Indigenous and Northern Affairs Committee on May 3rd, 2022

[The Chair, Liberal, Marc Garneau]

Good afternoon, and welcome to the 17th meeting of the Standing Committee on Indigenous and Northern Affairs.

We are gathered here today on the unceded territory of the Algonquin Anishinabe nation.

Today we are continuing our third study, which is on the administration and accessibility of indigenous peoples to the non‑insured health benefits program.

In our first panel today, we'll be hearing from the Honourable John Main, Minister of Health, Government of Nunavut; the Honourable Julie Green, Minister of Health and Social Services, Government of the Northwest Territories; and the Honourable Tracy-Anne McPhee, Minister of Health and Social Services, Government of the Yukon.

I would like to remind you to respect the requirements of the Board of Internal Economy regarding physical distancing and wearing masks.

To ensure an orderly meeting, I would like to outline just a few rules for our witnesses and members to follow.

Members or witnesses may speak in the official language of their choice. Interpretation services in English, French and Inuktitut are available for the first part of today’s meeting. Please be patient with the interpretation. There may be a delay, especially since the Inuktitut has to be translated into English first before it can be translated into French, and vice versa.

The interpretation button is found at the bottom of your screen for either English or French, or Inuktitut. If interpretation is lost, please inform me immediately. We'll have a pause and we'll fix the problem before we carry on.

The “raise hand” feature at the bottom of the screen can be used at any time if you wish to speak or to alert the chair.

Before speaking, please wait until I recognize you by name. If you are on the video conference, please click on the microphone icon to unmute yourself. When speaking, please speak slowly and clearly. When you're not speaking, your mike should be on mute. As a reminder, all comments should be addressed through the chair.

For each organization, each witness will begin this proceeding by speaking for up to five minutes. We'll start with the Honourable John Main, Minister of Health, Government of Nunavut.

Minister Main, you have five minutes.

[John Main, Minister of Health, Government of Nunavut]

Matnaugavit.

I'm going to speak in Inuktitut briefly and then switch to English.

[Witness spoke in Inuktitut, interpreted as follows:]

Thank you.

I want to start by thanking the committee members for the invitation to attend as a witness on this important topic. I’d like to take a moment to recognize the member for Nunavut, Lori Idlout. Ubluttiaq, good day.

[English]

Good day.

As you are likely aware, since the creation of Nunavut in April 1999, certain vital aspects of the non-insured health benefits program, NIHB, have been coordinated by the Government of Nunavut's Department of Health on behalf of the Government of Canada. We achieved the coordination and delivery of this program through a series of contribution agreements negotiated between our governments.

NIHB is essential to our territory in ensuring reasonable accessibility to non-insured health services and is considered a vital portfolio that often reaches the public spotlight here in Nunavut.

This program—I have a few examples—provides the means by which a child in Arctic Bay can be escorted by their mother to a specialist appointment in Iqaluit without incurring costs for travel, accommodation or expenses. It ensures that an elder in Kugluktuk can obtain corrective lenses to see family on the horizon returning from a hunting trip and that our residents who seek care in their neighbouring jurisdictions are as comfortable as possible during vulnerable moments in their care and healing journey.

The challenge of providing a wide range of care and services to a small population over an immense geographic landscape makes access to all required medical services difficult.

While changes to the NIHB program are at the discretion of the Government of Canada, Nunavummiut employed by the Government of Nunavut are directly involved in delivery of this program and in turn advocate on behalf of Nunavut Inuit to improve access to non-insured health care services.

Currently under the NIHB program, we're responsible for the delivery of medical transportation, accommodation and meals, dental services and eye exams by an optometrist. Unfortunately, while the services just listed have been successfully delivered to our residents, we have run into issues in having them fully covered under NIHB, creating costs that our government has been perpetually required to assume.

The territory has lost hundreds of millions [Technical difficulty—Editor]—

[The Chair, Liberal, Marc Garneau]

Madam Clerk, I see a freeze on Minister Main. Has everybody else noticed the same?

[The Clerk of the Committee, Ms. Vanessa Davies]

Yes, sir. We're going to address it right now.

Unfortunately, Minister Main was dropped. We have a tech on it.

[The Chair, Liberal, Marc Garneau]

In the interests of time, do we have the other two witnesses with us at the moment?

[The Clerk]

Yes. I see Minister Green and I see Minister McPhee.

I see that Minister Main is still with us.

[The Chair, Liberal, Marc Garneau]

You have about two minutes left. Could you resume your presentation, please?

[John Main]

My apologies. It's Nunavut Internet at its best—average.

