Health Committee on May 24th, 2024

[Linda Silas]

Honestly, stop stalling on providing Canadians' access to medication. This is opening the door for equality in our health care system. I support this bill and will work on improving it in the years to come.

[The Chair, Liberal, Sean Casey]

Thank you, Ms. Silas.

The last person to pose questions to this panel is Mr. Naqvi for five minutes.

[Yasir Naqvi, Liberal, Ottawa Centre, ON]

Thank you very much, Mr. Chair.

I'm going to start by reminding members of the committee that I had the great honour of serving at the provincial level in Ontario for 11 years. I was part of the government that actually brought in OHIP+, and I was quite involved in the creation and development of that program.

I can tell you—forget it from the government side—just from the perspective of a member of provincial Parliament and in talking to countless constituents of mine, I know that young people, parents of young people, were able to benefit from OHIP+, because all of a sudden they were able to get access to life-saving medications without any cost through just using their OHIP card. It was a game-changer in terms of providing the kind of support needed by people, especially for young people. Anybody who's a parent in this room or listening knows that there's nothing more important to a parent than making sure of the well-being of their children.

I met so many constituents of mine, so, with all due respect to Mr. Kitchen, I can share with you my personal experience being a member of the provincial Parliament at that time in Ontario in terms of the impact it made—and the lack of it once Doug Ford's government took away that option, that choice, and the suffering lots of people faced.

I'll go to Ms. Silas. It's good to see you again. Thank you for your hard work and advocacy.

“Choice” is coming up here often, and that somehow this legislation is going to undermine choice and take it away. I see it as the opposite. I see it as actually creating choice, creating more options for people who don't have pharmacare or who are uninsured or under-insured.

Can you, from your perspective and all the work and research that your organization has done, tell us what your thoughts are on choice and what this bill does in terms of the choices available to Canadians when it comes to access to life-saving medications? In this case, start with diabetes and contraceptives.

[Linda Silas]

First of all, I totally agree with you on OHIP+. We all celebrated when it was introduced. The only downfall was that we were hoping the federal government would be doing that, similarly as they did with the dental plan.

When you use the word “choice”, I see it again as an equal playing field for the essential medications that are prescribed across this country. The choice will be for those who can afford more. However, the equal playing field for diabetics across this country, for women across this country, will be putting them on equal footing with everyone else. The choice will be the extras.

[Yasir Naqvi, Liberal, Ottawa Centre, ON]

Thank you. You've looked at this bill fairly closely and in detail. Did you find anywhere in this bill a mention of private insurance or how that will disappear, or that people will not have the option to access or rely on their private insurance?

[Linda Silas]

No. When you look at the principles in clause 4, it's, again, talking about working with indigenous peoples, provinces, territories and stakeholders on how to implement the funding aspect. Again, as we mentioned earlier, “rare diseases” are especially identified there. It continues with diabetes treatments and contraceptives.

It's important to look at the simplicity of this bill, which the experts will be able to work with.

[Yasir Naqvi, Liberal, Ottawa Centre, ON]

Nowhere in this bill is there any reference to removing drugs or reducing the drugs covered by private insurance.

[Linda Silas]

No. There is not one union in this country that would agree to eliminating the private programs that exist everywhere.

[Yasir Naqvi, Liberal, Ottawa Centre, ON]

Can I ask the same questions of Ms. Berg and Dr. Wong-Rieger in terms of private insurance?

In your analysis of this bill, do you see any reference to private insurance not being available for those who want to access it?

We'll start with Ms. Berg.

[Angelique Berg]

Thank you.

We're actually not familiar with the private and the public plans. It's business-to-business throughout the supply chain.

I would defer to Durhane. I know she's done tons of work on that.

[Yasir Naqvi, Liberal, Ottawa Centre, ON]

Great.

Thank you.

[Dr. Durhane Wong-Rieger]

Thank you very much.

For us, the concern is to make sure that.... As you know, there are essential medicines, but in many cases, there are much more personalized medicines. There are much higher-level medicines that are especially for those people who have that need.

Therefore, I would agree very much with Ms. Silas. If you need an essential medicine, if you need a basic medicine, as you say, with OHIP+, that would be available. Quite frankly, we would love to have the bill make it so that everybody gets the medicine they need and so that nobody is actually reduced to a common medicine if, in fact, what they need is much more specialized.

