Health Committee on May 24th, 2024

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

I have two Canadian experts who had nothing to do with this. This scares me.

That being said, Dr. Gagnon, you talked about the universal health care system and a universal pharmacare system. I was a family doctor for a long time. The Canadian Medical Association president from a couple of years ago, Dr. Katharine Smart, said that the universal health care system was on the brink of collapse. Clearly we have a system that, for a whole host of reasons, is not working. It's not managing well, and it's not being managed well.

Why would we want to enter into a universal pharmacare system? I'll even put myself in the same boat. It wouldn't matter if it was a Conservative government or a Liberal government. Why should we trust the federal government to make another system that, in my mind, is probably just going to fail Canadians?

[Marc-André Gagnon]

When it comes to implementing universal pharmacare, it doesn't have to be the federal government that does this. It can be done at the provincial level. It can be done through specific agencies that are being put in place for this through different types of social insurance systems. You can have an independent agency taking care of this.

With the current fragmented system, there are no common objectives, and there's massive waste. Right now we have 100 different public drug programs, and we have more than 100,000 private drug programs going in every direction. You end up with a system that, if you want to navigate and play the game, basically, doors are very much open for abuse, and we're seeing this a lot.

When it comes to cleaning up what's happening, a universal single-payer public system remains the best thing to do. Then you can have all the other players adding on with supplementary coverage. Be they provinces or private payers, it's not an issue, but we need a solid foundation that works well, is efficient, works rationally, gets us value for money and also promotes a more appropriate use of medicine.

If we have these building blocks, then we can see in terms of.... In French, we say la finition. We basically see what adds up, and we can build different things. However, we need the solid foundation, and it's not there right now. For example, we are not prepared for all these new, superexpensive drugs coming to the market. We are not prepared to face the music. Canadians are not prepared, because we don't have these foundations now.

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

Thank you very much.

Dr. Morgan, I'll turn to you. The other thing is that often we've heard in the last couple of days testimony related to the length of time it takes a medication to get on formularies on behalf of Canadians, often thousands of days. We have Health Canada, PMPRB, CDA, CADTH and pCPA, etc. It would appear to me that it would also have been a good idea in this Bill C-64 to add some oversight of those agencies, specifically the newly formed CDA.

Do you think that would be of benefit here, or do you have some other ideas around the necessity to get drugs to market on behalf of Canadians?

[Dr. Steven Morgan]

I have a couple of points. I'm glad you raised the issue around timeliness in terms of drug approvals and coverage decisions. Some of the evidence that's been cited in testimony in these hearings comes from reports that start the clock, so to speak, when a medicine is first approved in any country internationally. It doesn't take into account the fact that manufacturers themselves choose to delay the introduction of a drug into some markets for strategic purposes, but also often they'll trial drugs in markets like the United States, Germany or Japan and then choose whether ever to even launch in other markets. Nearly half of all drugs that are trialled in that way don't make it to other markets. That's important to know.

With regard to delays in approval times, I think there are concerns about making sure that Health Canada is adequately staffed and resourced to make its timelines. There are also concerns about the fact that the fragmented system we have right now, with CADTH and the pCPA and then the provincial decision-making that follows it, is one that does beget long delays in coverage decision-making. In fact, it is one of these processes where no means no in terms of the recommendations from the advisory bodies, but yes only means “maybe”, because provinces are not bound to complete the coverage equation.

A truly national program, managed by an agency such as the Canadian drug agency or something like that, which was given the budget to manage and the task of making sure there was timely access, would be a system that would make sure we don't have those kinds of delays. It should be reasonably independent, but it should be accountable for performance.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Morgan.

Next we have Mr. Naqvi, please, for six minutes.

[Yasir Naqvi, Liberal, Ottawa Centre, ON]

Thank you very much, Chair.

I'll start my line of questioning with Dr. Morgan and Dr. Gagnon.

You both are experts in pharmacare. You've studied this. Can you talk about the impact of the lack of a pharmacare plan on the general health of a population? We can talk about Canada. What's the impact? I'm assuming it's negative. If it is negative, in what ways does that manifest itself?

Dr. Gagnon, perhaps we can start with you first.

[Marc-André Gagnon]

That's an excellent question. Basically, lack of access is a very important issue, and low-income workers are normally the most impacted by this. For racialized communities, in particular, based on surveys that were made looking at barriers to access, looking at issues of race, it was a big problem.

What the PBO did not include in all the costing was how much money we would be saving in hospitals, in emergency rooms, if people could have the right access to the drugs they need.

Keep in mind, the PBO report showed that we would be saving more than $2 billion a year, but also by extending it by 13.5%, we will be increasing, basically, the number of prescriptions by 13.5%. This is 13.5% of the people who need prescriptions right now and are not getting them. They are the people who end up in emergency rooms, and then this is for hospitals...because if they go there, then it's not the same budget. Their drugs are being paid for by the hospital. We see this a lot, and it is something super important when we do all the budget and costing and stuff.