The territory has lost hundreds of millions of dollars by covering costs not fully covered under the NIHB. This is lost funding that we could have been funnelling into improving health care programs, services and infrastructure here in Nunavut.

Over the last four years, our respective governments have been working together in negotiations towards a resolution. I'm pleased to advise that recently we have seen movement. Since the 2020-21 fiscal year, the Government of Canada has agreed to an increase in the medical travel copayment amount, a notional $20-million increase to the NIHB contribution agreement, as well as a supplemental $58-million contribution agreement intended to cover remaining incurred NIHB expenses, an interim measure to facilitate these discussions. While we're still in negotiations, opportunities like this one here today allow us to listen, ask questions and educate each other to ensure we're working together for a common cause.

It's expected that a long-term agreement between the federal government and Nunavut will be reached before the end of the 2022-23 fiscal year, an achievement both parties can be proud of. As we move towards this milestone, the Department of Health will continue to collaborate with the Government of Canada to ensure that services are accessible and provided to Nunavummiut.

Another area of concern I'd like to mention briefly is the provision of dental services and eye exams. Like many jurisdictions across Canada, Nunavut is facing a backlog in these areas due to COVID-19, which is impacting our residents. Aside from the shorter-term challenge, there is a larger question around whether the number of service days established within the NIHB will be sufficient to meet the dental and eye needs of Nunavut residents in the longer term.

Once again, matna. I look forward to answering any questions. My apologies for the technical difficulties.

[The Chair, Liberal, Marc Garneau]

No problem. Thank you, Minister Main.

We'll now go to Minister Green.

You have five minutes.

[Julie Green, Minister of Health and Social Services, Government of the Northwest Territories]

Thank you very much, Mr. Chair.

I'd like to thank you and the committee on indigenous and northern affairs for the opportunity to contribute to your study of the accessibility and administration of the non-insured health benefits program.

I am on the line from Yellowknife, capital of the Northwest Territories and traditional home of the Yellowknives Dene First Nation and the Métis.

As Mr. Main explained and as is similar here, the GNWT administers portions of the NIHB program on behalf of the federal government, with a service agreement worth $16 million a year. Our current agreement with the federal government expires on March 31 of next year, so the timing of your discussion is important. You have an opportunity to recommend changes that will strengthen the NIHB program.

First, I have a little background on the NWT. We have a population of 44,000 residents living in 33 communities dispersed across one million square kilometres. A total of 44% of the population is eligible for benefits under NIHB and an additional 6% receive Métis health benefits. Métis health benefits are aligned with NIHB and are paid for by the territorial government at a cost of $3 million a year.

Because of the number of small communities and a lack of access to year-round roads, access to benefits under NIHB, particularly medical travel, are critical to good health outcomes. The GNWT offers benefit programs pegged to the same level of coverage provided under the federal NIHB program to eligible residents, including the Métis and non-indigenous populations.

The GNWT recognizes the importance of providing a safety net to residents to reduce financial barriers to access health benefits not covered by the NWT health care plan. The GNWT's medical travel policy, for example, mirrors NIHB and offers the same benefits.

The federal government has been an important partner in supporting the integrated service delivery model by providing funding to improve health services in areas of home care, mental health and addictions, system innovation and, most recently, of course, to assist in the response to COVID-19.

Now I would like to explain some aspects of the GNWT role in the federal NIHB program. The GNWT administers some parts of the NIHB program, as I said, on behalf of the federal government, including medical travel, dentist trips to communities, applications for medical supplies and equipment, arranging for the vision care team to visit communities for their NIHB clients and pharmaceutical coverage.

Our role as an administrator puts us in a position where we implement the federal program and the public holds us responsible for it. In fact, we are the filling in the sandwich. This is not our program; however, in our role as administrator, we do receive feedback from NIHB clients on issues and concerns with the program, which we share with the federal government for their awareness. Based on our experience in administering benefits, we know that not all residents who self-identify as indigenous have access to non-insured health benefits because their Indian Act status is in dispute.

Medical travel, as I mentioned, is a very important part of the benefits of the NIHB program in the NWT, given how remote most communities are. It's also the area in which we receive the most complaints. The complaints address who is eligible for a non-medical escort and the timeliness of approval for medical travel and for escorts. As Mr. Main outlined, the GNWT incurs additional costs associated with medical travel that are not recognized or remunerated by Canada. For example, 75% of the cost for non-medical escorts for NIHB clients is based on its service criteria and currently costs the GNWT $3 million a year.

