Health Committee on May 24th, 2024

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

That's great. Thanks.

Ms. Eagan, to you in the few final seconds we have left, we've talked a lot about public plans and private plans, etc. You have incredible experience with respect to this.

Have you ever come across a public plan that is better than a private plan and, if so, what is it?

[Carolyne Eagan]

Do you mean within Canada?

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

Yes.

[Carolyne Eagan]

I have not heard of one that is better, but I would defer to doing further research, but to my knowledge, I have not been made aware of one. When you talk about lists of drugs and time to access, I have not heard of a better public fund.

[The Chair, Liberal, Sean Casey]

Thank you, Ms. Eagan.

Thank you, Dr. Ellis.

The last round of questions will go to Ms. Sidhu for three minutes.

[Sonia Sidhu, Liberal, Brampton South, ON]

Thank you, Mr. Chair.

My question goes to JDRF.

Yesterday we heard from Heart and Stroke that more than 600 people in Canada die every year from ischemic heart disease because they cannot afford their medication. We also heard testimony from a type 1 diabetes patient, Mr. Bleskie, who said that insulin is not a luxury; it's a necessity. We also heard that they have to pay $1,600 a year per patient, so there is a lot of savings from this legislation.

Ms. Diniz, from our work on the framework, we know how important this legislation in front of us is to all patients and their families.

What are you hearing from the young type 1 diabetes patients and their parents? What expectations do they have from the committee when it comes to Bill C-64? Can you explain that?

[Jessica Diniz]

Thank you very much for the question.

I agree that diabetes is a very expensive disease to manage. I think there are points in time, with respect to insurance coverage, when it can be more costly. This bill will help the uninsured and the under-insured significantly.

As I've stated, insulin is required to stay alive. It's not a luxury. It's not an add-on. It's something that's needed. I encourage the committee to make sure we're focused on first principles of providing better access to the medications and devices that are required and then look at the mechanism of how. That's how we're looking at this. What's our first principle here? It's to have better access for Canadians.

In terms of your question regarding what people are looking for, it's better access that's affordable and equitable. It shouldn't matter which province you live in or what age you are. All Canadians with diabetes should have access to the medications they require.

[Sonia Sidhu, Liberal, Brampton South, ON]

Thank you.

My next question is for Mr. Thibeault.

We know that education and awareness.... You know how important education is, living with type 2, especially.... In Brampton, you and I have talked about that and Diabetes Canada is helping with the awareness campaign.

What are you looking at for the diabetic devices and also the education campaign, when we roll it out? What are your thoughts on that?

[Glenn Thibeault]

Thank you for the question.

As an individual who is fortunate enough to wear a continuous glucose monitor, it has completely changed the way I can manage my diabetes. It's allowed me to stay in the green—for those of us who have it and understand what that's all about.

Therefore, making sure we can get access to devices—I know we're going to talk about the device fund at another time—is an absolute game-changer for people who live with type 1 or type 2 diabetes. I think that when we have the opportunity to start talking about the device fund in a more fulsome discussion—right now, it's pharmacare—we are going to be able to raise all boats.

Through the advocacy we have been doing over the last year within Diabetes Canada, we now have provinces and territories right across the country with some form of continuous glucose monitor or insulin pump coverage. That's great, but there are still gaps that need to be filled. Having the device fund, and then coming in with the education component that will be needed to teach people and ensure they understand how they can do this, will be key.

We're going to continue to advocate and do our job within Diabetes Canada to talk about the importance of devices, education and medications at the provincial and territorial level.

We work with NIDA as well, which was here yesterday on the indigenous component. We do a lot of work with JDRF. We met with the minister as a team yesterday to talk about some of the clarity we're looking for on choice and we were thankful to hear that.

As such, we'll continue to be a strong voice for the people who are living with diabetes in this country.

[The Chair, Liberal, Sean Casey]

Thank you, Mr. Thibeault, and thank you to all of our witnesses on this panel.

It's hard to get time with a panel that's so diverse and large. Ms. Diniz, we very much appreciate your sticking with us to get the technological issues resolved. We appreciate your participation and everyone's participation.

We're going to suspend now until 3:30 to allow these witnesses to take their leave and for the next ones to get in.

Thank you again, and have a good weekend, everyone.

We are suspended until 3:30.

[The Chair, Liberal, Sean Casey]

I call the meeting back to order and welcome our final panel of witnesses.

In accordance with our routine motion, I'm informing the committee that all remote participants have completed the required connection tests in advance of the meeting.