There are other issues that for me are also very important. When it comes to social security, if I'm in Quebec, on social security, I will be getting something like more or less $15,000 a year. If I try to start working, let's say, 15 hours a week, because that's all I can do, I get access to my drugs with no premiums. There's nothing to pay. Everything is for free as long as I'm on social assistance. However, as soon as I want to get out of this, basically, then I need to pay huge premiums in Quebec. I need to pay my full premiums even if I'm only working part time. If I'm working only 15 hours a week, basically, I end up with maybe $20,000 in terms of revenues, but then something like maybe $2,000 a year in premiums for my prescription drugs.

In terms of creating poverty traps, Sheikh Munir met with people and wrote this report about the reform of social assistance in Ontario. That was one of the huge barriers, the huge poverty traps. Basically, people end up trying to stay in programs where they can have access to their drugs, because if they switch to a different status they might lose access and that has an impact on their health—morbidity and mortality.

Maybe I have one last point on diabetes. There was a study 10 years ago, basically showing if, in Ontario only, we had universal, single-payer, first-dollar coverage for people with diabetes, that would save 700 lives a year. This is amazing. We're not doing anything about this, because it's not two planes that are falling onto the street and everybody is dying. It's just, “Oh, well, these are statistics somewhere. It's 700 people, and they were sick anyway. This is not important.” This is freaking important.

Yes, these are some of the issues.

[Yasir Naqvi, Liberal, Ottawa Centre, ON]

Thank you, and I appreciate your passion.

Dr. Morgan, do you have any points to add to Dr. Gagnon's?

[Dr. Steven Morgan]

No, other than to say that this has been thoroughly studied, and the business case for making sure we have universal access to appropriately prescribed medications is unequivocal. It is good for the country's health. It's good for the health care system.

[Yasir Naqvi, Liberal, Ottawa Centre, ON]

I want to come to Dr. Norman. Thank you for being here and bringing the perspective of Action Canada to this conversation.

On the same theme of cost savings in the health care system, can you talk about what kind of impact we can see from having universal access to contraceptives, which is contemplated in Bill C-64?

[Dr. Wendy Norman]

Absolutely.

As a family doctor who's been working in family planning for most of my professional life, I regularly see people coming in for recurrent unintended pregnancies. They do not want to be pregnant, they hadn't wanted to be pregnant and they have no access to the ability to manage their lives so that they can continue in their education, get out of a toxic relationship or be able to undertake the job training to move into a profession they would like. They're saddled again with an unintended pregnancy. Some of them will go on to ensure that they aren't pregnant through to delivery. However, most will end up having to look after other children and then have child care and other actions in their homes that take time of their lives that they could have used to advance the care of the children they already have and for themselves and their lives.

When we talk about cost savings, we can show—and all over the world systems have shown—that single-payer, first-dollar, universal contraception coverage will be able to have better health outcomes and lower pregnancy-care costs.

I think we have to look, as well, at the costs to our next generation and to the fact that they will have lower achievements throughout their lives due to the inability of their parents to have accessed universal contraception, so then it becomes intergenerational in—

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Norman.

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

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

Thank you, Mr. Chair.

Greetings to the witnesses who are with us on this third panel.

My first question is for Mr. Adams, from the Best Medicines Coalition.

Mr. Adams, in recommendation 6 in your brief, which I have here in my hand, you say that the Minister of Health is required to establish a special pathway so that, in certain conditions, patients may be prescribed a drug or treatment that doesn't appear in the formulary.

As you know, under the Quebec plan, patients who require drugs that constitute a treatment of last resort may be reimbursed for the cost of those exception drugs.

The proposed plan provides no guarantees regarding those drugs.

What would you recommend if we found support for that concern?

[John Adams]

Pardon me, but I'm going to answer in English.

We've heard a lot about Quebec today in the conversation. Thank you very much for the question because it highlights one distinct aspect of Quebec that the rest of Canada should emulate.

The other thing we heard a lot about is that not every patient responds in the same way to the same drug. We need some variety and some choice. Quebec has a mechanism where a doctor can apply to a truly independent scientific review committee that is outside of the health bureaucracy for a drug that the doctor knows the patient needs, whether or not it's been approved by Health Canada and whether or not it's being funded through the existing system.

I come from a rare disease community. PKU, phenylketonuria, is not life-threatening; it's only brain-threatening. I have a son with it who is a responder to the first pharmaceutical, a true and full responder. Every patient with PKU who has received access to that first drug for PKU has been approved through Quebec's unique exception patient program. There will always be outliers.

What we need to achieve and work towards is precision medicine, a molecule that works for the individual given that individual's genetics and biochemistry. We're not all the same. One size does not fit all. It would be a great improvement for national pharmacare, as a concept, to always have that safety valve for the exceptional patient. There are decades of working experience in the province of Quebec that we can all learn valuable lessons from.

