Indigenous and Northern Affairs Committee on May 10th, 2016

[The Chair, Liberal, Andy Fillmore]

Seeing that everyone seems to be here, we'll come to order, even though we're a few minutes early. We can fit more in that way.

Welcome everyone. Thanks for being here today. We are going to be hearing from the first nations and Inuit health branch in the first hour of our meeting. On behalf of the committee, I'd like to welcome Sony Perron, senior assistant deputy minister; Keith Conn, ADM, regional operations; Scott Doidge, director general, non-insured health benefits; Tom Wong, executive director, office of population and public health; and Leila Gillis, director, primary health care systems division. Thank you all for making time for us today.

We're having our meeting today on unceded Algonquin territory, as we always acknowledge.

I'm happy to give you 10 minutes to present your remarks, and you're free to divide that among yourselves, as you like. Is there more than one speaker this morning?

[Sony Perron, Senior Assistant Deputy Minister, First Nations and Inuit Health Branch, Department of Health]

There will be one.

[The Chair, Liberal, Andy Fillmore]

There's just one. Okay.

Without further delay, let's get started, please. You have the floor. Thank you.

[Sony Perron]

Mr. Chair, members of the committee, thank you for inviting Health Canada's first nations and Inuit health branch for this briefing on first nations and Inuit health programs.

Health Canada is committed to ensuring that first nations and Inuit communities and individuals are receiving a range of health programs and services that are responsive to their needs. The overall objective is to improve health status.

As you may know, first nations and Inuit communities are facing major health challenges. Compared to Canadians as a whole, they have shorter life expectancies, higher rates of chronic illness and infectious disease, and higher mortality and suicide rates.

They are also faced with greater challenges in relation to the social determinants of health, such as high unemployment rates, lower education levels and higher rates of overcrowding in homes.

In addition, first nations and Inuit face historical legacies, such as colonialism, the disconnection of culture, and the intergenerational impacts of Indian residential schools.

The health care system for first nations and Inuit is complex. Provinces and territories deliver hospital, physician, and public health programs to all Canadians, including first nations and Inuit, but do not operate health systems on reserve for most. In order to support first nations and Inuit in reaching an overall level of health that is comparable to that of other Canadians, Health Canada funds or provides a range of health programs and services in first nations and Inuit communities.

Within this context, Health Canada works with first nations, Inuit, provincial, and territorial partners to provide effective, sustainable, and culturally appropriate programs and services to improve health outcomes and support greater control of the health system by first nations and Inuit.

As part of this effort, Health Canada invests more than $2.5 billion annually in first nations and Inuit health to supplement programs and services provided by provinces and territories. This includes over $840 million for primary health care and public health on reserve, and $1 billion for health benefits. It also includes over $440 million this year for the British Columbia tripartite initiative, an innovative, precedent-setting development in first nations health, which took effect in October 2011, when B.C. first nations, the Province of British Columbia, and Health Canada signed the British Columbia tripartite framework agreement on first nation health governance.

Spending also includes $240 million for health infrastructure support, which promotes first nations and Inuit capacity to design, manage, and deliver their health programs and services, while supporting health service innovation, integration, and partnerships.

There are five key elements funded by Health Canada to support first nations and Inuit health: health promotion and disease prevention programs, public protection programs, primary care services, supplemental health benefits, and health infrastructure support.

In the area of health promotion and disease prevention, Health Canada provides funding to support community-based health promotion and disease prevention programs to support mental wellness, healthy child development, and healthy living.

Services related to mental health promotion, addiction support, suicide prevention, and counselling are funded under a range of programs, such as the national native alcohol and drug abuse program, Brighter Futures, Building Healthy Communities, and the national aboriginal youth suicide prevention strategy. In the area of healthy child development, it supports children to have the best start in life through programs such as aboriginal head start, the Canada prenatal nutrition program, and maternal child health.