Today we have private and public insurance for rare disease drugs. I have to say that the sad news is that we get, over and over again, patients who tell us that the first question they'll be asked is whether they have private insurance. If they don't have private insurance, then they won't even get prescribed the appropriate medicine because it's not going to be covered by the public plan.

If there's a plan that provides, as you say, the optimal choice for each and every patient so that they can get what is absolutely the best for them.... In many cases, people end up in hospital because they don't have the right drug.

Yes, we would love to have a plan that would allow everybody to get what they need regardless.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Wong-Rieger.

Thanks to all of our panellists for being with us here today. We very much appreciate your testimony and the professional manner in which you've delivered it.

Colleagues, we're going to suspend now until 1:45. We'd like you to come back right at 1:45 because we're actually going to have five witnesses on the next panel.

Thanks again to all of you for being with us.

The meeting is suspended.

[The Chair, Liberal, Sean Casey]

I call the meeting back to order.

I'd like to welcome our second panel of witnesses for today. We have a couple of witnesses participating remotely, so I will just inform the committee that, in accordance with our routine motion, all remote participants have completed the required connection tests in advance of the meeting.

For our remote participants, you will see on the bottom of your screen that you have the choice of floor, English or French. That's to be able to access the simultaneous translation, should you require it.

Here are the witnesses we have with us today. From JDRF Canada, we have Jessica Diniz, president and CEO.

Ms. Diniz, thank you for your patience as we worked through the technical issues. We're going to start with you.

From the Association québécoise des pharmaciens propriétaires, we have Benoit Morin, president, and Geneviève Pelletier, senior director, external and pharmaceutical affairs.

Representing the Canadian Association of Retired Persons, we have Bill VanGorder, chief policy officer, appearing by video conference. On behalf of Diabetes Canada, we have Glenn Thibeault, executive director, government affairs, advocacy and policy.

Welcome back, Mr. Thibeault. It's good to see you again.

We also have Russell Williams, senior vice-president, mission. Representing the Smart Health Benefits Coalition, we have Carolyne Eagan, principal representative.

We're going to begin with opening statements in the order listed on the notice of meeting. We're going to start with JDRF Canada.

Ms. Diniz, welcome to the committee. You have the floor.

[Jessica Diniz, President and Chief Executive Officer, JDRF Canada]

Thank you, Mr. Chair. I'm honoured to be here.

Good afternoon, members of the committee. My name is Jessica Diniz, and I'm the president and CEO of JDRF Canada.

JDRF is the world's largest charity focused on accelerating research to cure, prevent and treat type 1 diabetes and its complications, as well as helping to make life better every day for the people who live with it. We also advocate on behalf of the 300,000 Canadians living with type 1 diabetes, representing their voices on critical issues such as national pharmacare.

JDRF supports the goal of making access to medications and devices for treating and managing type 1 diabetes equitable and affordable for all Canadians. Patient choice needs to be a priority.

Type 1 diabetes is a lifelong autoimmune disease in which a person's immune system destroys insulin-producing cells in the pancreas, making them dependent on daily injections of insulin to survive. I just want to underscore that they require insulin to stay alive. I just want to make sure that is very clear.

Managing diabetes represents a significant financial burden for Canadians impacted by the disease, and many treatments and devices remain out of reach for some Canadians. We thank the government for bringing diabetes and the high cost to manage the disease into focus through coverage under Bill C-64.

While we align with the intention of Bill C-64 to provide fulsome, barrier-free access to treatments and devices for those living with diabetes, we'd like to raise a couple of recommendations to ensure that Bill C-64 meets the needs of all Canadians living with type 1 diabetes.

First, national pharmacare should not preclude anyone from using existing private and public insurance coverage to access insulin, whether they are listed on the national formulary or not. Bill C-64 should include a provision that clearly articulates this principle.

Second, based on consultations with health care providers and those living with type 1 diabetes, we'd like to see the list of insulins on the formulary be expanded to include more advanced insulins that help better treat the disease. It's a very limited list, including insulins that are rarely used and prescribed. It's important that physicians have therapeutic options to address the wide variation in individual patient responses to and tolerance of any particular drug, and that patients can access these, as one insulin may work well for one person and not for another. I think this is a very important point. By expanding the choice of medicines, you increase the number of treatment options available to help eliminate side effects, reduce complications and improve health outcomes.