Joining us for this panel as individuals are Dr. Marc-André Gagnon, associate professor at the school of public policy and administration at Carleton University, and Dr. Steven Morgan, professor at the University of British Columbia, who is appearing by video conference. On behalf of Action Canada for Sexual Health and Rights is Dr. Wendy Norman, Public Health Agency of Canada chair of family planning and research. From the Best Medicines Coalition, John Adams is the board chair.

We're going to invite you to offer opening statements of five minutes in length.

Before we do, I will remind everyone that if they want to submit amendments for Bill C-64, the deadline is in 25 minutes, as was pointed out at the start of the meeting.

We're going to proceed now with opening statements in the order listed on the notice of meeting, so we're going to start with Dr. Gagnon for five minutes.

Welcome to the committee, Dr. Gagnon. You have the floor.

[Marc-André Gagnon, Associate Professor, School of Public Policy and Administration, Carleton University, As an Individual]

Thank you very much.

My name is Marc‑André Gagnon, and I am a professor of public policy at Carleton University. I have been working on pharmaceutical policy issues for the past 20 years and have written more than 150 articles, chapters and technical reports on those same issues. I have no commercial conflicts of interest.

I am always astounded by the way our governments kowtow to the power of pharmaceutical companies and commercial lobbyists to the detriment of the Canadian public.

The evidence is clear: As recommended in the Final Report of the Advisory Council on the Implementation of National Pharmacare, the Hoskins report, a universal public pharmacare program would help to provide better access to drugs for all Canadians and to lower costs by approximately 20%.

However, the government still hesitates and has only announced coverage for contraceptives and diabetes drugs, while trying to maintain the present hybrid private-public system, which has become a model of inefficiency and waste all around the world.

The problem stems from the fact that drug coverage in Canada is a system of fragmented and disparate parts. It is an unfair and ineffective system lacking any consistency or overall objective. There are some who believe we can solve the problem by adding new parts, but the fundamental problem is that the system is fragmented.

Let's remember that Canada is the only country with a universal public health insurance system that doesn't include prescription drugs, as if the latter weren't an essential health care service. Canada ranks third, after the United States and Germany, among countries with the highest per capita drug costs in the world. Canada remains one of the countries with the biggest percentage of citizens who, for financial reasons, can't access the drugs they need. More than 10% of Canadians avoid filling their prescriptions for financial reasons.

Today I've heard many people with obvious conflicts of interest proposing that we introduce a mandatory private system such as the one in Quebec. By the way, Quebec is the only province in Canada where per capita drug costs exceed those of Germany. Thus, by following Quebec's example, Canada could become the country with the second-highest drug costs in the world after those of the United States. That would mean that we essentially want a publicly funded Quebec-style system with expensive drug coverage for high-risk patients receiving the highest-cost treatments.

A Quebec-style system would increase drug spending by $5 billion a year and would do very little to lower financial barriers for access to the drugs people need. We would be introducing a mandatory private plan that is incapable of providing coverage for the most costly patients, who constitute a bad risk and would be offloaded to the public plan for expensive drugs.

In short, we would be asked to pay more to create an inefficient system by making private plans mandatory and undermining our ability to negotiate lower prices, while demanding public funding to cover the risks of the private plans. We want a mandatory private insurance program that doesn't cover risks. It's quite fascinating. That's what we're demanding. That's what I've been hearing.

There's a dangerous barrier to the introduction of a universal public plan as the Hoskins report recommends, and that's the fact that too many stakeholders, including provincial and territorial governments, benefit from the present system of unclear prices and whisper discounts. The provinces' public plans don't know how to contain costs and merely shift them around within a fragmented system.

Take Repatha, for example, an anti-cholesterol drug. Its official price is $6,000 a year, and the whisper discount is an estimated 90%. So the actual cost of the drug is $600 a year, and the difference is a rebate that goes to the payer. In Quebec, patients insured under the public system pay a deductible of $23 a month, and their copayment is 33%. To buy Repatha, they will ultimately have to pay $1,200 a year out of their pocket for a drug that costs only $600 a year. In addition, to be guaranteed this kind of coverage, they are required to pay a premium of $731 a year. This isn't insurance; to a certain degree, it's a scam.

On the other hand, the private plans, innocent as doves, have to pay the full price of $6,000 a year without any whisper discounts, not the government-negotiated price of $600 a year.

The present system has become an opaque institutionalized scam, which is unacceptable. Too many actors are lining their pockets and have every interest in preventing anyone from eliminating waste.

We need an efficient universal public program to contain costs for Canadians; we can't just shift costs elsewhere in the system onto the shoulders of the patients and workers. We need a universal public plan with the necessary institutional capacity to ensure that we get value for our money and promote good prescription habits based on solid evidence, not the arguments of corporate marketing campaigns. We need a rational insurance plan, as proposed in the Hoskins report. I would remind you that the Trudeau government has committed to following that report's recommendations.