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

Thank you, Mr. Adams.

I'm glad you acknowledged that distinction, which, as you know, goes beyond pharmacare. We could definitely conduct another study on that subject alone, but I'm not sure it would be in the Standing Committee on Health. But we'll have that discussion at a later date.

Mr. Adams, you say in your brief that no patients in Canada should lose the drug coverage they currently have with a private plan as a result of the reforms and programs under Bill C-64 and that the changes made must not leave patients in a worse situation than before the reforms were introduced.

Would you please explain your concerns to us?

[John Adams]

We hear many concerns and criticisms of the version of the model proposed in Bill C-64, and I've heard additional criticisms from my fellow panellists today. We're hearing mixed messages about whether this is such a good idea or not, as proposed.

As the parent of two sons and two daughters, I care about sexual reproduction and sexual health all the way around. Also, as I used to be prediabetic and am no longer, I care about medicines for diabetes. The drug that turned me from a prediabetic into a non-diabetic is not on the list as proposed by the Minister of Health at the moment. Those are specific examples. There's a great deal of uncertainty.

Also, in previous government initiatives at the federal, provincial, territorial and indigenous levels, there have been unanticipated or unintended consequences. Therefore, you should make haste slowly. I think the bill is a useful start, but this legislation is in need of improvement and has many opportunities to be improved.

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

Mr. Adams, again in your brief, you make a very important point:

All governments—federal, provincial, territorial and indigenous—must work together and consult stakeholders, including patients and the organizations that represent them. The emphasis must be on establishing an effective and simplified infrastructure designed to improve patient care and guarantee a high degree of fairness, with a full range of drugs available to all based on medical needs and provided in a timely manner.

I completely agree with you that everyone should get the best care. With that in mind, don't you think the federal government should increase health transfers to enable Quebec and the provinces to improve their health systems and thus the care given to patients?

[The Chair, Liberal, Sean Casey]

Please give a brief response if you can, Mr. Adams.

[John Adams]

I'm old enough to remember when medicare was sold to Canadians and to provinces and territories on the general concept of fifty-fifty cost sharing. We should take a look at that.

[The Chair, Liberal, Sean Casey]

Thank you, sir.

Ms. Zarrillo, you have six minutes, please.

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

Thank you so much, Mr. Chair.

I want to get some clarity from you before I begin my questioning. You mentioned that the time for amendments was a while ago, so any input that comes today will not be able to inform an amendment. Is that correct?

[The Chair, Liberal, Sean Casey]

That's correct.

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

Okay.

I want to say what an amazing and informative panel this has been. Because we cannot have a technical influence on the bill at this time, I do have some questions around equity and fairness. I want to focus on gender equity, because I think that, if there had been more women in the government at the federal level, we would be a lot further along, certainly, on contraceptives.

Dr. Norman, I want to ask you specifically about getting results. We know that B.C., as you mentioned, has free contraceptives now. Could you share some of the arguments or factors that got the B.C. government to implement free contraceptives? Obviously, it's something that I, along with many people right across the country, would like to see.

[Dr. Wendy Norman]

Thank you very much, Member Zarrillo, through the chair, for your question.

We were funded by CIHR to conduct a study in which the Government of B.C.'s Ministry of Health was one of the partners in setting the main research question and how to analyze the results so that we would be able to support it in what the impact of a subsidy system for contraception would be on health and equity in B.C.

First, our study undertook a province-wide sexual and reproductive health survey. In 2021, this government was able to use the basis that we made for that sexual and reproductive health survey to implement a sexual and reproductive health survey across Canada, which we'll be fielding later this year. It will be run by Statistics Canada.

I think this is key moving forward, as we implement precontraception through this bill, in my hopeful way, to be able to measure the impact. This is because this was what B.C. used to measure the need, and it was how we determined where there were inequities and how those inequities could be addressed through universal contraception.

Undertaking surveys of people and being able to look at health systems and health administrative data in comparison with the survey data.... StatsCan's new survey that will go out will also be linked with a personal health number to health administrative data so that we'll get specific, disaggregated equity data on the gaps for people in achieving their sexual and reproductive health.

The baseline in 2024, of course, will be before any impact of this bill, but I think it will be very important, moving forward, for the government to continue to have, as one of Statistics Canada's core surveys, a sexual and reproductive health survey that allows us to disaggregate and understand those equity barriers across Canada.

I don't know if I've answered your question in the way you wanted.

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

You have, and it's spurred another question.

You've been working in reproductive health for a very long time, so I'm sure you have some indication of how those surveys are going to come back. However, my question is about what factors you think contribute to the difference in prescription insurance coverage described for the population overall and for those at risk of unintended pregnancy. I'm quite sure you're going to get information about the disaggregated groups that have unintended pregnancies.