Health Committee on May 24th, 2024

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

Thank you, Mr. Morin.

Going back to what you said in your remarks, I can tell you first-hand how important it is to have access to a pharmacy in a rural community. I proudly represent 39 municipalities in the Bas-Saint-Laurent region, and I can tell you it's essential to have a pharmacy when there's no hospital nearby.

You mentioned that the federal government's present program jeopardizes the pharmacy model, and even community pharmacies, and you cited the example of New Zealand, where 371 pharmacies shut down. I'm very concerned by your remarks. This makes no sense to my mind. We're talking about local services, individual welfare and keeping people in their communities, especially with an aging population as we have back home, the second fastest aging region in all of Quebec.

What should we do to prevent these closures, which would be a real problem?

[Benoit Morin]

First, you shouldn't put undue pressure on key actors, on front line actors like the community pharmacies. The Bas-Saint-Laurent example is a telling one. We had the front line single-window pilot project for orphan patients who had no family doctor and were given access to the services of pharmacists at pharmacies to which they were directed, where that was possible.

This is an excellent example of how pharmacists can provide those services, even though they're underpaid for the clinical acts they perform relative to needs. They can provide those services because they're in good financial condition, but undermining that condition would threaten the system and the presence and number of pharmacies in those regions.

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

Thank you for your answer, Mr. Morin.

The drug formulary of the Régie de l'assurance maladie du Québec covers approximately 8,000 drugs. That isn't perfect, but I think we're doing all right. That's a lot of drugs. Do you think there's any risk that we may lose certain coverages under this new federal pharmacare program?

[Benoit Morin]

If you compare Quebec's formulary to the one being proposed, even though it's not final, you can see that several millions of diabetes-related prescriptions would be lost. A significant percentage of patients would have to switch drugs, which makes no sense. It's impossible. Quite honestly, we manage stock shortages every day in community pharmacies. Adding a draconian change in coverages to that could be disastrous for the health of Canadians and Quebeckers. We really need to ensure that this formulary at least covers Quebec's formulary, even though the Quebec one is generous.

Broad coverage is needed for diabetes, for reasons that my colleagues mentioned regarding the individual contribution of each drug to the treatment of that disease. This availability, this wide range of covered drugs, is essential in maintaining the health of Canadians.

[The Chair, Liberal, Sean Casey]

Thank you, Mr. Morin.

Next is Mr. Julian, please, for six minutes.

[Peter Julian, NDP, New Westminster—Burnaby, BC]

Thank you, Mr. Chair.

Thanks to all the witnesses for being here.

Your remarks are interesting. You're giving us good information.

I'd like to go to you, Mr. Morin and Ms. Pelletier.

Pharmacists will definitely play a major role in the future of drug insurance.

Yesterday a large group of nearly two million Quebeckers, including members of the Centrale des syndicats démocratiques, the CSD, the Confédération des syndicats nationaux, the CSN, the Fédération des travailleurs et travailleuses du Québec, the FTQ, the Union des consommateurs, the Fédération interprofessionnelle de la santé du Québec and many other organizations, had this to say about the present situation in Quebec:

…the current Quebec drug insurance program can in no way guarantee all Quebeckers reasonable and fair access to drugs…“The various fees charged to drug purchasers are in fact copayments that have a deterrent effect: People skip doses or deprive themselves of certain drugs because they can't afford to buy them”…Furthermore, rising drug costs also put increasing pressure on private plans, leading workplaces to abandon their insurance and thus lose all their coverage.

These groups are calling for parliamentarians to pass Bill C-64.

You've obviously raised the matter of the formulary of drugs that will be covered. That aspect will be negotiated with the Quebec government. Other countries are fortunate to have universal, public drug coverage without any pharmacy closures.

Do you think it's important to ensure universal access to drugs that keep people alive and in good health, while being careful to negotiate repayment and to pay attention to how pharmacists are affected by this universal public system?

Is that the message you want to send today?

[Benoit Morin]

Thank you for your question, Mr. Julian.

I think we have to guarantee coverage for everyone before considering the pharmacists. I think that's the first step.

Under a measure in Quebec, no one pays a deductible or copayment of more than $996 a year, regardless of whether the coverage is public or private. It's what's called “the ceiling.”

For low-income individuals, the ceiling is zero. They therefore pay nothing. People who have incomes have a ceiling of $996 per year. The public program has a monthly ceiling, and private plans have an annual ceiling. I think it would be helpful to spread that amount out over 12 months because a single amount of $1,000 might be too much for certain individuals. It might cause them to question their decision to take their drugs. However, $90 or $100 a month might be possible.

