Health Committee on May 24th, 2024

[Dr. Wendy Norman]

Yes, absolutely.

As you have heard from other panels here today, I'm hearing that experts in the insurance industry say 97% of people have some form of coverage. Well, we are certainly not seeing that in sexual and reproductive health. When our studies have looked at those presenting with unintended pregnancies, we find that up to 70% have no coverage at all.

When we've been able to look overall at the prescriptions accessed in B.C. through the pharmacy, for people who have already accessed and purchased a contraceptive, 40% had complete out-of-pocket payment with no insurance whatsoever, and another 20% were required to copay. This copay and not having insurance for that 60% of those accessing contraception don't even illuminate for us the wide range of people who weren't able to access contraception at all because of that inequity of cost.

The people who need contraception tend to be those in the reproductive age range. The age range of the highest fertility among women and people of any gender who are pregnancy-capable has one of the lowest rates of permanent, full-time jobs that offer coverage. There's a gig economy. People are still in school.

The coverage that people in this sector of highest fertility have—where they might have it—is often through a primary plan holder for coverage, who has power over this person. The need to disclose their use of contraception is a barrier for people in coercive relationships or for adolescents on parents' plans—

[Bonita Zarrillo, NDP, Port Moody—Coquitlam, BC]

I'm going to interrupt you there because I want you to go on with that one a bit.

I'm a female. Like many people, by the time you're 16, you're having conversations about contraceptives and needing contraceptives. I made note of your comments about parents or coercive partners. Maybe you could share the risk that presents to teens and very young females.

[Dr. Wendy Norman]

Yes. As many of you are aware, the highest fertility rates are at the time closest to your teens and decline after the late twenties. In this age range, people are often still living at home, or if they are away from home, they're often in relationships, sometimes with a partner who is the person controlling their access to contraceptives or to funds.

These individuals face so many intersecting barriers to achieving their own gender equality. They have to choose between buying a contraceptive or paying their tuition, rent or food. Clearly, the other three aspects are their first priorities so that they can continue on in their lives, and they'll use no contraception or a much less expensive method that has high pregnancy rates and then present with an unintended pregnancy that may stop their education altogether and prevent them from going into the workforce.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Norman.

I have Dr. Kitchen, please, for five minutes.

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

Thank you, Mr. Chair.

Thank you to all for being here. It's greatly appreciated, given that it's late on a Friday. Our windows are closed, so I have no idea what the weather is like outside, but I appreciate your all being here at this point in time with your presentations and comments.

As you all understand, ultimately, we're looking at the legislation. To me and to you, I believe, this is about what we can do to make this piece of legislation better. What steps and suggestions can you put forward that we should be able to utilize so that we can make amendments, if needed, to this? That's a huge challenge because, as we've heard, those amendments have to be in by four o'clock today, so there are concerns as to whether they will be put forward and whether they even be passed or not. Time will tell along those lines.

One thing that I think is being alluded to but not really hit on is that health care is provincial. It's been touched on by a number of you that it is a provincial issue, and it comes to that aspect of the provinces being able to do what they need to do.

Dr. Gagnon, you made some comments on looking at steps that could be done, and you did indicate or suggest, at least what I thought I heard you say, that it could be done at the provincial level.

Are you suggesting that we as the federal government should be putting in legislation to tell all the provinces that they should be putting in a universal health care plan?

[Marc-André Gagnon]

Certainly having some help from the federal government to implement this would be something that would make things way easier, I think, for provinces.

You say that health care is a provincial jurisdiction. I don't want to get into legal stuff, but constitutionally, health care establishments are of provincial jurisdiction. When it comes to prescription drugs, it is more complicated, because this is outside health care establishments. That's one thing.

When it comes to drug approval, this is criminal law in terms of determining which substance is illegal versus legal, and if it's legal, there are ways to have some access to it with pharmacies and everything. This is why we have Health Canada, basically, approving the drugs. And at the same time, when it comes to the pricing of these drugs, this is based on the Patent Act, which is also at the federal level.

Like it or not, when it comes to prescription drugs, the federal government already has two feet, basically, in this field. It doesn't mean that the provinces shouldn't have anything to say about this. I mean, I'm a proud Québécois. When we put in place our pharmacare system in 1997, at the time, basically, it was perceived as a first step towards universal pharmacare, but when we put in place a hybrid system, we kind of locked in all these commercial interests, basically, that can abuse the system in different ways. It is not normal that, in Quebec, we are the second place on this planet with the highest cost per capita when it comes to prescription drugs. Nothing is being done about it. Instead of containing cost, we'll just shift the cost elsewhere in the system.

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

I appreciate it. I apologize for having to intervene. It's because I have such limited time.