As part of the Indian residential school settlement agreement, Health Canada also funds and provides health support services to former Indian residential school students and their families so that they can safely address a broad spectrum of wellness issues related to the impacts of these schools.

In the area of health protection, the department delivers public health protection programs, including communicable disease control, monitoring of drinking water and waste water, and environmental public health inspections of facilities and housing on reserve. In this area, services are provided by a combination of Health Canada and first nations-employed workers.

In the area of primary health care, Health Canada supports access to primary health care services in 80 remote and isolated first nations communities where access to provincial services is limited. Efforts are ongoing to enhance the inter-professional team approach, increase the number of Health Canada nurses, including nurse practitioners, and increase access to physician services.

Health Canada delivers primary care in 52 first nations communities, while in the remaining locations these services are totally under the control of first nations.

Through home and community care programs, Health Canada supports home care nursing, respite care, client assessments, and personal care or home support in over 500 first nations and Inuit communities. Most of these services are delivered by first nations community-employed health workers.

As indicated before, Health Canada also provides supplemental health benefits. Health Canada supports one of the largest health benefit programs in the country and provides coverage for medically necessary goods and services to over 824,000 eligible first nations and Inuit.

NIHB provides program coverage in different benefit areas to supplement those that are usually available through provinces, territories, and private insurers. This includes coverage for prescription and over-the-counter drugs, dental services, medical transportation, medical supplies and equipment, vision care, and mental health counselling.

The NIHB program does not require co-payments or deductibles and encourages health service providers to bill the program directly so that clients do not face out-of-pocket expenses.

The NIHB program provides important coverage for medical transportation to health care services. Approximately 125,000 clients accessed medical transportation benefits in 2014-15, accounting for over 300,000 medical-related trips. Medical transportation coverage includes emergency transportation and transportation to access medical care, such as appointments with physicians; hospital care; diagnostic tests; medical treatments; alcohol, solvent, drug abuse, and detox treatments; traditional healers; vision and dental appointments; and mental health counselling.

Specific to dental care, the NIHB program provides eligible first nations and Inuit with coverage for diagnostic, preventive, restorative, endodontic, periodontal, removable prosthodontics, oral surgery, and orthodontic services.

Health Canada also provides support for the infrastructure of 700 health care institutions across Canada. This supports the delivery of services and helps first nations with health services accreditation, the adoption of cyber health technologies, human resources in Aboriginal health care, and service integration.

Health Canada does not do this alone. First nations and Inuit also take on various degrees of responsibility for directing, managing and providing a multitude of health services funded by the federal government.

Efforts to assist first nations and Inuit in their desire to influence, manage and control health programs and services that affect them continue to be essential for improving health outcomes and expanding access to the health services and programs they need. This approach has been motivated not only by the desire to give first nations and Inuit greater autonomy in matters that could improve their health, but also by the evidence that better control can improve health outcomes and make public health activities more effective and respectful of the culture.

A majority of health programs have been transferred to over 400 first nations communities, to varying degrees. Some first nations communities receive funding to design and deliver autonomous health services that meet their needs, while others work with Health Canada to develop community health plans in order to model the programs to their health services needs. And in some communities, Health Canada personnel deliver health services jointly with local health teams.

We have made significant progress in health services integration in the last ten years. In many regions, we see examples where there are more doctors in the communities or the continuum of health services provided within and outside the community has improved through collaboration agreements. These efforts have resulted in better outcomes and made it possible to implement a more patient-focused approach, in spite of the complexity of the system.

The national organizations are consulted regularly and the two main national organizations representing first nations and Inuit sit at the management table of the First Nations and Inuit Health Branch. There are co-management tables and tripartite tables in most regions of Canada for holding official discussions with the provincial and territorial partners and the first nations and Inuit partners, in order to advance common priorities and resolve systemic issues.

I would like to speak briefly about some of the priorities with which we are concerned.