We also have two areas of caution on how this program is implemented that we'd like to raise. Number one is changes in insurance coverage. The bill also creates a risk whereby the existence of the national formulary may motivate private insurers not to cover brand name insulins because some of the generic equivalents would now be available through the national pharmacare program. If this happens, the consequence could be the automatic substitution of a different insulin, which can impact health outcomes.

Another concern, number two, is stakeholder engagement and consultation. This will be critical to ensuring the implementation of a national pharmacare program that best meets the needs of Canadians living with type 1 diabetes.

JDRF is supportive of legislation that improves access to medications and devices for Canadians living with type 1 diabetes. We ask the government to provide clarity on this legislation to ensure it lives up to its intentions of equity and affordable access to medications and devices, and considers the input of various stakeholder groups that must have a voice now in how national pharmacare is rolled out.

It's critical to get the implementation of this legislation right to ensure it delivers on its promise, not only for those living with type 1 diabetes but for all Canadians who will benefit from this program in the future.

Thank you very much.

[The Chair, Liberal, Sean Casey]

Thank you, Ms. Diniz.

I now invite Benoit Morin, from the Association québécoise des pharmaciens propriétaires, to take the floor.

[Benoit Morin, President, Association québécoise des pharmaciens propriétaires]

Thank you, Mr. Chair.

Good afternoon and thank you for inviting me to appear before you in my capacity as president of the Association québécoise des pharmaciens propriétaires.

I am here today with Geneviève Pelletier, director of pharmaceutical affairs.

I represent the 2,050 proprietor pharmacists of the some 1,900 community pharmacies operating in all chains and under all banners across Quebec.

A significant characteristic of the Quebec industry is that only pharmacists may own a pharmacy, as a result of which professional independence and ethics take precedence over business decisions, and patient welfare is owners' main priority. We have a unique pharmacy network in Quebec.

From the outset, I would emphasize that our association supports the Canadian government's wish to improve access to and the affordability of prescription drugs for Canadians. However, we assert that the health minister's objectives can already be met under the system in place in Quebec.

Accessibility and the primary care they provide are distinguishing features of Quebec's community pharmacies. Our pharmacy teams offer a multitude of services that extend far beyond drug dispensing and monitoring, and the efficient provision of those services is largely responsible for our pharmacies' financial health and thus for the funding of those services.

However, we are very concerned about Bill C-64 in its present form. A national single-payer pharmacare program would jeopardize the pharmacy model to the detriment of patients.

The current funding of Quebec pharmacies relies mainly on professional fees associated with the dispensing and monitoring of prescription drugs. Variations in those fees can influence pharmacies' ability to provide services to patients. Under the mixed public-private system, pharmacies can provide their services in a stable, predictable manner for the plan manager, the Régie de l'assurance maladie du Québec.

Under the proposed public single-payer principle, pharmacists' fees for dispensing and refilling prescriptions for diabetes medications and contraceptives would be a single amount negotiated for covered drugs. In that scenario, the impact on Quebec proprietor pharmacists would be significant because those drugs are commonly used by patients who are covered by the private component of the general drug insurance plan. That accounted for nearly 7 million acts in 2023.

It is precisely the flexibility of the present mixed public-private model that enables Quebec pharmacies to develop, operate in all regions and provide a host of services to patients. The mixed nature of the system allows proprietor pharmacists to adjust to the specific needs of their local clientele and to react efficiently to market competition. Without that flexibility, the financial health of the pharmacy network would be undermined, and the impact would be even greater in remote regions. It is therefore essential that you maintain the mixed system, which will guarantee our network's survival and effectiveness.

The financial health of pharmacies both guarantees access to prescription drugs and protects pharmacists' clinical role in the provision of primary care and the management of chronic illnesses.

In the past 12 months alone, more than 7 million clinical acts have been performed in Quebec pharmacies in support of primary care. If that primary care, so essential to the health system, were undermined, even more patients would be left to their own devices.