I will be pleased to answer the committee members' questions.

[The Chair, Liberal, Sean Casey]

Thank you, Mr. Gagnon.

Next up is Dr. Morgan, please, who is online.

Welcome to the committee, Dr. Morgan. You have the floor.

[Dr. Steven Morgan, Professor, School of Population and Public Health, University of British Columbia, As an Individual]

Thank you.

I'm an economist and professor of health care policy who has studied pharmacare systems for 30 years. I have published over 150 peer-reviewed research papers on related topics, and I serve on the World Health Organization's technical advisory group on pricing policies for medicines. I have no financial ties to commercial interests in this sector, and I have no have financial ties to health professionals, unions or other groups who also take an active interest in this file.

I am here simply because I wish to help Canada develop the institutional capacity necessary to fairly and efficiently provide access to necessary medicines in a very complex sector that involves some of the world's most powerful corporate interests and very serious, truly global challenges regarding the reasonableness and transparency of pricing.

I want to start by saying that we do not need another study of whether or how Canada should implement a national pharmacare program. These questions have been thoroughly investigated by four separate inquiries since the mid-1990s. All of these inquiries have recommended that carefully selected, medically necessary prescription drugs be included in Canada's universal single-payer public health insurance system.

The latest of these studies, the June 2019 report of the advisory council on the implementation of national pharmacare, was conducted by a council of experts from across the country and chaired by Ontario's former health minister, Dr. Eric Hoskins.

The Hoskins council, as it is known, consulted with provinces and territories. It consulted with first nations. It consulted with patients, health professionals and other stakeholders in the sector. It consulted with Canadians from coast to coast. It concluded with a detailed and feasible plan for implementing a universal single-payer public pharmacare program that would save Canadians billions of dollars every year while improving access to medicines from coast to coast and reducing strains on our health care system.

The foundations of Bill C-64 are backed by thorough discussion and analysis. I believe Bill C-64 can, if the government actually wishes to do so, move us toward the fair and efficient pharmacare system that has been recommended by commissions time and time again.

However, as it is written, Bill C-64 will not do this. This is because it does not make absolutely clear what type of pharmacare program the bill would establish. This ambiguity in Bill C-64 allowed the Parliamentary Budget Officer to conclude that the system that would be created would be a fill-the-gaps pharmacare system involving a patchwork of literally thousands of private and public drug plans. Indeed, even the Minister of Health testified yesterday that he would create such a program with the powers that Bill C-64 would give him.

This would be disastrous for Canada because patchwork pharmacare systems inject needless and costly inefficiencies into the system. They impose significant inequitable financial burdens on individual households and employers, they diminish a country's purchasing power on the global market for pharmaceuticals and they isolate the management of medicines from other key components of the health care system.

It would be especially problematic to have for-profit insurers involved in the core of a national pharmacare system. This is something that only the United States permits. It is problematic because insurers can actually profit from higher drug prices through higher administrative fees charged to plan sponsors. They can also profit by pocketing secret price rebates that they can and do negotiate with drug manufacturers and pharmacies.

If the first stage of national pharmacare is allowed to be a fill-the-gaps program involving a mix of private, public, for-profit and not-for-profit insurers, subsequent stages of national pharmacare will almost certainly be locked into that model too.

If, contrary to the recommendations of its own advisory council on the topic, the government wishes to implement a fill-the-gaps system, then it can leave Bill C-64 as it is, because that is what this legislation will deliver. In this case, the NDP should understand that their supply and confidence agreement has been broken.

If, on the other hand, the government does indeed wish to implement the recommendations of its own advisory council on this topic, then it must amend Bill C-64 to set out crystal clear standards for a national program that will prove that Canadians are, in fact, stronger together. That is what Canadians deserve, but as the bill is currently written, that is not what Bill C-64 will deliver.

Thank you.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Morgan.

Next, from Action Canada for Sexual Health and Rights, we have Dr. Wendy Norman.

Dr. Norman, welcome to the committee. You have the floor.

[Dr. Wendy Norman, Public Health Agency of Canada Chair, Family Planning Research, Action Canada for Sexual Health and Rights]

Thank you, Honourable Mr. Chair and members of the committee. Thank you for the opportunity to speak today to your study of Bill C-64.

I am a family doctor and a UBC professor, and I have had the honour to serve for the past decade with the Public Health Agency of Canada as the chair for Canada for family planning research. I'm the co-chair on Statistics Canada's expert committee for sexual and reproductive health. I have worked with Health Canada to advance several of the programs within the sexual and reproductive health themes over these past several years, and as a long-time collaborator with Action Canada for Sexual Health and Rights.