As you know, first nations and Inuit are more likely to experience complex mental health and substance abuse issues. We have been working with the Assembly of First Nations over the last few years to develop the first nations mental wellness continuum framework. This framework was endorsed and released by the Assembly of First Nations in January 2015, and implementation is under way with first nations partners at the regional and national levels.

Health Canada will also participate in the whole-of-government approach to address the call for action of the Truth and Reconciliation Commission. We are also working jointly with the Assembly of First Nations on a joint review of the non-insured health benefit program. This is a benefit-by-benefit review with the AFN to discuss improvement of the health programs and services.

I want to thank this committee for giving us an opportunity to be with you today, and we will be pleased to answer your questions.

[The Chair, Liberal, Andy Fillmore]

Thank you very much, Monsieur Perron, and to your colleagues as well. I know that 10 minutes goes fast, and if there's more that you want to share with us today, we'll find a way to fit that into the questions as they come up.

We'll move into a round of seven-minute questions, and Michael McLeod first, please.

[Michael McLeod, Liberal, Northwest Territories, NT]

Thank you to you all for coming to present to us today. This is an area that I think concerns all of us throughout Canada, the area of health care. I'm from the Northwest Territories, and we certainly have our share of issues across the north. We are a large area with 33 communities, struggling to have the services provided in our communities. It's very rare that you'll see a doctor twice in the communities. Even the nurses are locums, for the most part, who come in for a short stint and then leave.

About 70% of the Government of the Northwest Territories budget is spent in the area of the social envelope. A lot of it is being spent on health. When it comes to our aboriginal population, we have first nations people who are covered through non-insured health benefits, and we have the Métis people who are covered through a program funded by the Government of the Northwest Territories. So they are carrying a huge burden of costs. It's really causing a lot of challenges for them to provide health care for aboriginal peoples.

I'm very curious to know how the non-insured health benefits are calculated. In the Northwest Territories a set amount of money is provided on an annual basis. I'm not sure if it has increased over time, but I know the government is spending roughly three times what is provided, because the federal government hasn't, up till now, been willing to cover the actual costs. There seems to be a formula that is used and it is not really measuring the health needs of the first nations people.

My first question is on that area, then, the real needs of aboriginal peoples in the Northwest Territories. We don't have treatment centres either, so addictions is an issue. Health is an issue. Off-loading to the territorial government is an issue.

Maybe you could just talk about that a little bit, and then I'll ask my next question.

[Sony Perron]

To give a little bit of context, around 20 years ago there was an agreement between the federal government and the territorial government about the transfer of primary health care services responsibility to the Northwest Territory government. Health Canada's first nations and Inuit health branch doesn't provide community-based health services in this territory. We do have an agreement with the territorial government to provide them, over a multi-year agreement, funding for public health programming—for example, home care services, maternal and child health, and these kinds of programs. We have a master agreement with the territorial government to fund these programs. Some of these resources flow directly to the community from the territorial government, but the main responsibility of the territorial government for primary care would ensure that health services in the territory is with the territorial government. It's not with Health Canada.

Where we also intervene is that first nation or Inuit people living in NWT are covered by the non-insured health benefits program. For medication, dental care, medical supply and equipment, and vision care, these benefits are totally administered by Health Canada and funded by Health Canada. We pay the full cost of these benefits for a client living in Northwest Territories like anywhere in Canada.

For medical transportation, we work with the territorial government to pay our share of the transportation costs for a first nation client. You referred to the Métis. Métis are not eligible clients under the non-insurable benefit. The policy for this program is for Inuit and first nation at this time.

We also have a territorial funding arrangement to supplement funding to territorial government to assist with costs of the health system. In there, there is an envelope—I cannot remember the exact amount, sorry—for medical transportation. The territorial government is receiving an additional envelope to support the cost of medical transportation in the territory, because it's known that the cost of transportation there for client to access needed care is pretty high.

So in addition to the main transfer, there is that envelope provided annually to the territorial government to assist with the cost of medical transportation.