I appreciate that comment, but ultimately it still comes down to the provinces needing to make those decisions on what they believe—as Quebec has done, and every other province should be doing—is best for them.

Mr. Adams, I appreciate what you presented and the eight recommendations you put forward. I think there are some good things about them. Ultimately, when we look at the legislation and the amendments we're dealing with in this little piece that we have right now. The scary part is whether that will grow over time. I think in some ways one of your recommendations relates to what's talked about with the national formulary, when we talk about the Canadian drug agency.

I'll just read one of your recommendations to you. It says, “The Canadian Drug Agency must be established in legislation rather than at the direction of the Minister of Health, subject to Parliamentary oversight, the Access to Information Act, Auditor General scrutiny and interventions by a Patient Ombudsman.”

Those are recommendations that are suggesting in many ways, in particular for this agency...but we've also seen this in the legislation where we talk about building a committee but we have no idea who those people will be in those roles. I'm just wondering if you could comment on that.

[The Chair, Liberal, Sean Casey]

Answer briefly, please, Mr. Adams.

[John Adams]

Thank you.

I don't know if there's procedurally any way to get an extension to five o'clock for those amendment guidelines. I toss that out there for what it's worth.

This bill gives the minister substantial new powers. It could be improved by building in various forms of transparency and accountability, as I've said. Those are some of the things.

With all due respect, I think it defers too much to the black box called the Canadian drug agency and doesn't put transparency or accountability mechanisms around what could become a very important role in system reform. That's the plea.

You're members of Parliament. Don't cut yourselves out of accountability and transparency. Build it into this legislation by amendment.

Thank you very much.

[The Chair, Liberal, Sean Casey]

Thank you very much.

Ms. Sidhu, go ahead, please, for five minutes.

[Sonia Sidhu, Liberal, Brampton South, ON]

Thank you, Mr. Chair.

Thank you to all of the witnesses for being with us. Thank you for your amendments and submissions to the committee. Thank you for your work.

My question is for Dr. Norman. It's mostly a question for you.

First of all, are you able to speak about the B.C. program? It's a successful program. Do you have any data to share with us? I know it's a successful program. Can you share the data?

[Dr. Wendy Norman]

Thank you, Member Sidhu, for a great question. I'm very proud of the work we've been doing with the Government of B.C. over the last 10 years to build toward this program. I am working within the ministry under a non-disclosure agreement to assist the ministry in evaluating the implementation of the program. I have access as well to independent research we've been conducting at UBC on health administrative data. I can share with you things that we've found on our own but not the wonderful, amazing things that we're finding within the government in our own evaluation.

What we can see from the health administrative data access that we have through the university is that we have thousands of people requesting these new contraceptives and the most highly effective contraceptives since the policy was put in place about a year ago in B.C. There are thousands every month. In fact, we had such a surge, such sustained requests for these most effective contraceptive methods, which have been out of reach for people in their personal and household economies before this, that the B.C. media has been reporting on the wait-lists in the health system and the service factors that are now being addressed to be able to meet this unmet need. When you see that even the media notices there was such a high degree of unmet need in the province that the rush of people to access intrauterine devices and contraceptive implants....

This matchstick-sized device that people can put in their arm has a lower rate of pregnancy than tubal sterilization, yet it can be removed at any time. It can last for up to three years. People are rushing to be able to get these more effective methods rather than what we've had before. The rates for birth control pills might have nearly 100 times as many people pregnant each year.

Yes, B.C. has been a success story. We are superexcited about the numbers we're seeing from the comprehensive data within the government and even from the data available in media reports and through the publicly accessible data we can access through UBC. It's an out-and-out success story. This is a way that people are now meeting their needs to be able to stay in school, to contribute to the workforce and to realize their own dreams for whether and when to have children and how to space them.

[Sonia Sidhu, Liberal, Brampton South, ON]

Dr. Norman, what recommendation can you give to this committee on the education component during the implementation? How can we work with the provinces, territories and indigenous groups in working with young women and girls, their families and potentially schools on raising awareness about the program? You talked about contraceptive stigmatization. Yesterday we heard about teen pregnancy.

Can you talk about that?

[Dr. Wendy Norman]

Thank you. This is a wonderful question. I think it's a piece of the puzzle that we all need to pay attention to.

I would come back to the need across Canada for a comprehensive national sexual health survey that's iteratively and regularly administered so that we can disaggregate and understand where we can target education programs and where we can target outreach health systems that can get to those populations that inequitably aren't able to understand the knowledge, the methods and the services they require to achieve their own reproductive health goals.