I would remind you that, by promoting accessibility, affordability and optimum use of pharmaceutical products and by providing universal coverage for all residents, the Quebec model already meets the objectives that would be established under the proposed national program.

In some situations, particularly for low-income individuals covered by the Régie de l'assurance maladie du Québec, the insured's contribution declines to zero under the present system.

Consequently, Quebec's mixed system both meets the objectives set forth in the bill and enhances the public system currently in place.

In conclusion, a national single-payer plan in Quebec would be counterproductive and would run counter to the objective of improving drug access. It would also undermine Quebec's community pharmacy model, a system well established in the communities and the envy of the other Canadian provinces.

[The Chair, Liberal, Sean Casey]

Thank you, Mr. Morin.

Next, we're going to the Canadian Association of Retired Persons and Mr. VanGorder, who is online.

Welcome to the committee. You have the floor.

[Bill VanGorder, Chief Policy Officer, Canadian Association of Retired Persons]

Thank you very much.

Thank you to the committee for allowing me to appear on behalf of the Canadian Association of Retired Persons and our 225,000 paid members from across the country.

We applaud the government's intention to work with the provinces and the territories to sign the agreement that would provide what is called universal single-payer, first-dollar coverage. We applaud that, and the plan to allocate that funding to the provinces and territories is a goal in improving the cost of the coverage of medicines for a selection of drugs and diabetes drugs.

However, we're very concerned about the federal government's proposal of a single public-payer approach to deliver pharmacare, because we fear that this could crowd out the private payers that currently cover the majority of Canadians, including one in three seniors. CARP believes that this would not be of interest to older Canadians for a number of reasons.

First of all, a single public-payer system would make it harder to access many of the newest and most effective treatments. Public drug plans are notoriously slow in covering new drugs and much more limited in terms of what they offer than private plans. As well, a good example is the list of the diabetes medicines, as has been mentioned before, that the federal government is planning to cover. It's very limited and doesn't include the very latest treatments used by seniors with diabetes.

Second, off-loading all Canadians onto a single public plan could lead to serious disruptions. There were challenges a few years ago when Ontario moved all youth under age 25 to OHIP+, the government-administered plan. During that transition, many Ontario kids lost coverage for medicines that were previously available to them under private plans. A reform of the current drug insurance system could lead to similar challenges with potentially devastating consequences for many older Canadians who rely on their medications and can't afford any disruption in their access.

Third, most Canadians already have coverage for targeted diabetes and contraceptive medicines through private plans. The government's plan to invest $1.5 billion over five years to provide coverage to these Canadians would be a waste of public funds. There are many other areas where additional federal funding could be put to better use, including addressing the challenges of the current system such as the high out-of-pocket expense for medications due to insufficient spending and coverage of medicines by public drug plans. This can be a major financial burden, particularly for seniors, many of whom, of course, are on fixed incomes.

The Canadian Association of Retired Persons surveys our members on a regular basis, and they are telling us that they believe we could build a successful mix of public and private programs to achieve universal coverage through a targeted approach that focuses on those most in need, the uninsured, the under-insured and those facing affordability challenges. We've already seen this model successfully implemented with the federal government funding agreement with Prince Edward Island. The province provided the provincial funding to help expand the number of drugs it covers and to reduce out-of-pocket costs for island residents. This approach, which builds on existing pharmacare programs, will likely be easier and quicker to implement than significantly reforming the current system.

Canadian seniors want to see timely results that make a real, positive difference in how they access medicines and ultimately manage their health conditions in order to enjoy longer and better lives.

Thank you for this opportunity.

[The Chair, Liberal, Sean Casey]

Thank you very much, Mr. VanGorder.

Next it's over to Diabetes Canada with Mr. Glenn Thibeault, executive director, and Russell Williams, senior vice-president, mission. I'm not sure how you plan to divide your time. As parliamentarians, you know the drill.

Mr. Williams, you have the floor.

[Russell Williams, Senior Vice-President, Mission, Diabetes Canada]

Thank you very much, Mr. Chair and members of the committee.

Diabetes Canada has long advocated at the federal, provincial and territorial levels for improved access to medications, devices and services for the over four million people with diabetes. The goal of Diabetes Canada is to improve the quality of life for people living with diabetes.