I don't think the solution is necessarily to make drugs free for everyone. Instead we should educate people who have a certain income level, by which I mean people who can afford to pay for their drugs. They should be told that their drugs are essential and a priority, that they should attach to them the importance they deserve and that they shouldn't choose other products that might undermine their treatments. However, people in the public system who can't pay for their drugs should enjoy full coverage; there should be no barriers preventing them from taking their drugs.

[Peter Julian, NDP, New Westminster—Burnaby, BC]

We agree that the status quo isn't acceptable.

Thank you for your answer.

I'd like to go to Ms. Diniz.

We had very compelling testimony yesterday from Mike Bleskie, who is a young person with type 1 diabetes. He talked about what happens if he loses contracts. He talked about going into his line of credit to keep paying for the medication that keeps him in health—in life. I asked him what happens if the contracts don't come in and he can't go into the line of credit. I thought he talked very movingly. He said that within 24 hours, he could find himself in the hospital. Within days, he could be facing amputation or worse.

I'd like you to tell us what happens when people can't afford to pay for their medication now. When it comes to diabetes, what are the impacts? When you can't afford to pay for medication, what happens to you?

[Jessica Diniz]

First, thank you very much for the question and for bringing this area into focus.

I agree. It is critical that patients have access to the medications and devices they need.

For type 1 diabetes, this is a matter of life or death. They don't have a choice. Think of insulin as being like air. They need insulin to stay alive, so to answer your question of what happens to the individual when they can't afford their medications anymore, they ration them. They don't take enough. That leads to worse health outcomes and more complications, and that actually costs our health care system more money later down the road.

It's important to think about the young person entering the workforce who no longer has coverage under their parents' plan and is choosing their profession based on the benefit programs that are being offered, which can cover their medications.

It's critical that Canadians living with type 1 diabetes have access to medications to control their diabetes, which will eventually prevent long-term complications.

[Peter Julian, NDP, New Westminster—Burnaby, BC]

Mr. Thibeault, I'd like to ask you the same question. What are the impacts when people can't afford their medications?

[Glenn Thibeault, Executive Director, Government Affairs, Advocacy and Policy, Diabetes Canada]

Thank you for the question. It's very similar to what our colleagues at JDRF are talking about. Someone who lives with type 2 diabetes will also have serious complications if they can't access the medications they need.

I also live with type 2. I was diagnosed in 2016 when I was an elected official. Learning the process of what types of medications, you need to go through.... I went through three or four different types of metformin before I was able to get on the right one. That's why we've talked about choice and making sure it is available to everyone who lives with either type 1 or type 2 diabetes. It's important to make sure we can avoid all of the complications that we know can happen out there.

I know, Mr. Julian, you've talked about Amber in your riding, who spends $1,000 a month.

[The Chair, Liberal, Sean Casey]

Thank you, Mr. Thibeault.

[Glenn Thibeault]

Are we out of time?

[The Chair, Liberal, Sean Casey]

We are indeed.

[Glenn Thibeault]

We can talk about that next time.

[The Chair, Liberal, Sean Casey]

We now have Dr. Kitchen, please, for five minutes.

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

Thank you, Chair.

Thank you to everybody for being here so quickly and on such short notice. To the many of you who provided us with briefs, I greatly appreciated seeing those in advance. I'd love to go over each one of them with every one of you individually. It is appreciated.

I'm trying to ask questions as quickly as I can.

Mr. Williams, you've indicated to us that you met with the minister yesterday. Did the government actually come to you at any time before they were setting up this plan, or was it purely an opportunity to speak with the minister yesterday?

[Russell Williams]

Thank you for the question. We talk with the governments regularly, mostly on the implementation of the framework. We did not talk before about the specifics of this bill.

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

Thank you.

We've heard from many groups, yesterday in particular, that there has been a lot of concern about no one discussing it. That's from the provincial health ministries all the way up to individuals, whether it's diabetes, etc., and experts along those lines, so I appreciate those comments.

Part of what you talked about was your conversations with the minister. He was here yesterday, and he basically said, “Trust me; everything's going to be good.” Apparently, from what I'm hearing you say, that's what he said to you: “Trust me; it's going to be good.”

However, this is from the same government that said the carbon tax would never go above $50, which they campaigned on in the 2019 election, and now it's going to be up to $170.