[Michael McLeod, Liberal, Northwest Territories, NT]

I'm quite familiar with the arrangement with the territorial government. I spent 12 years in cabinet with the Government of the Northwest Territories.

Maybe we can get into the specifics. I'm certainly familiar with the fact that the Métis are not included. The Government of the Northwest Territories has taken that responsibility on itself.

I have two questions, given the short period of time. First, given the results of the Supreme Court ruling in the Daniels case now, would you be able to give us some insight on the plans for including the Métis in the non-insured health benefits?

The second question is regarding the Truth and Reconciliation Commission's call to action, which states that we should:

...provide sustainable funding for existing and new Aboriginal healing centres to address the physical, mental, emotional, and spiritual harms caused by residential schools, and to ensure that the funding of healing centres in Nunavut and the Northwest Territories is a priority.

I'm very eager to learn what that means and what that will to translate to.

[Sony Perron]

Regarding the coverage for Métis, at this time the policy coverage we have for the program at Health Canada is about providing service for first nations and Inuit. Since the court decision, there has not been a change in terms of the eligibility for these programs. The responsibility for providing health care remains with the territorial government or the provinces and territories in general for the rest of the population.

As for the TRC call for action, there are seven recommendations that are directly related to health care or health services. We are in the process of working with the Assembly of First Nations, the Inuit Tapiriit Kanatami, and also the Métis National Council to engage them to support and get their views in the context of the health accord process.

We do expect that during that process we will be able to get the perspectives of these three groups about how we implement these seven recommendations that are directly related to health care. Some of them, as you probably know, are in the range of the responsibilities of the provinces and territories, so we do expect that this process will give an opportunity to learn about how we could best implement these measures.

[The Chair, Liberal, Andy Fillmore]

With that question and others, there's a lot of subject matter here. If you would like to provide any further information in writing, we'd happily receive that as well. Thank you.

The next question comes from Cathy McLeod, please.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

I'm sure you're aware of some recent testimony by a doctor who was here at committee. Also, the APTN did a bit of a series on the non-insured health benefits.

What strikes me, if you look perhaps at the federal service plan, is that it's pretty seamless. For orthodontic work, the dentist might flip a picture in, and the approval comes very quickly. To my knowledge, I don't know of any declines in orthodontic services for people under, say, the public sector plan. So it seems that there are plans out there that are seamless and very burden-free in terms of their paperwork and process. In comparison to the stories that we've heard, that is an issue. You talked about working with the AFN in a review of non-insured health benefits. Are you looking at your systems and processes for a more seamless provision of service, which is the norm? That's the first question.

The second part of that—and then I hope to talk about primary care—is that we heard that the formulary is very restricted. I would like to know if your formulary compares to what is routinely available, for example, in the province of Ontario.

[Sony Perron]

I will start with the non-insured health benefits joint review process and ask my colleague Scott Doidge to share a few more details.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

Could you let me know when I have two minutes left, Chair, for primary care? Thanks.

[Sony Perron]

The joint review will allow us to go benefit by benefit and look at the irritants in the system. One of the things we know is that we are running a plan that has coverage in 13 jurisdictions across the country, and most of the health system is driven by provincial and territorial considerations. Formularies are different, program coverage is different, and physicians' practices in terms of prescribing are different. We have to learn about where the irritants are to be able to fix that.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

Can I just interject? Sun Life covers federal government employees across the country, and they don't worry about all of that.

[Sony Perron]

I think that during the review process we will have to examine this with the AFN, because the design of this program is pretty important. I mentioned earlier that there is is no copayment and there is no deductible. I should have mentioned that there is no maximum amount either. We do have clients who receive hundreds of thousands of dollars in coverage annually because that amount is what they need.

However, in order to balance the plan, plans that have no limits, like that one, will have some criteria for coverage, which is that it's for something is medically necessary. For example, in the area of drugs where we ask for predetermination, it's mostly around drugs that have an addiction issue built in that needs to be controlled. This program has been recognized as one of the most sophisticated in terms of preventing over-prescribing, but it does bring with it some rules, and this is what we want to discuss with the AFN.