Diabetes Canada applauds the government's intention to include diabetes medications and devices in the initial scope of the pharmacare plan. In fact, we see this as another step in building from the diabetes framework that was tabled last year.

Thank you, MP Sidhu, for your leadership in that.

However, there is an urgent and pressing need for those who are uninsured and under-insured. With broad consultation and careful implementation, this could represent a significant step toward reducing barriers. Providing comprehensive coverage and patient choice, continued improvement of care and a robust consultation system are our three key recommendations.

We recognize that there are significant gaps in coverage for some people living with diabetes. Our belief is that any public coverage should focus on addressing those gaps. As a first principle, we believe that government should focus on the uninsured and under-insured individuals, but the approach to diabetes management must also be comprehensive and align with Diabetes Canada's clinical practice guidelines. These guidelines are created by the country's experts and are one of the foundations on which physicians make informed decisions about patient care.

Unfortunately, the formulary that was tabled along with the law by the government is not aligned with the clinical practice guidelines or the NIHB program. It is limited in scope, excluding several key newer treatments while including older and outdated treatments.

We have produced a comparison of the proposed formulary of the CPGs and NIHB program. This document demonstrates that for many uninsured and under-insured individuals living with diabetes in Canada, most of the commonly prescribed medications would not be covered by the proposed plan. This is why filling the gap to focus on the uninsured and under-insured individuals to start with is so critical.

We met with the minister yesterday and he confirmed, though, that this list will grow and will move forward in terms of greater coverage.

We have to remember what we're talking about here, too. Let me underline the human reality. I know you all feel this. We're talking about the most vulnerable.

On our 1-800 line, which is open to all Canadians, we get a number of calls regularly from senior citizens who are choosing between rationing their drugs or going without. We get calls from people who are not taking the right amount of their medication because they can't afford it. Recently, we were getting calls about people concerned about their private insurance and whether they'd lose it during the transition to this law.

Again, we were assured by the minister, when we met with him yesterday, that people would not be shifted off their private insurance. These are two of the fundamental questions we had.

A further recommendation was the adoption of our principle of continued improvement and access.

Our CPGs have shown and new data continually indicates improvements to services, care and products. A pharmacare system must incorporate the principle of ensuring that new techniques and products that are more effective get incorporated into that plan when they become available. The system should actually welcome diverse approaches and creativity, including private insurance, while seeking universal coverage. Every province and territory has a distinct approach to its public formularies and pharmacare should be no different.

We already heard that Quebec's hybrid model is an interesting example and a good example to consider.

It's a universal plan, but it's mixed, both public and private.

We must ensure that all individuals do not lose access to drugs that they already have covered by private plans and are not included in the formulary. Unfortunately, we've seen examples of that issue in the past. Therefore, we are calling for a “do no harm” inclusion in the law to safeguard existing access to medications and ensure that persons living with diabetes can continue to access the latest treatments in care.

With these recommendations in mind, we believe that Bill C-64 needs a process of evaluation and practical analysis to ensure we set up the most effective system and ensure it's not just a debate about ideas, but a practical analysis for the effective system to improve access to medicines for people with diabetes.

We call for a more robust and transparent consultation process in the next steps of this law with people, patients, people with lived experience, health care providers, drug plan managers, researchers, provinces, territories and the indigenous communities.

We encourage parliamentarians to carefully ensure that this emerging national pharmacare delivers on its promise of improving access and ensures that no one gets left behind.

We appreciate the opportunity to share our ideas and are certainly open to questions.

Thank you very much.

[The Chair, Liberal, Sean Casey]

Thank you, Mr. Williams.

Finally, we have Smart Health Benefits Coalition, represented by Carolyne Eagan.

Welcome to the committee, Ms. Eagan. You have the floor.

[Carolyne Eagan, Principal Representative, Smart Health Benefits Coalition]

Thank you to the committee for the opportunity to appear today.

The Smart Health Benefits Coalition is a united advocate for smart, innovative solutions that result in timely and positive change for Canadians. Through our seven member organizations, our on-the-ground advisers support and advise more than 65,000 plan sponsors with their employee drug plans, including over 4,800 union plans. Together, our thousands of advisers across Canada support robust benefit plans for 10 million Canadians and their families.