How trustworthy do you see this being? Would it not be better to have something within the legislation that would support and provide protection from that?

[Russell Williams]

One of the things we talked about yesterday, which we've supplied to all the members, is a comparison between the list provided by the government and our clinical practice guidelines, to say that there's work to be done on this. We've also supplied all the lists of what's happening in each and every province.

I'd like to have all the answers, and we've been working at this for some time, but I'm leaning towards trying to move this forward for the most vulnerable people as soon as possible.

One of the things we have to do here is get answers to those questions, for sure. There are other stages of this law. There's going to be negotiations with the provinces. Should we move on with this? I'm not entirely comfortable with this. However, on the other hand, for the people we're trying to serve, is it worth trying to move forward on whether there are enough checks and balances on it? I understand your question. We put those questions to them, and we'll share any of the answers we get.

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

I appreciate that comment, and you did mention the uninsured and the under-insured, and those are aspects of things. I do appreciate your document because I have it here.

It's interesting. I am a type 2 diabetic and to you, Mr. Thibeault, I too went through a number of aspects, and my wife as well, regarding what metformins would be there. I appreciate the comments in here where you've listed the differences and where you've indicated that, for the NIHB, basically the plan that they have is better than the plan that was proposed by the government. We got that information as well from first nations yesterday, who indicated that the avenue is there. Basically, the clinical guidelines are there, which are very appreciated too.

I see where, for example, under Quebec, the listings are either restricted—in other words they need to have permission to get them—or they're listed, and they're the most prevalent of all the provinces. In Saskatchewan...I'm on Jardiance and ultimately it indicates that it's restricted, and that's true. I need to get permission from my doctor in order to get that aspect of it.

Those are huge challenges that are there and where we don't have doctors available even to provide the ability to get that done.... The challenges we have as we move forward on that is that the plan that's being proposed basically is a very basic plan, but there's no avenue to indicate that it would change. There's no avenue to indicate—and that's what we heard from different people—that as medicines improve that list would be changed.

Do you not see that as an amendment that might be available and that we need to put into this legislation to make certain that it is complied with?

[Russell Williams]

That's why we put in our second recommendation the principle of continued improvement of care. Our clinical practice guidelines change from time to time as we get new evidence, and we have to make sure that, as new medications come up we have a system that allows for it. It shouldn't be just a system of older medications, but it should have that capability.

Our recommendation would be that this principle be built in, and again, in the discussions we had yesterday, we expressed that. We understand that there's an opportunity, and ultimately, it's discussions. I hope every province will also embrace that principle and that we'll build a stronger system, more than that base list that we saw tabled with the government, which the minister, once again, said will grow. We'd like to see how much it will grow in the discussions with those who know, and again, I really would like us to get to the next level so we can have discussions with the health care providers to understand some of those questions.

Thank you very much.

[The Chair, Liberal, Sean Casey]

Thank you, Mr. Williams.

Next is Dr. Powlowski, please, for five minutes.

[Marcus Powlowski, Liberal, Thunder Bay—Rainy River, ON]

Bill C-64, except for diabetes medication and contraception, does not create a single-payer system. We don't know what the national pharmacare system is going to look like at the moment. It won't necessarily by the sounds of it be a single-payer system.

However, Ms. Eagan, in response to the idea of a single-payer system, you said this was wasteful because all Canadians would have to pay for it with taxes—which is true—but that, right now, many Canadians get it as a benefit from their employer.

It's not like that's free. That's part of your pay. You get paid a certain amount of money, but you get some benefits. It's a cost to the employer, and if the employer doesn't have to pay that cost presumably you would get more in your salary. If the government can have a system that is cheaper to run—and there is some indication that with a government-run system, a non-profit system, because of economies of scale, government could provide that system more cheaply than the employer could—that would be a net benefit to Canadians.

Would that not be the case?

[Carolyne Eagan]

What I would like to highlight here is that today it's $15 billion. How much lower could that number be? That's what's being paid by employer plans.

Secondly, I would say that four out of five Canadians are enjoying that system without any reported incidents or challenges.

We agree. Let's get the coverage. Let's not take the money where it's working well. Let's leave that in place and allocate those dollars, those extra dollars, to those who have no coverage or those who struggle in any capacity, whether it's 20% of a $100 copay or 20% of a $10,000 copay. People are struggling at both ends of that spectrum. For the ones, the four out of five, that it's working for, let's leave those in place, leave what's working and get the dollars allocated.