On dental care, you referred to public service employee plan. Again, there is a maximum. If you go above this maximum in a given year, you're on your own. For orthodontic treatment, you have a maximum amount. I think it's around $2,000. The rest of the bill is for the family to pay.

In the case of non-insured health benefits, if a client receives coverage we will pay in full. We pay the full cost. There won't be a copayment and there won't be a deductible. However, the medically necessary criteria will be applied, so some of the opportunities to get orthodontic treatment or even dental treatment that is not medically necessary will not be covered like it would be covered under a private plan that only covers a portion of the cost. It's a choice. Public plans usually will have more elements of predetermination in them in order to be able to cover more and to offer more coverage for the clients.

In terms of the administrative process, maybe Scott can give us a sense in terms of the percentage of claims that receive approval without any prior approval or predetermination. It's pretty important.

[Scott Doidge, Director General, Non-Insured Health Benefits, First Nations and Inuit Health Branch, Department of Health]

Maybe I'll tackle your comparability question after that.

About 99% of pharmacy claims are ultimately approved through NIHB and the majority of those claims—over 90%—are approved on the spot through our electronic claims processing system. There's no out-of-pocket cost for the client, and the provider is subsequently reimbursed for that.

There are some claims for which we do require further information, as Sony mentioned. Many of those drugs are ones that are subject to abuse and are part of something we call our prescription drug abuse strategy, so we do seek further information through our drug exception centre here in—

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

I'm sorry, I'm going to cut off you because I've two minutes left and I have to get to the question of primary care.

We heard that you run 52 of the primary care services across Canada. My first question is that in every one of those settings, is Internet service such that there is a good opportunity for telemedicine?

The second is that we hear about the lack of resources and of services.... Having run a number of rural community centres, I know that communities have huge challenges with physician services, nurse practitioners, and mental health counsellors, so I appreciate the recruitment challenges. Do you run those services at a comparable level to a non-indigenous remote community in terms of the service level? Have you studied it? Can you table any studies?

That will use the minute.

[Sony Perron]

The objective is to run at the same standard. There are some challenges from geography, and distance, and recruitment of nurses, but also in the availability of the physician services that are provided by the province. We have, over the last year, been able to increase the presence of physicians in the communities and when the physicians are not present, the nurses have access on call to a physician to get some direction in terms of service.

Maybe, Leila, you want to comment on the level of care and the recent assessment we performed following the 2015 OAG report.

[Leila Gillis, Director, Primary Health Care Systems Division, Department of Health]

We're certainly challenged by geographic location and we do have models that are similar to those in other geographic locations. We are about to do a comparative descriptive analysis where there are comparable locations where provincial services are provided. However, we do have, and have increased, nurse practitioners in many of our nursing stations, and part of our analysis of each nursing station and their essential services is the plan to enhance the mix of skills, collaborative practice arrangements for physician coverage, and also to increase the number of nurse practitioners in our current nursing teams within the nursing stations.

[The Chair, Liberal, Andy Fillmore]

The next question is from Charlie Angus.

[Charlie Angus, NDP, Timmins—James Bay, ON]

Thank you very much for being here and, Mr. Conn, it's nice to see you here. We're both in our suits today. The last time we were in Attawapiskat, we were in our rubber boots.

I only have seven minutes and I have so many questions. I wish we could do this all day, but I only have seven minutes. I don't want to sound rude, but I have a bunch of short questions and, hopefully, will get short answers.

Can you confirm that the Conservative government set aside money to implement Jordan's principle between 2008 and 2012?

[Sony Perron]

There was actually an active fund that was created at the time, yes.

[Charlie Angus, NDP, Timmins—James Bay, ON]

I didn't see it in this budget. Is that fund there now to implement Jordan's principle?

[Sony Perron]

The fund has been eliminated in the context of the deficit reduction action plan.