that too. The vast majority of Canadians have very robust plans that cover essentially everything in the market. We work really hard to make sure we're doing that in a sustainable way, and we know they don't want to see that put at risk with any new government programs.

[The Chair, Liberal, Sean Casey]

Thank you, Mr. Frank.

Mr. Naqvi, please go ahead for six minutes.

[Yasir Naqvi, Liberal, Ottawa Centre, ON]

Thank you very much, Chair.

I want to thank all the witnesses for coming here today. I really appreciate it.

In particular, I want to thank you, Mr. Bleskie, for being here and sharing your lived experience. That has been the most important testimony I've heard. I was struck by some of the choices you have to make on a regular basis, given your health and the cost of medication.

Can you elaborate on some of the challenges you face currently? Talk to us a little bit about what impact this legislation will have on your life if it passes into law.

[Mike Bleskie]

In my case, I know that at one point when I had finished a work contract, I did have private insurance. When it came time to finish that work contract, I was told by the private insurance provider that because of my pre-existing condition, I was not able to go on to the bridging insurance that would normally be offered to an employee. Therefore, I had to pay significantly more in order to stay on an insurance plan with that company.

In another sort of tangential way, I recently started on an insulin pump. I have been on an insulin pump for about six months now. In the months before I was a diabetic—and I'm sure Dr. Powlowski will be able to agree that these numbers are a little bit terrifying—my A1C before I started with my insulin pump was 11.4. The target for a type 1 diabetic is to be under 7. Since starting the insulin pump, my numbers have now improved to 7.7. That is a huge increase in my personal health, but I made financial sacrifices to do that because I am paying out of pocket for a lot of these expenses.

One of the things that I've done in the past to try to make my dollar stretch was to take my infusion sets, the cannula that goes into my skin to deliver my insulin, and to try to squeeze an extra two days out of that infusion set. What that means is that I'm risking scar tissue damage on my stomach. I've seen folks, friends of mine, who have been on insulin pumps who have been in that same situation, and they have pockmarks all over their stomach from their infusion sets because they've had to ration the supplies that they have access to. Those are the kinds of things that you often hear about.

There are also the other knock-on effects. When I was talking to different patients from around the country, I got a letter from a family in Prince George who have a 16-year-old son with diabetes. They have not been able to go on vacation since his diagnosis because they put in upwards of $250 a month in order to try to pay for their specific supplies in order to keep him healthy. We see some significant challenges financially, but also in terms of the knock-on health effects of people who don't have access to these medications.

I think that this also stretches over to other areas of medications that aren't even in the current wave of this act. I think that as we start to expand access to medications, we'll start to see those upstream and downstream costs change significantly over time, which will lead to personal savings in people's pockets as time goes on.

[Yasir Naqvi, Liberal, Ottawa Centre, ON]

Thank you. We appreciate that.

I come now to Mr. Frank.

I think you were present in the room when I asked the minister about the notion around choice and whether this undermines the choice that Canadians would have, or in fact enhances the choice that's available to them. He was very clear that the choice will be maintained and that people would have the choice, that this is really creating a floor on two sets of drugs and that there is an important role for the private health care systems that you are representing.

You in your presentation still made an argument in talking about practical and legal barriers, and I'd like you to elaborate as to what you think they are. Are you not satisfied, after listening to the minister, that the choice that Canadians have available right now will not be impacted by this legislation?