There are two points I hope to bring expertise and experience to and highlight for you today. The first is that universal access to free contraception to prevent unintended pregnancy will support immediate, lifelong and intergenerational impacts for individuals and families, and society as a whole, that improve health and health equity throughout Canada.

Secondly, our modelling in Canada and examples in practice across the globe indicate that universal, comprehensive, single-payer, first-dollar coverage of contraception is required to address the needs of people at risk of unintended pregnancy. In Canada, 40% of pregnancies are unintended, and contrary to what you might expect, most unintended pregnancies result in unplanned births. The devastation of facing an unintended pregnancy and managing whatever outcome can have lifelong and intergenerational consequences not only for that pregnant person and their partner, but for the unplanned children and the children and other relatives already in the home.

The most comprehensive, most effective contraceptive methods have the highest upfront costs. The least expensive contraception has the highest rates of unintended pregnancy. In the case of longer-acting contraception, such as implants and intrauterine devices, which are our most effective methods, the cost can be over $400 up front. For many, this need for contraception conflicts with the money they need for rent or food. Due to their much higher effectiveness to prevent unintended pregnancy, however, those same “most expensive” methods have the lowest overall cost for government.

More effective contraceptive methods offer families a better and safer start for their planned and appropriately spaced children, while supporting family members to pursue advanced education, to better their opportunities, to contribute to the workforce and our economy, and to service their communities. In contrast, people unable to afford to manage their own fertility face lower educational achievements, lower household income and higher exposure to intimate partner violence. Their children, in turn, suffer lower rates of food safety, adequate shelter and graduation from high school.

Through a Canadian Institutes of Health Research-funded, UBC-led study from 2015 to 2019, the Government of B.C., Action Canada and a wide range of our collaborators modelled the cost effectiveness for prescription coverage in B.C. We found that among people who experienced unintended pregnancy and sought abortion, only about 30% had access to any form of subsidy for contraception, and the contraception cost was the factor most related to those subsequent unintended pregnancies.

For over two years, we worked with the B.C. government on variations of patchwork contraception coverage and compared them to comprehensive coverage through the modelling process. We looked at all kinds of models to address specific gaps. In every case, as soon as we moved from universal, comprehensive, first-dollar, single-payer systems, the rates of unintended pregnancy went up and the overall health system costs went up.

With a model of universal coverage, the B.C. government most effectively reduces unintended pregnancy while lowering overall health system costs by over five dollars for each resident of the province each year.

Evidence from health systems around the world indicate that a universal, first-payer prescription subsidy, rather than partial, fill-the-gap coverage is required to support health equity. Analysis after the institution of the U.S. Affordable Care Act determined a savings of over seven dollars for each dollar invested in contraception and contraception counselling. Similarly, Public Health England has found it's saving nine pounds for each pound it spends on universal prescription contraception.

An important factor here is that contraception is a stigmatized prescription. This is particularly true among equity-deserving populations and those in our society who face the most intersectional barriers. Our study found that reproductive-aged people, and particularly women at the ages of highest fertility, are the least likely to have stable, full-time jobs providing prescription benefits.

In fact, in analyzing the impact of the new B.C. policy for free contraception, we found that prior to its institution, 40% of those who bought contraception had to pay out of pocket completely, and another 20% had private coverage that required copayments. This isn't even looking at all of the people who weren't able to access contraception at all because of cost. Once B.C. implemented their policy, these out-of-pocket costs decreased to less than 10% of those accessing contraception.

We know that among those—

[The Chair, Liberal, Sean Casey]

Dr. Norman, I'll get you to wrap up. You'll have lots of time to elaborate in the questions and answers.

Thank you.

[Dr. Wendy Norman]

Thank you.

I'll just say, then, that adolescents and people whose insurance is held by a parent or a coercive partner are in a particularly difficult situation and much less likely to access coverage if they need it.

There are few investments in health that have the potential to offer both health system savings and improved equity and health equity for children and families. Bill C-64 would support improved health for people throughout Canada.

I apologize, Mr. Chair, for going over the time.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Norman.

Next is Mr. John Adams on behalf of the Best Medicines Coalition.

Welcome, Mr. Adams. I know you've been in the room. You know the drill. You have the floor.

[John Adams, Board Chair, Best Medicines Coalition]

Mr. Chair and health committee members, thank you for the invitation to be a witness at these historic hearings regarding pharmacare for Canadians.

Our Best Medicines Coalition represents 30 patient organizations, from Parkinson's, arthritis, hemophilia and blindness to cancers and other complicated and rare diseases. Together, we represent the interests of millions of patients and their caregivers.