To support opportunities to provide feedback on the NIHB program, GNWT works closely with ISC to facilitate trilateral engagement sessions with indigenous governments, and we expect one of these sessions to be held later in the year.

Our vision for the future of NIHB administration comes from the TRC calls to action, in particular action 20, which states in part “we call upon the federal government to recognize, respect, and address the distinct health needs of the Métis, Inuit, and off-reserve Aboriginal peoples”.

One way to implement this action and advance reconciliation is to explore opportunities for greater direct involvement and leadership for NIHB in the NWT by indigenous government organizations.

We are happy to work in partnership with the federal government and the IGOs. I hope this information is helpful, and I look forward to answering any questions you may have.

Thank you.

[The Chair, Liberal, Marc Garneau]

Thank you very much, Minister Green.

We'll now go to Minister McPhee.

If you're ready, you have five minutes.

[Tracy-Anne McPhee, Minister of Health and Social Services, Government of Yukon]

Thank you for the opportunity to be here this afternoon.

I'm speaking to you from the traditional territory of the Kwanlin Dün First Nation on the Ta'an Kwäch'än Council.

Thank you to my colleagues across the north for the important details about how the NIHB process operates in their territories. We have some similarities and some differences.

In the Yukon context, we have 14 individual first nations that operate here in the territory and reside in their traditional territories. Eleven of those first nations are self-governing under the Umbrella Final Agreement from the early 1990s. That makes us a bit different and unique compared to other parts of Canada.

While I certainly agree with my colleagues about the benefits of the NIHB process, our approach is certainly not as coordinated as, for instance, that in the Northwest Territories, which administers the federal program. Our Canadian system of health care is complex, a patchwork of policies and legislation and relationships.

We certainly submit to your committee for your consideration that a better coordinated approach is needed, but it does remain a challenge. In order to improve clarity and consistency of delivery, we are working hard here in the territory to improve our own system and certainly to make changes to the way in which NIHB operates in conjunction with the Yukon system and how we provide service delivery to individual Yukoners, which, of course, is the primary goal. That is critical.

A number of years ago, we had an independent review of Yukon's health care system, which was known as “Putting People First”. One of the recommendations from “Putting People First” was, in fact, to have a better coordinated system with the NIHB. It indicated that uncertainty in that process definitely causes inequities. The territory has the responsibility to provide universal publicly funded insured health services to all residents of the Yukon territory, including Inuit, Métis and first nations individuals. Our “Putting People First” is an example, I think, of a health transformation project, and we know others have happened across Canada. It is aimed at improving health outcomes and access to services for all Yukoners, and in the process we are now focused on determining how first nations people can be a part of implementing the “Putting People First” recommendations from a transformational standpoint.

We know that will require organizational capacity and ultimately engagement with our Yukon first nations as well as service delivery improvements, not only in the Yukon health system but in NIHB and the way in which the two interact. We're focusing on new models of health service delivery.

The current process we have, without going into too much detail, involves NIHB being a pair of last resorts with respect to determining whether or not individuals happen to be status first nations individuals or otherwise and whether or not the Yukon health care system makes looking after their costs a priority. The lack of coordination does create barriers to service consistency.

As I've noted, our own insured health services need to be improved, and we are focusing on that. The “Putting People First” focus will be for people-centred, patient-centred, client-centred, trauma-informed wraparound services across the territory. This is particularly critical at this time when better coordination will be our goal, especially as we face the substance-use health emergency here in the territory that was declared by our government on January 20.

We are seeking to provide harm-reduction strategies that are new and improved. We certainly have individuals who, for instance, would qualify to have treatment outside of the territory for addictions, which might be covered by Yukon government. They might be covered by NIHB. Those two things are not necessarily the same. The locations they might be able to go to for treatment are not necessarily the same, and that certainly provides confusion.

That whole process, those experiences and the lack of coordination, I'll say, exasperates individuals and adversely affects those Canadians who are often most in need.

Our experience here in the territory is also that individual first nations governments—of which we have 11—often end up absorbing costs for health services that are not theirs and for which other governments are provided funding, whether they be the Government of Yukon or otherwise.

I want to focus just for a moment—I know my time is running out—to come up with a few solutions.

I think language is incredibly important as we proceed to modernize our structures and make sure they are meeting the needs of Canadians.

I think we need to recognize that diverse governing structures do exist across Canada for first nations, Inuit and Métis people. Perhaps references to “traditional territory” or “self-governing first nations”, rather than just “reserve”, or “on reserve”, is just a small example. We do not have reserve land or individuals who live on reserve here in the territory and, unfortunately, just referring to the language sometimes confuses folks.