To have the ability to address a problem, we first need to understand it. To understand it, we need to measure it. I think the baseline sexual health survey that will go out this year will provide a lot of data for the government on where we could be going, but it won't help us understand how this bill and other future efforts by the government in terms of the amazing work the government's been doing to advance sexual and reproductive health through Health Canada.... These impacts need to be measured as we go forward.

[The Chair, Liberal, Sean Casey]

Thank you.

Mr. Blanchette‑Joncas, the floor is yours for two and a half minutes.

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

Thank you, Mr. Chair.

I'm going to continue my questions with Mr. Adams.

Mr. Adams, earlier today, a group of witnesses told us it was important to ensure that the expert committee that is struck isn't a pro forma group, by which I mean one that has no actual responsibility or that has an advisory role. Those witnesses asked that the pharmacare advisory and national strategy implementation groups be given the information they need to provide genuine advice rather than serve as a sounding board or merely provide tacit approval of decisions made in camera. Do you agree with that? What you have to say to us about that?

[John Adams]

We had many lessons recently from a little thing called a pandemic.

Some of us took the time to observe the advisory processes in another jurisdiction south of Canada. The CDC and the FDA advisory committees, whether they were dealing with vaccines, therapeutics or other things, I could watch those on Zoom. I could read the background materials and I could come to my own informed view. Did they get it or did they miss it?

When those advisory processes take place inside a black box and you can't see.... I welcome this opportunity. We're in public. People can make their own evaluations on whether I get it or not. I can make my evaluation on whether you get it or not. It's open, it's transparent and we can be accountable.

Too much of the process at the federal, provincial and territorial levels takes place behind closed doors, in black boxes. I would appeal to this committee to move amendments to start opening doors, opening windows and letting the sunshine in.

[The Chair, Liberal, Sean Casey]

You have 28 seconds left.

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

Mr. Adams, what essential measure would you add to ensure that things are well done?

[John Adams]

There are specific things in our written submission.

I think you need to try to do your best to ensure that freedom of information and access to information rules apply to the new model that this bill is trying to build for pharmacare. Ensure that there's accountability, so the Auditor General of Canada can go in and do value-for-money audits.

There should be a new function of an ombudsman, so that people who think the system has not responded to them in a fair and reasonable way have an ability to access, without going to court, a review and oversight function. Those officers and the health minister should be required to report back to Parliament on a regular basis on steps, progress, problems and alternatives.

[The Chair, Liberal, Sean Casey]

Thank you, Mr. Adams.

Ms. Zarrillo, you have two and a half minutes, please.

[Bonita Zarrillo, NDP, Port Moody—Coquitlam, BC]

Thank you.

I just wanted to ask a question each of Dr. Morgan, Dr. Gagnon and Mr. Adams. I only have about 30 seconds for each answer. Each of you said something that I'm interested to know, outside of this bill.

Dr. Gagnon, you referred to an institutional rip-off. What can we do to fix that, outside of this bill?

Mr. Adams, you said “postal code lottery”. What can we do to fix that?

Dr. Morgan, you talked about fairness and efficiency.

Maybe I could start with Dr. Gagnon.

[Marc-André Gagnon]

One example is Trintellix, which is an SSRI antidepressant. It came to the market and CADTH, at the time, basically did the evaluation. There was no clinical evidence that this new drug was bringing anything more as compared to existing drugs. The recommendation was to not pay a penny more for this drug than the lowest-priced drug of this category. Trintellix still entered the market with a price 10 times what it was for other drugs in the same category.

I was reading an annual report from the company Lundbeck that said that in Canada, Trintellix—this drug that doesn't have any clinical evidence that shows any advantage as compared to other drugs—managed to capture 24% of the antidepressant market in Canada.

In terms of rip-off, if we have a system that says that you can make a commercial blockbuster with a drug that doesn't bring anything new, basically the message we're sending, in terms of incentives for innovation, is don't innovate. We have a crappy system that will take in anything at any price. In terms of institutional rip-off, this is what is missing in terms of getting value for money.

[Bonita Zarrillo, NDP, Port Moody—Coquitlam, BC]

Thank you.

Mr. Adams, go ahead, and then Dr. Morgan.

[John Adams]

For the “postal code lottery” line, I have to give credit where credit is due. It's not my line; it's the line used by the immediate past federal minister of health, Mr. Duclos, in March of 2023 when he announced the go-forward of the plan for drugs for rare disorders. I was there. It was ad libbed by the minister. It wasn't in his prepared text.

It captures the essence of some of the inequities in the lists of drugs that are or aren't covered in various jurisdictions.

I think there is a compelling role for the Government of Canada and the Parliament of Canada to make financial contributions, so that access gets not to the lowest common denominator but to a much higher common denominator for all patients, no matter where they live and no matter what postal code in Canada they're in.