I'm happy to have moral support from JK Harris of the Canadian Breast Cancer Network and one of our member organizations, who's here today. Thank you very much, JK, for being here.

BMC's aims are simple.

Number one is to fix the postal code lottery by ensuring all patients have access to the medically necessary medicines they need and ensure patients are meaningful participants in the development and oversight of pharmacare policies.

We at BMC recognize that Canada is the only developed nation with a universal health insurance system that does not include universal coverage for prescription drugs used outside of hospitals. This gap results in disparities within and among provinces, territories and indigenous jurisdictions where individual programs provide varying levels of drug coverage. This is what we call the postal code lottery.

As a result, one in 10 Canadians reportedly do not take their prescribed medications due to out-of-pocket costs. This highlights significant inequities in access to necessary medications. Up to 7.5 million citizens—one in five Canadians—don't have prescription drug insurance, have inadequate insurance to cover their medication needs or do not enrol when eligible.

Cost and coverage aren't the only problems.

Here's the bad news for anyone in the Ottawa bubble: Sixty-four per cent of Canadians believe that the federal government is not transparent enough about its health care policies. This lack of transparency erodes public trust and hinders the effective implementation and uptake of health initiatives.

Then there's data. Inconsistent reporting and lack of transparency in health data hinder the measurement of performance and outcomes, decrease opportunities for identifying gaps in data and services, and impede the capacity of the health system to integrate patient voices.

There's also a lack of representation of patient voices within governments and government-funded organizations in generating and implementing drug policy. One result is a health care system that is less responsive to patient needs. This can potentially compromise the quality of care and lead to a disconnect between patient expectations and the care provided.

In addition, existing complicated patient pathways cause significant stress and anxiety for patients and their caregivers, potentially exacerbating health conditions and leading to worse health outcomes. Thirty per cent of Canadians experience difficulties in navigating the existing health care system, leading to significant delays in receiving necessary medical attention. Changes in pharmacare must not create new barriers to innovations to address the unmet needs of patients.

The involvement of patients should be done with more than an expedited and truncated consultation on such a foundational expansion of the social safety net of Canadians. Patients should be built into the programs and the structure, not just with an occasional consultation. For example, patients—and that's plural—should be on the board of the Canadian drug agency.

We have eight friendly recommendations for amendments to the bill. I'm right at the clock, so if somebody could do us a courtesy, we'd love to have those eight submitted. They're in our written submission.

I want to highlight two key points of patient interests.

First, create a chief patient officer at Health Canada. Second, create a patient ombudsman who reports directly to Parliament. Only MPs and senators can make this ombudsman role come to life.

The chief patient officer at Health Canada would work within the organization. It should be someone with lived experience whose role gives them authority to ensure that the patient experience and expertise is recognized and used to drive reform and improve patient outcomes. This person should further be supported by an advisory committee with diverse patient representation, which this legislation doesn't quite contemplate yet.

The patient ombudsman would work outside the organization and report independently to Parliament. Besides reporting on any failures to uphold the act and regulations, this ombudsman would also assess barriers and concerns as expressed by patients when it comes to accessing medications and would recommend changes.

These amendments to Bill C-64 would enable and reinforce transparency and accountability. It's not enough for any government to say that they want universal access to medications. Bill C-64 should speak to the role patients must take in improving equitable access to medications.

With your questions, I'd be pleased to go into detail on all eight of the proposed amendments we suggest to better support patients.

The Best Medicines Coalition calls on Parliament to do its best for Canada's patients. On behalf of all patients, nothing about us without us.

Thank you.

[The Chair, Liberal, Sean Casey]

Thank you, Mr. Adams.

We'll now begin with rounds of questions starting with Dr. Ellis for six minutes.

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

Thank you very much, Chair.

Thank you to everyone for being here.

It's certainly with interest that we'll pursue this next round of questioning.

I don't want to start a fight between Dr. Gagnon and Dr. Morgan, because your bios both say that you're Canada's leading expert in pharmacare systems. It's a good thing you're not both in the room. It might be interesting.

That being said, I'll start with you, Dr. Morgan.

You've written 150 papers about pharmacare and how to implement it. I'm interested to know how much consultative time you spent with the government on this Bill C-64.

[Dr. Steven Morgan]

I was not directly involved in developing this piece of legislation or the bill at all.

I've worked with government and advised different people within the bureaucracy and government over many years, but I was not involved in drafting Bill C-64.

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

Thank you for that.

Through you, Chair, to Dr. Gagnon, were you involved in the drafting of Bill C-64?

[Marc-André Gagnon]

Absolutely not.