We are very supportive of a trilateral table and tripartite conversations. I think Yukon's unique situation can contribute to some of those solutions. We are very committed to doing that work at those tables because we do think that this is a system that is ripe for improvement, but we can do that together in partnership.

There is an example of some rather successful reciprocal-type agreements that exist, for instance, with the first nations governments and Canadian provinces and territories around social assistance, as an example, so there is a framework—

[The Chair, Liberal, Marc Garneau]

Minister, I'm going to have to ask you to wrap up.

[Tracy-Anne McPhee]

Yes. Thank you so much.

There is a framework that might be a guide for us.

I appreciate the opportunity to chat today. Thank you.

[The Chair, Liberal, Marc Garneau]

Thank you, Minister McPhee.

We'll start with the first round of questions.

Mr. Shields, you have six minutes.

[Martin Shields, Conservative, Bow River, AB]

Thank you, Mr. Chair.

Thank you to the honourable ministers who are presenting today. It is very much appreciated.

Minister Main, we've heard from the Minister of the Northwest Territories the percentage of the population that would qualify for NIHB. Do you have that number for Nunavut?

[John Main]

It's roughly 85% Inuit. Nunavut is overwhelmingly Inuit. I can get a more accurate number and get back to the committee in writing if that would help.

[Martin Shields, Conservative, Bow River, AB]

That would help, and it relates to my next question.

In a decision-making process, if it were block-funded—in determining that the block funding had the amount in it—do you believe you have the expertise to make the decisions for your residents that need to be made?

[John Main]

If it were block-funded, there would have to be an escalating payment schedule, because what we're seeing here in Nunavut year over year in the demand for services is that our needs are increasing quite steadily when it comes to medical travel and when it comes to mental health and addictions.

I think it's a reflection of the very young population we have. We've very young. If you look at the demographics, you can see that it's very wide at the bottom end of the age categories.

We also have some very serious social determinants of health issues that we're dealing with here in the territory, such as housing, so—

[Martin Shields, Conservative, Bow River, AB]

Minister, I understand that. I'm sorry to interrupt. I have limited time.

I understand, and I know what the determinants of health are.

My question is, though, with the funding. Do you believe you could make the appropriate decisions to match those health standards?

[John Main]

I would have to take some time and ponder that. I apologize. I just can't give you an answer off the cuff. That would be such a shift for this program to go to block funding, because right now it's based on the services and based on the quantity and those can vary from year to year, and as I mentioned, they are increasing. I can't fully understand how a block funding model would work. It would be such a drastic change from the existing program.

[Martin Shields, Conservative, Bow River, AB]

Thank you.

This is how the provinces work and it's one of the things that I would ask about. It's how the provinces deal with their health.

Minister Green, from the Northwest Territories, what is the number one recommendation you would have if you could change it? This committee could make a recommendation.

What is your number one issue that we could have as a recommendation that would make it work better for those health determinants for the NIHB clients in your territory?

[Julie Green]

It would certainly be helpful if medical travel was fully funded and there was some consideration of the escort policy and whether it was a culturally safe escort policy. We get a lot of complaints from people coming from small communities who are not accustomed to travelling to places even the size of Yellowknife, which is a very small city, let alone to Edmonton and further south. They would like people to accompany them. Elders, especially, would like people to accompany them.

This kind of compassionate accompaniment is not considered in the benefits of NIHB. They consider whether you need interpretation, mobility assistance and so on, but not compassionate travel. I'm concerned that what we're offering is not really culturally appropriate to the population, and I would like to see some discussion around that as a change.

Thank you.

[Martin Shields, Conservative, Bow River, AB]

Thank you.

Minister McPhee, I think you have moved into an area that I see happening, even in my own riding, when you talk about language, for example. Could you explain a bit more about the recommendation that you started with?

[Tracy-Anne McPhee]

It's incredibly important that the language be inclusive. A lot of our interactions with the federal government, not only on this topic, involve us starting, although we've been at this for a while. There's great understanding now throughout government that there are no reserves in the territory and that we have first nations governments that are governing their own traditional territories under the Umbrella Final Agreement.

However, there's no provision for any of those languages or inclusion of that kind of governance structure in policies or in directives that come out, even in programming that comes out through a budgetary process, for instance. As a result, first nations governments and our government, all getting quite sophisticated, are saying, “Okay, where do I fit into this program? How does my governing structure benefit from this program? Will we qualify?” It's these kinds of things.

My point is that we should be as inclusive as possible, and language is a good place to start.