Let me summarize our top-line perspective on pharmacare.

We fully agree that it is unacceptable that Canadians are currently living with little or no coverage for essential medications, stuck in the gaps between public and workplace systems. Even though 97% have some drug coverage, nearly one in five Canadians still report having some difficulty affording out-of-pocket drug expenses. We recognize that this is an affordability and access challenge that needs smart solutions.

Canada can work with provinces to better solve these challenges faster and more cost-effectively by focusing net new public resources and policy energy on filling the gaps and by taking a progressive approach to affordability.

We believe that universal pharmacare can be done with less money spent, with better and quicker access to drugs, and with less disruption to Canadians' health care treatment plans if the government does it through a targeted, multi-payer system rather than on its own.

We believe that there are a few critical considerations that need attention.

A universal, single-payer, first-dollar coverage model will require taxpayers to carry the whole cost of drugs and fees. Currently, employer plans pay over $20 billion in drug claims, providing medications to Canadian families every year as a well-functioning part of our comprehensive health care system. When looking at the challenges facing Canadians, spending precious new health care dollars where workplace coverage already exists is an expensive, missed opportunity.

The biggest cost pressure and pain point for any Canadian, whether they have coverage or not, lies in high-cost therapies associated with conditions such as cancer, Crohn's disease, cystic fibrosis and many more chronic and rare health conditions that have innovative, life-changing drugs. These cost pressures are potentially devastating and deserve a higher priority within the pharmacare discussion.

We've recently been very concerned to see comments by the government stating that Canadians would retain their ability to choose a new public plan or their existing workplace plan. Like other stakeholders, we are seeking clarity on what universal, single-payer, first-dollar coverage means. This is important. From our industry perspective, this term means that if the public system pays for a certain list of drugs under the Canada Health Act, then employer plans are not permitted to pay for those drugs. The result would appear to have the unintended consequence of impacting the PBO's estimates, which currently assume continued employer coverage, resulting in a savings of $4 billion per year.

This is critical to resolve. If the intent is, in fact, to permit Canadians to choose where they get their coverage from, then we believe this part of the bill needs to be written with clarity and with no room for assumptions.

Let's go over some smart solutions we're proposing.

Let's use net new taxpayer funding in a way that gets coverage and cost relief to those in need, absolutely. Let's require a common, minimal formulary for all employer-sponsored and provincial drug plans to create predictability and a floor of coverage, work with provinces to create a coordinated national system of rare disease and high-cost drug coverage, update the Canada Health Act and work with provinces to include common out-of-hospital therapies, for example, cancer treatments.

Now, specifically, we have proposals to strengthen the bill and framework.

First, ensure that coverage is available to Canadians regardless of province. Without intervening in the core aims of the bill, we propose an amendment that would provide for the Minister of Health to enter into secondary negotiations with a province in the event that a province formally rejects the single-payer pharmacare. This should allow for Canada to negotiate and enter into an agreement with a province where universal, no-cost treatments are made available without the restriction of a single-payer, first-dollar model.

Second, examine opportunities to explore pricing reductions.

Third, provide Canadians with a cost-benefit analysis prior to further steps. We propose an amendment that would ensure that public accounting and cost-benefit analysis be prepared and released prior to any consideration of an expanded single-payer system. Canadians deserve to know the facts and costs before governments take further steps that may irrevocably impact their ability to access and afford the wider range of medications currently provided under workplace plans.

In closing, I want to thank the committee for the opportunity to appear today, and I'm happy to answer members' questions.

[The Chair, Liberal, Sean Casey]

Thank you, Ms. Eagan.

We're now going to proceed with rounds of questions, beginning with the Conservatives.

We'll go to Dr. Ellis for six minutes.

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

Thank you very much, Chair.

Thanks to everyone for being here on this important topic.

Ms. Eagan, I'll start with you.

We're going to be here for 15 hours to talk about this, not that I mind being here with my colleagues, but I guess my plea is that it's just not enough. When we see legislation like this that has the potential to impact the future of all Canadians in terms of accessibility to funding for medications, it would seem to me that this is a pittance of an amount of time to spend debating this and how it should be rolled out.

I wonder if you might have some comments around that and the consultations that you have had with respect to this bill.